Perspective and Commentary

The View from Oregon

This column is about the chiropractic profession's role in the current and future health care system. It is about how chiropractors must learn to "do the right thing" -- to borrow a phrase from Spike Lee -- if we are to survive in the managed care environment of the '90s and prosper in the 21st century.

Our profession holds the passport to the future in one hand, and in the other we carry the baggage of our past. We have done enough credible research to demonstrate the efficacy of chiropractic treatment for a limited number of spine-related conditions. On a recent airline flight I saw an ABC documentary about chiropractic in which Paul Shekelle, MD, an internist at UCLA and a principle researcher in the RAND study, stated there was more evidence demonstrating the effectiveness of chiropractic treatment for back pain than for most of the procedures performed by neurosurgeons.

In the area of standards of care, we have recently published a document which creates guidelines for chiropractic evaluation and treatment on a national scale. This effort puts our profession in the forefront of all the medical specialties in this respect.

Furthermore, we have recently completed a legal war against the medical establishment which spanned nearly my entire career in chiropractic, starting in 1976 when I first entered chiropractic college. The result of all these efforts is a greater, albeit reluctant, acceptance of chiropractors as part of the health care team and chiropractic treatment as a viable option for musculoskeletal back complaints.

The baggage which I spoke of earlier may yet prevent chiropractic from becoming an equal participant in the health care system of the 21st century. This consists of 19th-century ideas of subluxations and nerve interference combined with 20th-century, practice-building techniques, which place productivity ahead of patient care. I may be treading on some sacred cows here, so let me state that I do not advocate relinquishing our philosophical heritage. We need to continue supporting research of the vertebral subluxation and other chiropractic tenets while at the same time not allowing dogma to cloud our perception of our present and future role in health care.

So, who am I to be offering such grand pontifications? I would like to share my professional experience with "DC"'s readers and tell you what has happened to chiropractic in Oregon. I believe the Oregon experience foreshadows what is to come in the rest of the country.

I started my chiropractic practice in Portland in 1981. Five years later I began to do second-opinion examinations at the request of third parties. When these are done at the request of insurers and defense attorneys they are referred to as IMEs or sometimes ICEs. Chiropractors who do these evaluations often are called "hired guns" or other more derogatory terms by our colleagues. My purpose here is not to debate this issue except to say that I have always offered fair and honest opinions based upon objective evidence. I believe it has been important for our profession that insurers obtain reliable independent opinions from chiropractors rather than have to depend solely upon medical judgments. Those of us who did these evaluations established a reputation of credibility among employers and insurance companies. This record of responsibility proved to be invaluable when Oregon's workers' compensation system underwent a dramatic change.

In 1989 several chiropractors, including myself, founded a nonprofit managed care network or PPO. Before we were able to enlist the first provider, we were asked to become a part of Vantage Onsite, a newly formed managed care organization (MCO) for injured workers, run by Sisters of Providence Health Plans. The following year, the Oregon state legislature voted to limit chiropractic treatment of injured workers to 12 visits or 30 days, whichever came first. Additional chiropractic care would have to be prescribed by an MD or DO. The legislature also voted to allow workers' compensation insurers and self-insured employers to contract with MCOs. This meant that someone injured at work would be required to go to a doctor on a list provided by the employer. The intent was to improve the quality of care while controlling costs. Fortunately, MCOs are required to include chiropractors, and chiropractors may see injured workers without a referral from a primary care physician (PCP). Chiropractic treatment may be no less than the minimum 12 visits/30 days, but the MCO may arrange to provide more than that amount of care with the chiropractor remaining as attending physician.

The new workers' compensation mandate provided a window of opportunity for chiropractic in Oregon. And our PPO was in the right place at the right time. Through Vantage Onsite, coverage expanded to include over 170,000 employees, primarily in Portland, Salem, and Eugene. Contracts with other workers' compensation MCOs followed. Our business also expanded to include health benefit plans. In 1991, Kaiser Permanente, not wishing to lose out on its share of the workers' compensation market, decided to become certified as an MCO. This necessitated a contract with a chiropractic provider group. They chose our network. That choice was determined largely by the influence of some large self-insured employers who offered Kaiser plans to their employees. Most recently, Blue Cross/Blue Shield of Oregon has chosen to offer a managed chiropractic plan using our PPO as its exclusive providers.

There are other chiropractic networks operating in Oregon. "Managed competition" is not an entirely new concept here. We have placed a strong emphasis on utilization review procedures and quality insurance, areas which are very important to our clients and to the delivery of cost-effective and responsible chiropractic care. But we have also placed equal emphasis on credentialing, that is, the screening of chiropractic applicants.

In a speech to chiropractors, Oregon Governor Barbara Roberts exhorted the profession to work to regain privileges lost in workers' compensation reform by earning a record of responsibility. This is precisely what we have attempted to accomplish.

Credibility and a record of responsibility is very important to chiropractic. Research and standards of care go a long way to establish the validity of the profession. But it is not enough for the leadership of chiropractic to advocate sound guidelines of practice when individual practitioners continue to place practice building ahead of patient care and resist utilization review and quality assurance programs. What is sorely needed at this critical juncture is for individual practices to embody nationwide standards. We must each "do the right thing" in order that our practices and our profession enter into the mainstream of health care.

The words of Sociologist Walter Wardwell, who has followed developments in chiropractic very closely for 30 years, are quite appropriate at this time. He said that a problem for contemporary chiropractic in the United States is that some chiropractors "... have made the best of a bad situation for so long and have organized their careers, lives, and psyches around (the ideology of an oppressed minority) so well that many of them find acceptance more difficult to endure than marginality." Managed care and "managed competition" will offer chiropractic new opportunities. I have to share with you how to do the right thing so we all may benefit.

J. Michael Burke, DC
Portland, Oregon