Workers' Compensation, Our Golden Opportunity -- Part III

Independent chiropractic examiners (ICEs) have enormous influence in creating the image our profession enjoys within the insurance community. Those who cut care for a living frustrate reasonable case management and often paint good work as poor work. A bum rap at best.

This author perceives a distinct lack of energy by carriers to solicit high quality chiropractic opinions. Indeed, one of the most common complaints heard throughout the profession regards the poor quality of chiropractic consulting one sees. Such chiropractic consulting results in enormous frustration and delay. Left alone, the unscrupulous practices of too many chiropractors acting as "independent" consultants for insurance carriers promises to keep the true worth of reasonable chiropractic bottled up much longer.

The political wars within various states' workers' compensation programs are inspired in part by poor work from both providers and carriers. To this is added the actions of the state itself using the power of law to accomplish its ends. With everyone rushing to serve their particular needs, a crisis atmosphere is inevitable. In such a setting, animosity often arises from a serious lack of communication, pure stubbornness, unadulterated bias, or plain ignorance.

The insurance industry would have us believe that increasing costs arise primarily from greedy doctors and lawyers acting in concert with claimants who exaggerate the severity of their injuries. While there is some truth to such arguments, little is written about costly inefficiencies in case management and consulting practices within carriers themselves.

I recently treated a work-injured claimant who had been off work for three years, winding up with lumbar disc surgery. He continued to have low back and leg pain complaints after his operation and, on his own, came to see me. I treated him as needed and had him back to work in five months. Sitting very long or doing repetitive bending and trunk twisting aggravates his problem. He will never be 100 percent. He will have a tendency to continuing residuals.

Shortly after his return to work, the carrier sent him to a chiropractic consultant who said his need for chiropractic treatment should end in six months. Here we have a case going exactly where everyone wants it to go. The record clearly shows that chiropractic was the only treatment that caused an improvement in the man. Using a consultant who insists on "capping" care in a case with a legitimate need for ongoing attention of some sort introduces controversy, frustration, and delay, and for what reason? What will all this cost in the long run?

Why wasn't this claimant sent to a consultant during the three years he spent off work, seeking an opinion as to what might be offered the man besides time off? He was seen once each month by his family doctor over the entire three years. He reports that each visit was about the same:

"How ya' doin'?

"My back and leg hurts."

"Okay, we'll check you again in a month."

Thirty six visits. What for? Never a trip to any consultant. I saw him for five months and returned him to work, and the carrier sends him to a consultant to see if he needs chiropractic?

Wouldn't you think that the consultant would at least recognize the value of the work done to date? Would it be improper for him to suggest that the carrier was getting good value from the chiropractic delivered to this claimant; that the treatment schedule was prudent? Given the record in this case, the long history of this claimant's complaints, and the less than optimum clinical record of at least half postlumbar disc surgery patients, chiropractic should be strongly recommended, not discouraged. Clearly the medical treatment, coupled with his long disability, was the most expensive course of treatment to pursue.

Who is responsible for the high cost in this case? The surgeon, the family MD who saw him for three years without help, the chiropractor who got him back to work, or the claims adjuster who failed to be impressed by the record itself?

What I haven't told you was this patient had a long history of low back and sciatic complaints going back several years. I had treated him four years ago and had him working for over a year. One day the employer changed his job, requiring the claimant to sit in a cramped position for long periods. I wrote a note asking for a 30-minute sitting restriction. The employer refused to honor it. The claimant, for reasons unknown to me, discontinued his chiropractic care. A transcript of a court hearing in the case simply said further chiropractic was not authorized, nothing further. This led to a three-year disability and lumbar disc surgery. What did that cost? Why?

The record is clear. Claims management can stand improvement; this case is only one expensive example.

Changes certainly are warranted. To be effective, everyone involved in the system must participate in creating workable changes for the good of the claimants we serve. A realistic view would fault everyone across the board before undertaking needed reforms.

The problems faced by the workers' compensation system across America are real and growing. The enormous increase in the cost of workers' compensation cases from the mid-1980s have caused serious losses in every state, driving some carriers and state funds to the wall. This affects everyone and deserves serious attention from every player in the system.

The good news for the chiropractic profession is that because we see the smallest percentage of workers' compensation claimants, the current problems the system faces simply cannot be laid at our feet. The current, costly mess arises primarily from the other guys. Maybe cases treated medically should be sent to a chiropractic consultant.

