Local Utilization

Since the Wilk decision and the forced statements of accommodation from the American Medical Association, the American College of Radiology, et al., the chiropractic profession has witnessed a few rather dramatic changes regarding interprofessional cooperation. Some of these events, such as the utilization of various medical authorities to speak before chiropractic conventions, to instruct developing chiropractic students, and to assist in the investigation and development of various research projects have demonstrated the long-awaited benefits for the patient which mutual cooperation can achieve. Certain of these activities over the last few years might easily be considered as having been altruistic and therefore laudable.

On the other hand, some of the interprofessional cooperation which has developed has not been founded on altruism, but more specifically a guise for pecuniary success. As an example, witness the number of hospitals throughout the country which have recently opened their doors to the chiropractic profession. Unfortunately, experience indicates that, for the most part, these doors have opened for us only when dire financial straits are recognized by the institution's financial administrator. Recognizing that new patients equate to new dollars and, therefore, represent a new source of revenue to help balance the books, these administrators have sought to take advantage of the new interprofessional policy to broaden the number of doctors who might refer patients to their institution. While considered a dramatic breakthrough and achievement for the chiropractic profession initially, it was soon recognized that the new open-door policy was created in response to any legal mandate or altruistic concern for the patient, but rather solely on the need for pecuniary enhancement.

In many parts of the country today, various computerized tomography and magnetic resonance imaging laboratories have begun to open their doors to patients referred by the doctor of chiropractic. The CT and MRI capabilities are sophisticated and provide the DC with considerable information not typically demonstrated on the plain-film radiograph. This arrangement, i.e., the chiropractic referral of patients to an imaging laboratory, greatly enhances the diagnostic capabilities of the doctor of chiropractic and hopefully will add significant information related to the therapeutic regime designed for each patient. When used appropriately, this availability of newer diagnostic imaging procedures represents a significant contribution to patient care and interprofessional relations.

This scenario of interprofessional cooperation between the chiropractic physician and the diagnostic imaging laboratories is regarded as a giant step in the care and management of the chiropractic patient. There are however, pitfalls of which every practicing chiropractor should be made aware. First, these diagnostic imaging laboratories encourage the participation of utilization by chiropractic physicians, not because of altruistic concern for the patient, but for the income enhancement created by new business. This, in itself, is not necessarily bad. Any business needs customers/patients in order to remain profitable and to continue serving other customers/patients. The economic investment in these diagnostic imaging laboratories is considerable, and the investors are permitted a fair return on their investment. This profit production requires that utilization of the equipment is necessary and ongoing. To ensure this, various activities which encourage demands are undertaken. For the diagnostic imaging laboratories, the acceptance of chiropractic referrals, as in the scenario relating to the hospitals above, represents a whole new area of potential business. To encourage this sector of new business, the new policies of interprofessional relations between medicine and chiropractic are found not only convenient but good business.

The second, and perhaps the most important consideration for the chiropractic physician, is also related to utilization, but from the referral aspect. While many members of the profession have long awaited the commencement of interprofessional relationships, particularly relating to services which will benefit the patient, the mere availability of these services does not negate the need for careful utilization. The radiation cost to the patient as well as the economic cost to both patient and third-party payer, must be carefully weighed before ordering these more sophisticated procedures, against the anticipated information gained. Just as routine laboratory procedures, e.g., CBC and urinalysis, have long been considered routine procedures because of their availability and ease of accomplishment, even these have come into question regarding their utilization when insufficient clinical documentation of need is lacking. Regardless, if the vendor is a clinical laboratory, hospital, or diagnostic imaging laboratory, these are still businesses which relate to economics. The chiropractic physician, therefore, must be constantly aware that the advent of new interprofessional relations are founded primarily on economic issues, and not on any newly acquired acceptance of the chiropractic premise. To be sure, the chiropractic profession now has an opportunity to demonstrate its professionalism and to establish interprofessional rapport, long denied. This is certainly to be encouraged. It will not be accomplished overnight, and must not be accomplished by sacrificing the patient's welfare or the professional integrity of the chiropractic physician.

In summary, we must continually be reminded that the development of interprofessional cooperation between medicine and chiropractic which has developed over the past few years, has not resulted from some altruistic change of heart or intellectual revelation relating to the chiropractic premise, but primarily in response to economic and pecuniary realities. The chiropractic physician may well exploit these developments to foster and encourage interprofessional understanding and sharing of concerns relating to patient management common to all providers. In time, benefits are likely to accrue for all concerned. In the meantime, the mere availability of any procedure is not sufficient scientific reason or logic to encourage its utilization. Any procedure, particularly relating to the diagnostic imaging modalities, must be utilized only after clinical documentation of need which indicates an expectation of information not discovered by other means, and which will have direct impact on the therapeutic regime selected in the care of the patient.