R. Michael Cessna, DC, DABCI
Certainly any informed doctor of chiropractic is aware of the serious threat that is facing the chiropractic profession today. Without question, some of the major problems include the following:
- Most of the services provided by our profession are being greatly limited by most insurance plans and completely eliminated by some; ERISA programs are being instituted in nearly all states which result in the total exclusion of chiropractic services; and there is an ever-progressing number of HMO and PPO plans that are failing to provide chiropractic benefits.
- The health insurance industry is compiling each day from thousands of chiropractic insurance submissions through ICD-9 codes that the chiropractic doctor in the United States only treats disorders of the neuromusculoskeletal system, does not routinely order diagnostic modalities and laboratory tests, or manage people with life-threatening internal disorders. Further, this data shows that the typical chiropractic doctor does not routinely use diagnostic methods and modalities for differential diagnosis and to identify serious disease.
- By estimate, the chiropractic profession treats less than eight percent of the nearly 250 million people in the United States. A sad track record for a profession that has been in existence for nearly 100 years, and is the second leading health care provider in the United States.
- From a member survey conducted by the ACA and reported in the February 1988 ACA journal, it was revealed that less than 12 percent of the practicing chiropractors in the United States are treating health problems other than neuromusculoskeletal.
- Private insurance and governmental health agencies believe that chiropractic services are either non-essential or are merely services that are a duplication of existing allopathic health care.
- The majority of undergraduate and postgraduate level chiropractic education is emphasizing the diagnosis, management, and treatment of back and neck disorders, and not the care of the whole person, resulting in field doctors who limit their services to neuromusculoskeletal conditions.
- With the advent of insurance equality in most states, chiropractic has now fallen under the rules and regulations of state and governmental agencies, and is being judged and compared on the same grounds with other health disciplines.
- National health insurance, in some form, will be a reality within the next five years.
Admittedly, many of the above issues may not seem very important to you if you are conducting a practice that is essentially "fee for service" (cash practice). If, on the other hand, you expect an outsider not directly involved in the services you provide (third party payer), to pay your patients' bill, then there are several details, rules, and regulations you must adhere to.
Certainly, if you do care about the growth of your profession and its exposure to the public (new patients); saving lives; improving the quality of the lives of the people you serve; and establishing a secure foundation for your profession within the insurance and managed care arena, then, unequivocally, the eight problems above are acutely critical to you.
Indubitably, for some of us our individual occupational survival will not be threatened, but our professional freedoms as we know them today may drastically change; we will become an impotent player in the health care industry if this professional dilemma is not solved. Granted the causes are complex, but they can be eliminated and the problems can be solved -- hopefully within this decade.
We seem to be a profession without identity. Look at the Yellow Page advertisements offered by chiropractors. Many of these are not only a "joke," but are disgusting. Often the message appears to demonstrate to the observer that chiropractic or the chiropractor is a "financial counselor" and says nothing about the services they provide. If these ads are demonstrating what chiropractors think chiropractic is, then surely this is the communication the public will believe chiropractic is.
We must keep in mind that as long as the majority of the profession holds to the treatment of functional, self-limiting sprains and strains focused solely on caring for non-life threatening conditions, our discipline will be observed by both private and governmental health agencies, and the scientific community as merely a non-essential "step child to medicine." Can you imagine the difficulty in attempting to convince the officers of a health maintenance organization, or the people directing the Department of Health and Human Services in Washington, D.C., that our profession is capable of primary care, that we are responsible physicians, and that we can diagnose serious disease when, in fact, the evidence does not support the claim. The evidence being, those several thousand chiropractic claim forms submitted weekly that show less than 10 percent of the total services billed are diagnostic, with less than two percent exhibiting blood tests of any type. Admittedly, because the chiropractic adjustment is the fundamental mode of service, it inherently becomes a treatment-oriented discipline. For this reason, often 90 percent of the total revenues earned by the chiropractor is for therapeutic service alone.
Of course, there are several components that are necessary for survival in the "third-party" system. Some include: improved diagnostic skills; better communication with the insurance carriers; sensitive and caring attitudes; empathy; disease prevention focus (especially with cardiovascular disease); generation of a lifetime patient base; patient education; better industrial relations; demonstration of accountability to patients; to the public; and to the insurance and governmental agencies. Many of the solutions to difficult and tough third-party issues reside in clinical skills, diagnosis, clinical documentation, and professional accountability.
Why does our profession see such a small population of people? I believe the answer is that the general public, in most instances, does not equate our services with full-body diagnosis, and for that reason they are very selective and hesitant to seek early chiropractic care. The potential patient is fearful that we may overlook a serious health problem since our emphasis appears to be solely on the back and not the whole body. Many people who have received chiropractic care and benefited, often again return to medical therapy when another similar problem returns, rather than returning to the chiropractic physician that helped them in the past.
Not infrequently, practice management consultants state that the "life blood" of a chiropractic practice is new patients. I would agree if it is the doctor's first year in practice, however, this should not be true in a practice that has been established over four or five years.
Many businesses and large corporations like IBM and AT&T claim that the established client or customer is three to five times as valuable as a new customer. The reason many doctors must constantly "hustle" new patients is that they simply can't keep the patients they already have. Its tragic indeed, but most DCs fail to keep a solid active patient base. If you don't believe this is true go back three years to your patient record list. Count the number of individual patients you treated at least one visit during a one-year period, three years ago. Now, review your patient treatment list over the past six months. See how many of these people that you treated three years ago you have seen at least one time during the past six months.
If you are not maintaining a minimum patient return of at least 50 percent, then you definitely are not building a practice. The ideal return is over 70 percent. Hopefully, you are one of the minority that is retaining over 50 percent of new patient production. Some doctors that have been in business 15 years have never learned to build a functional viable patient base and are merely repeating their first year in practice 15 times, i.e., they are depending essentially on new patients year after year for their livelihood.
Though our percentage is small, many in our profession believe that chiropractic will never be competent to significantly compete as a primary care health profession until we can diagnose to the degree that we can determine the potential state and seriousness of the patient's overall health problem. Continuing to merely limit chiropractic diagnosis to differentiating musculoskeletal symptoms may be very detrimental to our profession's future. So damaging, in fact, that it may result in the requirement that a person with an insurance plan must first be examined by a medical doctor (the gatekeeper) before they are allowed to seek the services of a chiropractor. This could happen!
R. Michael Cessna, D.C., D.A.B.C.I.
Tuscon, Arizona
