When you first think about this question, you will probably think of a number of answers. Unfortunately, you are probably wrong on all accounts. No, it is not ERISA, the AMA, Congress, Medicare, HCFA or any of the other forces which seem to be constantly impacting chiropractic.
Rather than simply tell you the answer, perhaps an example would be more explicit:
Not too long ago, our local paper carried a story about a fabulous new restaurant that had just opened. This was to be the only "real" New York delicatessen in the Southern California area. As a lover of Jewish deli food, I was quick to have dinner there.
The menu was incredible: fresh baked bagels (of every kind), hand carved lox, lotkas "like mama used to make" and more. Even the french fries were something special. This soon became my favorite place for Sunday brunches and those rare times of lunch out of the office. Eventually everyone I knew had at least heard about this great new restaurant and many were now eating there.
Telling everyone I knew was almost a regrettable action. There was soon as much as a 45 minutes wait for Sunday brunch. But the owners had worked very hard and deserved the success.
Then one Sunday, we went in for brunch. There was no line, so we were seated immediately. When our food came, we were shocked! The food was barely edible. When the check came, we were shocked again. Not only had the prices increased, but we were charged extra for every little additional item that made our meal the wonderful occasion it had been in the past.
Then suddenly it dawned on me ... why was the place half empty during one of their busiest times? The answer was in my stomach, on my plate and soon to come out of my wallet.
This analogy refers to a situation that has recently been brought more and more into the spotlight of the chiropractic profession: LACK OF QUALITY CONTROL!
Some recent examples of this problem have come to my attention:
First, is a situation where a DC billed an insurance company for 735 surface EMG diagnostic tests on 358 patients over a relatively short period of time. The particular insurance company did not wish to arbitrarily deny claims, but wondered if there wasn't some kind of peer review that might help establish what was reasonable.
Most recently, in order to better appreciate their dilemma, I was given the opportunity to examine some of the kinds of claims that many insurance companies are questioning. Among them were claims from injuries involving a "slip and fall" without any complications (according to the treating chiropractor). The patient was charged over $1900 for the first visit and $356 for every visit thereafter (usually 7 visits per week) for manipulation only. After only 7 months the bill surpassed $47,000 with a prognosis of another 18 months of treatment. (What's wrong with this picture?)
There are two components to quality control: quality and cost.
Strictly from the patient's standpoint, the quality of chiropractic care has probably increased. But the patient in many (if not most) cases is no longer the one paying the bill. From the standpoint of the insurance company, chiropractic care is costing more, much more.
Billing for multiple areas, "packaging" and extended treatment periods are running costs up much higher than in recent past. The advent of new diagnostic equipment has increased costs, not decreased them. (Perhaps the insurance companies will one day produce a study showing that "hands-on only" chiropractic practices are _in general_ more cost effective than those that utilize diagnostic and therapeutic equipment.) Unfortunately, the old ideals of get the patients "well" better and faster, that were the product of a time before insurance reimbursement when the patient paid the bill, seem less prominent today.
Ask any insurance company the question "Is chiropractic care more cost efficient?" and you will get another question: "Which chiropractor?" But the profession will not be judged by one or two. It will be judged by what is "perceived" to be true about all.
While this perception may not be totally factual, it will still have a very significant effect on out future.
Currently, the chiropractic profession operates without the benefits of peer review in most states. This is a very dangerous situation. This basically leaves the defense and determination of what is and is not reasonable to attorneys, judges and juries. While the personal injury attorneys have so far been able to get most claims paid, this still takes self-determination out of the hands of the profession.
As the economic pressures continue to mount, the insurance industry will continue their attempt to counteract spiraling costs, overutilization and insurance fraud. As was demonstrated in Oregon, the insurance industry will use whatever means are most expedient to solve these problems.
Some how, some way, the chiropractic profession must institute some kind of peer review. Without it, we are merely waiting for disaster to strike us. We will continue to be thought of by the worst that the public encounters.
In the next few issues, Dynamic Chiropractic will attempt to demonstrate just what the liabilities and casualties have been because of a lack of peer review. Hopefully, this will help you not only see the value, but also realize the immediate need.
By the way, I never returned to that restaurant. I think it went out of business.
DMP Jr., BS, HCD(hc)
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