In recent years, some state workers' compensation laws have placed "limits" on chiropractic care, allowing a set number of visits before review. This was done in an effort to curb "abuses" and ultimately lower the high cost of workers compensation premiums. How has it worked? Well, premiums keep going up. Was it an effective initiative? Same answer.
It is estimated that chiropractors treat some five percent of the population. In some states I have heard that chiropractors treat approximately 30 percent of the workers' compensation claimants. Still a minority. Given that we care for a minority of claimants in the current system, nobody in their right mind can lay the blame for the current fiscal crisis in workers' compensation at our feet. Regardless, there are those who are attempting to do just that. Why? Because we are a threat to their control. Also, because we have failed to convey the merits of reasonable chiropractic. The data is there, but it's just not getting through to those that count.
It was probably impossible from the beginning. There has never been an honest to goodness study to see which therapies were most effective and least expensive. Various studies compare chiropractors to general practitioners in treating workers' compensation patients. The studies come out lopsided because the MD sees the claimant one-half dozen times, while the chiropractor sees him 25-30 times. The simplistic conclusion is that chiropractic is more expensive.
The MD might have referred the claimant for x-rays and a prescription on one visit. His single office call is all that goes into the statistics. The cost of the x-rays or prescriptions are not counted. On another visit the MD might prescribe 15 physiotherapy treatments. Again, all that is entered in the "MD care" column is one office visit. The cost of the physiotherapy is not counted. The same thing occurs when the MD orders a CT scan, blood work, bone scan, MRI, internist evaluation, neurologist consult, or even surgery. Just one visit. I'm sure you get the message.
An honest study should compare the effectiveness and overall cost of work done by different disciplines when treating a workers' compensation claimant. This was never done in Oregon before they imposed a 12-visit limit on chiropractic. It has never been done in any state to my knowledge. Accordingly, merely limiting the number of visits to chiropractors (who treat a minority of claimants nationally) offers little hope to a seriously ill workers' compensation system.
The chiropractic profession is ready to help workers' compensation carriers solve their current financial problem. We can do it even if ten percent of our members are as crooked as the Snake river. There is so much waste and abuse in the current system that this is no idle promise. Are the carriers ready to hear our message? Are we sending such a message?
The chiropractic profession has a golden opportunity to make a meaningful contribution in solving the current workers' compensation problems. The place to start is in getting attuned to workers' compensation cases. Learn your state system and become familiar with its rules. Observe what you can of how it works at your local level. Develop strategies to improve what you see.
What kind of care are injured workers in your state getting today? Where is it deficient? Where are the greatest costs? What are they doing about disability? Can we document cases where chiropractic has produced a significant decrease in work loss? How many CT's and MRI's are done for purely administrative reasons? Given the clinical findings, how necessary are such tests? Can you document abuses in the way some of your current cases have been treated (medically) in the past? Poor care? Gross misdiagnosis? Such data is lying in our files, simply crying to be assembled. Impossible? No, it's not difficult at all. In fact, it's essential.
What about double standards? We hear about such things but see no documentation. Assembling these facts isn't hard; it takes a little time, discipline, and coordinated effort. Complaining accomplishes nothing. Pointed energy can move this mountain. Are we willing? Documenting discrimination, a different standard for chiropractic cases than those treated medically is a perfect assignment for any state chiropractic association committee. Call it a "Task Force"; pick good men; support them with political will, respect, and a small budget; and leave them alone for a few years. If they pay attention and get the word out, these people can gradually develop a mountain of evidence that can be used as the vehicle to approach and eventually move the state legislature.
For instance, the use of MD consultants in chiropractic cases is still all too common. It is usually a worthless exercise, something like asking a Kuwaiti to approve the presence of an Iraqi in this town. For the most part, it is both an expensive and an evil practice that does nothing to assure the patient's right to reasonable chiropractic. It most often creates controversy with all its attendant legal maneuverings -- a lawyer's dream, a claimant's nightmare. What does this single practice cost in your state? Would it help if we could document such waste? It would become just one more piece of hard, irrefutable evidence to support our position. Imagine how just this simple piece of information could be used.
The publication of practice guidelines and the recent endorsement of chiropractic methods by the respected RAND corporation, offers our national and state associations powerful tools to argue for more realistic chiropractic treatment allowances. Gathering hard data on discriminatory practices that hurt claimants, as well as their chiropractors, is a priority.
