Is a model of the future health care in America already in place in Vermont and Texas? Possibly so, but I hope not. On the front page of the February 11, 1994 Dynamic Chiropractic, readers were told about a plan in which a primary care MD gatekeeper would decide if patients would rely on that MD primary care provider's referral. This kind of program is already in place in Texas in a special Medicaid program called the Lonestar plan, and it is a logistical nightmare for just about everyone involved in health care, from MDs and DCs to hospitals and imaging facilities.
Under this plan, as in the Vermont plan, patients are assigned to a primary care provider who must by law be an MD. The person who knows enough about the system can request a certain MD and in fact, they are asked to list a first and second choice. Those who are not savvy enough about the system to ask, get arbitrarily assigned to a primary care doctor who they have probably never met. Now that this trial program has been in place for a short while, some of the faults are already surfacing. In reference to assignment of a PCP (primary care physician), I have seen patients who have seen an MD and been treated by the doctor for some time, yet they get assigned to a doctor they've never met and may not like. But this assignment problem is just one of the many problems that begin to surface with this system.
During the course of this article we will see that the new managed health care has a bunch of troubles brewing on the horizon. Instead of "managed health care" we can anticipate mangled health care.
The Portal Door that Won't Budge
In the managed health care theory, this system makes a lot of sense. The idea is that you have basic primary health care providers who should, theoretically, develop a good, personal rapport with their charges. When problems arise, they should be able to spot those which lie outside their area of expertise and refer them to a proper "specialist." The PCP (primary care provider) would act as a health care manager, a ringmaster if you will, who would be the person accountable for referrals and the financial management of the patient's care. The PCP would decide which tests were appropriate. Some degree of cost containment would be realized if the PCP were a "team player" and kept a conservative perspective. This system is based on what I call the Marcus Welby approach, the notion that you have this kindly, wise, gray haired family doctor who is always looking out for his patients, and yet is frugal and conservative with insurance company money.
For doctors of chiropractic and doctors of osteopathy, this plan is extremely unfair. DCs and DOs are really the best examples of perfect models of the family doctor concept and really should be PCPs. Both groups are more than willing to refer out to the appropriate specialists, are conservative in orientation and are excellent co-managers, but they are not allowed to be PCPs, only MDs. If a particular MD happens to be prejudiced against chiropractic care, and should he be the PCP for several Medicaid patients, you can bet that patients will be out of luck should they want to get chiropractic care.
Whose Patient Is this Anyway?
But lest the reader think that it is just the DC who is frustrated by this plan, think again. Medical doctors who see a patient and feel that the patient needs MRI testing or blood work in a hurry, also have to wait to get the OK from the PCP to have it done. Without a referral from the PCP, everyone else to whom that patient presents for care or testing will be out of luck and will not get paid. With some younger and more progressive PCPs, there really is not that much of a problem. Some will tell the patient that they will give the OK for the patient to go to whatever doctor that the patient wants if it will help. Although this is the best case scenario, still it holds things up while official referral letters or verbal referrals must be obtained. Sometimes the holdup is that the PCP is out of town.
I recently spoke with an official about the Lonestar plan and indicated that I wanted to write a letter of complaint about the system. She assured me that a greater part of her day was taken up just listening to complaints about it, apparently the only people that it pleases are the state officials who has a hand into writing the law.
Why Only MDs as PCPs?
Why aren't DCs allowed to be primary care providers? Well, the notion of a primary care, portal-of-entry provider is a generalized practitioner who can treat most minor ailments from strep throat to measles. The fact that we as chiropractic doctors are so limited in scope of practice and inability to prescribe medications or perform vaccinations or the like, rules us out of contention right off the bat. Under the current scope of practice in many states, to consider chiropractic doctors anything but a very limited specialist (in the minds of many, just as a temporary treatment for acute low back problems) would be ludicrous. To be anything but a very limited specialist, we would have to be able to cast fractures, prescribe at least antibiotics, muscle relaxants and pain killers, and have the clinical exposure to the same wide variety of diseases as our allopathic counterparts. I have received calls from doctors around the country who are getting more and more frustrated with the current state of affairs in their areas, and this is without exposure to the Vermont or Lonestar plans. From a sampling of the calls I have received in response to some of my past articles, it is clear that there is a great deal of dissatisfaction with the state of our profession, with the actions (or inactions) of our associations, and with the current health care reform proposals. To be brutally frank, brothers and sisters, chiropractic has not, in my opinion, taken an aggressive enough posture.
Trial by Television
I watched with disgust as the ABC show "20/20" went through a thinly veiled attack on chiropractic under the guise of investigative reporting about pediatric chiropractic. The report tended to emphasize what I will refer to as the "nutty fringe" element in our profession, and also tried to make it look as if we were a profession divided against itself. But of course, that is the apparent projection which "20/20" wanted. A similar hatchet job could have been done on our allopathic counterparts or on the pharmaceutical industry. The art is in the editing.
If a national referendum had been conducted with Americans who had watched this "report," do you think that there would be a chance in hell that they would pick us as portal of entry?
Suggestions
What can you as a lowly practitioner do to change the status quo? Number one, as a voter, write a letter to your congress person and to President Clinton indicating your concerns. For the cost of a 29 cent stamp, you can have the impact of 50 other people. I was told by a congressional aide that for every handwritten letter on a topic they receive (assuming it isn't written in crayon), congress people gauge that there are 50 other people who feel the same way, but don't have the wherewithal to write.
Number two, write associations you belong to and express your feelings. After all they, like Congress, are supposed to represent you. If you feel that our profession needs to have the ability to prescribe certain medication (i.e., certain pain killers or antibiotics or whatever), then try to get that idea across to your state politicians. Scope of practice laws have to be changed at state levels. We also need a national unification of scope of practice laws which are liberal enough to allow us to really assume a primary provider role. Further, our colleges need to expose students as doctors in training to the kinds of health care problems which they may encounter in the general population of patients. This can best be done in a hospital setting. Not only will hospitals rounds help educate future DCs to the spectrum of ailments and hone their diagnostic skills, but interactions with their allopathic counterparts will go far in breaking down the barriers of bias which often exist.
The Future of Health Care
In the next six years, health care reform is going to be a fact. Next year we celebrate the Chiropractic Centennial. There is a saying: "Change or die." As a health care profession, as doctors, it is imperative that we start making changes that will allow us to evolve into the kind of health care providers who who will be able to continue and even prosper in the lean, mean years of managed competition. We have fought too long and hard for parity to begin to start settling for the status of a glorified physical therapist. I urge doctors to get involved in this movement. I would urge doctors, pro and con to write me and let me know how you feel.
John Raymond Baker, DC
3565 Delaware Street #304
Beaumont, TX 77706
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Some doctors thrive in a personality-based clinic and have a loyal following no matter what services or equipment they offer, but for most chiropractic offices who are trying to grow and expand, new equipment purchases help us stay relevant and continue to service our client base in the best, most up-to-date manner possible. So, regarding equipment purchasing: should you lease, get a bank loan, or pay cash?