There is no doubt that the current workers' compensation crisis is a golden opportunity for the chiropractic profession. It offers us the opportunity to prove our worth in a most dramatic manner; and for the first time in history we are the first with the most. We have a trained profession with the excess capacity available, our work is safe, cost effective, and supported by excellent literature -- Mercy Center Guidelines and numerous retrospective studies. Clearly, we are ahead. Nobody can match us at this stage of the game. Now we've got to put it to work. We can't just let it lie there.

Imagine for a moment where we would be if the Wilk decision had gone against us. There is little doubt but what the AMA and its cohorts would have used every means at their disposal to publicize the decision. They would have used it to influence "discussion groups" everywhere they could in an attempt to cut us out of everything from Medicare on down. They would have gotten tremendous mileage out of that decision. Well, we won. What kind of mileage are we getting out of the Wilk decision? Not nearly enough. The reason is simple: Too few chiropractors support the state and national associations capable of performing this task.

Given the genuine benefit reasonable chiropractic offers workers' compensation claimants, we are in on the ground floor. Understand that 75 percent of workers' compensation money is spent on 25 percent of the cases: backs. Nobody has anything better for the majority of these problems than the chiropractic profession. We have a documented answer, not a perceived answer, to the money problems the workers' compensation system complains about.

And we can do it at a fraction of the cost, even with all those overutilizing chiropractors carriers would have us believe are responsible for the current fiscal crisis. However, just demonstrating our worth does not, by itself, open the floodgates. It only gives us the tools needed to establish a place for ourselves within the system. That place is currently occupied by somebody else that does not wish to give it up.

We need to do two things, both simple. First, document our work beyond question. Second, get the message of our effectiveness out with great force. The first we can do personally in our conduct of cases. The second demands the activity of efficient, well-integrated professional organizations. Either one alone will be only modestly effective. Done together a synergy develops that gives our efforts greater leverage. Given the tenacity and bankroll of the opposition, such synergy is not only desirable but essential. Some 45,000 DCs in the U.S. are reading this. Imagine the impact of a single initiative with that kind of support?

Do we really have the will to capitalize on the golden opportunity laying at our feet? Will we unify our efforts and lay claim to this ready-made showcase for our skills? If we do, we will be well ahead. If we sit on our hands, and some 25,000 of us are doing just that by not supporting our state and national organizations, nothing will happen. We will remain "peripheral" players, viewed as a "problem" to be addressed, rather than an important contributor in the workers' compensation program. The choice has never been more clear.

ACA has established a task force on managed care. Hard, respected data supporting our validity is available. Just having it is of little value. It must be disseminated, and that takes a strong national organization that can afford the staff to do the job.

The Foundation for Chiropractic Research has spent every cent possible paying for studies supporting our effectiveness. Our state organizations have much to do to lead the charge on the state level. They all need just one more thing, our individual membership and support, and our personal involvement. Let's remember that we don't join organizations because they do all the things we like. We join them to help define what they do and make certain that they stay at it.

Shakespeare wrote: "There is a tide in the affairs of men which, taken at the flood, leads to victory."

Nowhere in our history has the chiropractic profession been better poised to show our worth than with the current workers' compensation crisis. We have the resources. Do we have the will?

Shakespeare offered us more advice for us when he wrote: Our doubts are traitors, that make us lose the good we oft' might win, by fearing to attempt."

Failure to participate is expensive. We can't afford to waste another day. The opportunity is presented now, not next year, not when so and so does such and such. This is hardball. You can count on the opposition. They haven't given up in almost a hundred years. They're steady.

Join your state and national association. This isn't a commercial my friend, it's practical advice. These organizations offer the only vehicle that can generate the influence needed to affect their respective legislatures and compensation systems. In these times, recognizing the challenge that lies ahead, we withhold our support of these organizations at great personal peril. Of course it follows that once you pay your dues you should participate to make sure we go in the right direction. It's not really difficult. It just takes some commitment. The rewards can be enormous. This is our golden opportunity.

There are always distractions, reasons to change course, new arguments that cause confusion. That's part of the process. Stay the course. We can stay focused. We can prevail.

John H. Gantner, DC
Medina, New York