Everywhere one sees evidence of the superiority of chiropractic in successfully treating work-injured individuals. Why isn't this more readily understood? Because we haven't made it clear enough. Medically sponsored studies of the effectiveness of "manipulation" usually end with the conclusion that manipulation is "slightly better," or "as good as" regular medical care for this or that condition. I can say with confidence that each of us, (including the overutilizers and the most inept chiropractic clinicians) see irrefutable benefit from our work in a majority of our workers' compensation patients, often after years of absolutely no help with medical care. How come those cases don't find their way into the literature? Simple. They won't get there until we put them there.
George McAndrews asked the right question: "How come chiropractic must go outside the country to get an honest study done?"
In spite of our effectiveness, it is apparent that the profession itself has been less than effective in establishing its presence in most state workers' compensation programs. We just do what we can and throw up our hands. That's what everybody else does. Well, for chiropractors, that's a mistake.
The mess we see in workers' compensation is our golden opportunity. We have a real contribution to make. We must get busy.
Every practicing chiropractor has a number of excellent drugless, nonsurgical, inexpensive, and effective technics that can be offered a work-injured claimant. Properly used, especially in the area of spinal and extremity problems, these can offer cost effective answers to many of the most expensive injuries (back and musculoskeletal) caused by work injuries.
The proven benefits of timely chiropractic are our key to greater acceptance. We are guilty as a profession of too easily allowing our attention to be drawn to the abuses of a few of our colleagues. Stories of chiropractors' abuses are common among carriers' personnel. At the same time, each of us sees but says little about the great volume of good work being turned out by conscientious chiropractors everywhere.
While it is common to hear complaints about the high cost of workers' compensation these days, very little beyond rate suppression (by political bodies) or benefit reductions (by carriers) is offered to relieve the problems.
Workers' compensation systems across the country have failed to effectively address the high cost of medical care. In some measure, this is due to the fact that most state systems see medical care as essential. If they took a broader view, seeking more effective health care, their search might be more fruitful. It requires a conscious change of focus. While it sounds simple, it is not.
One of the greatest obstacles is the inertia of the current state workers' compensation systems. Insurance carriers have worked together with medical professionals since day one. They have a comfortable relationship. They understand each other. The relationship has its problems, but they are well-understood and tolerated. Both are reluctant to change anything. Is there really any difference between what we see with the current insurance/medical complex and what we are reading today about GM or IBM? They resist change, using their sheer size and market dominance to keep us buying their product. Did GM just discover within the past year that Japanese cars were better? Did IBM just discover this past year (when its stock started to fall) the true quality and quantity of the products put out by its competitors? Certainly not. They both knew exactly how good their competitor's products were for a long time. They just ignored them. Sound familiar?
Professions looking for greater participation in workers' compensation must work mightily to get "in," no matter how effective their contribution. Given our chiropractic experience, it's clear that you've got to be more than good.
This takes enormous effort, nothing new to the chiropractic profession. We need strong initiatives on both the national and state levels. Each of us must become involved; nothing less will work.
The effort is blunted when one observes that less than half the DCs in the U.S. support either their state or national associations. Doctor, it is abundantly clear that none of us can do it alone. Our state and national organizations are overburdened and underfinanced due to a lack of membership. We cannot go on like this. We're losing ground. The "Bentsen" amendment on the recent tax bill almost killed every insurance equality statute in the U.S. Had this bill been passed, every state and national organization would have had to hire literally hundreds of Kelly girls to help process all the membership applications. Of course, it would be too late then.
That would be a classic case of closing the barn after the horse walked away. Getting back what you have lost is much harder than getting it in the first place. When you try to get it back, you have a "record" of how it was when you had "it" that can work against you. While we must all try to do the best possible work, it is clear that we must also document our contribution alongside that of others. We need hard data. It's everywhere. Let's collect it.
Take a moment to ponder where we are today. Where are we going? If you didn't know, action is imperative. Start reading everything you can find. Read the state and national journals. See who is working and what they are doing; learn the issues and understand the initiatives. If you do not see reasonable initiatives in dealing with the workers' compensation problem, sponsor them. Get involved. Participate. Don't wait for "George" to do it. Each one of us is "George." Find out where we are going and join in the effort to make certain we get there.
We will never have this golden opportunity again. It is also certain that we cannot take full advantage of it without a strong commitment from many thousands of us.
Whose future is it anyway?
John H. Gantner, DC
Medina, New York
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