The chiropractic profession has undergone numerous changes since its humble beginnings, however no change has been as dramatic as the nation's move toward managed care. Managed care, in its present form, may deal a death blow to many natural health practitioners, including the nation's chiropractors. The present model is the monolithic HMO, supplemented by networks of preferred provider groups.
The problem with many of the more centralized health care corporations is their dominance by medical doctors. Natural health care practitioners, nurses, dentists, naturopaths, acupuncturists, etc., play an insignificant or secondary role within this hierarchy. This obvious physician slant, lacking any real internal competition, will make them likely to utilize allopathic therapies when other complementary therapies would be more rational or more cost effective.
In the HMO model, the physical therapists have been designated the hands-on, musculoskeletal providers. And due to the recent interest among physical therapists to provide manual therapy (adjusting techniques), we may see a gradual shift in physical therapists becoming the primary providers of spinal and extremity manipulation.
There is not a chiropractor in this country who has not already witnessed the erosion of of his or her insurance benefits because of the medical domination of HMOs and PPOs. Some chiropractors feel that the way to save chiropractic is to transform the profession into primary care doctors. Recent articles published in chiropractic journals, from reputable sources within chiropractic's major political and research organizations, extol the virtues of becoming primary care providers.
It is my opinion that to try to become primary care providers and gatekeepers is a flawed strategy which will waste valuable resources and encourage the continual erosion of chiropractic's status in the health care community. I believe this is true for a number of reasons:
- A primary care doctor is seen by the health care community as a doctor with the chief responsibility for diagnosing and treating systemic disease and referring these patients to a multitude of specialists. A chiropractic primary care doctor would be forced to understand areas which will, in my opinion, always be far removed from the average chiropractic practice. Whether or not a man would receive radiation or chemotherapy for advanced prostate cancer is not an issue commonly dealt with by the chiropractic profession. Understanding when a patient should undergo hospitalization for walking pneumonia or receive any number of popular oral antibiotics is another example of the types of problems not commonly dealt with in the traditional chiropractic practice.
- Chiropractic colleges are already filled with courses in microbiology, pathology, etc. Increasing this training to include at least one year of clinical study of disease in the hospital setting would rob the doctor of chiropractic of important training in the understanding of biomechanics, rehabilitation, and adjustment procedures. Also it is a pipe dream to think that in the next few years all chiropractic colleges will be able to make alliances with hospitals to provide the educational challenges of dealing with severely ill patients.
- Chiropractors have never been primary care doctors. They have always been portal of entry doctors. This distinction is important. Since the beginning of chiropractic history, chiropractors have always desired to maintain the ability of their patients to receive chiropractic care without the need for referral from a medical physician. This is in contrast to physical therapists, occupational therapists, nurses, respiratory therapists, etc., who rely upon medical doctors for referrals. It is my opinion that chiropractic should try to maintain its existence as an independent portal of entry profession, however to make up primary doctors would radically alter our present niche in the health care system.
- Soaring malpractice rates will result from becoming primary care doctors. As soon as the chiropractor is responsible for diagnosing life threatening illnesses, one of the mainstays of the primary care physician, our malpractice rates will climb with the trajectory of a guided missile. The reason for chiropractic's modest malpractice premiums is chiropractic's health-oriented rather than disease-oriented approach. The majority of our patients are not suffering from life threatening illnesses. Remember that it is not unusual for the family physician to pay malpractice rates which vary from $25,000 to $50,000. If the average chiropractor sees malpractice fees soar from $5,000 to $25,000 or higher per year, many will be forced to leave practice because of this added financial burden.
- There is presently a surplus of many types of medical specialists. Any serious student of the health care field knows that many medical specialists are presently undergoing soul searching about their own futures. Many of them will take further postgraduate training to convert their occupation from medical specialization to primary care. The likelihood that any large HMO or PPO would choose a chiropractor over a medical doctor is a misguided fantasy.
- There is a growing number of nurses who are becoming nurse practitioners and physician assistants. As you know, many nurses are now able to write prescriptions and are functioning within the medical system in a manner similar to the primary care physician. It is likely that should there be a shortage of primary care doctors, nurses would be happy to fill these roles. And, it is my opinion that a nurse-physician alliance will be proposed before a chiropractor-physician alliance. Our battles with medical doctors have resulted in a psychic split between the chiropractic and medical profession that will not be bridged within the next few years.
Thus those who desire to make chiropractors primary care providers fail to understand the glut of allopathic practitioners, confuse primary care provider with portal of entry status, and neglect to view the obvious burdens to the average chiropractor and chiropractic college in taking a pivotal role in the disease-oriented medical model.
Chiropractic has been gaining popularity with the American public while it has been losing market share in the group health care market. Chiropractic's exclusion from most HMOs, which constitutes almost 40 percent of the health care market, has severely wounded the average practitioner's income and prestige. However the solution to this crisis should not involve trying to become internists who cannot prescribe drugs.
The solution is to continue to improve the chiropractic educational system. We need to strengthen our training in exercise and rehabilitation, continue researching the value of chiropractic adjustments, and to continue to develop our role as our nation's primary holistic health care profession.
We need to demonstrate that chiropractors can work with physical therapists, orthopedists, occupational therapists, etc., in hospitals and large medical clinics. We need to continue to improve upon our historical social niche by improving our ability to be the nation's most popular form of natural healing.
However the notion that we should become primary care practitioners and students of disease, pharmaceuticals, and surgery is a suggestion developed by those who, in my opinion, lack a deep understanding of the transitions occurring in the allopathic health care system. Understanding the medical basis of disease should always be a vital part of chiropractic education. But to become the medical model may leave our profession divided and mortally wounded by a failed struggle.
Chiropractic was founded as a profession that understands the relationship between structure and function. Chiropractic should always be a blend of neuromusculoskeletal rehabilitation and natural therapy. To shift our focus to a rigorous allopathic approach will increase chiropractic's exclusion from our health care system. It will provide an entree for physical therapists to become the primary providers of manipulative therapy. If we allow the physical therapists to become the primary providers of manipulation, we will become a footnote in the history of American health care.
Curtis Turchin, DC
Palo Alto, California
