The Future of Chiropractic Within Workers' Compensation

A number of years ago, as a member of the Louisiana State Comprehensive Health Planning council, I became involved in what was then called comprehensive health planning. We were supposed to be developing a national health policy, which was going to dictate what national health insurance would include in order to meet the health care needs of the people in each area of the country.

In recent years, I was elected to the Louisiana state legislature and am now serving in my third year in the House of Representatives as well as on the Health and Welfare and Civil Law Committees. This allowed me to be involved in a major rewrite of our workers' compensation laws. Having the opportunity to sit in the governor's office, allowed me to be a part of a group of people who were drafting major, broad-sweeping reforms in our whole workers' compensation system. It was at that time that the importance of trying to protect the chiropractic profession from those factions that hoped to remove us from the system became evident to me.

What we were able to do in the governor's office was to debate the issues of utilization review and IMEs to determine the appropriateness and necessity for chiropractic care, and the need for these to be done by health care providers of the same field or what the governor felt was widespread abuse and overtilization of specialty as the treating provider. After much discussion with the governor and his staff (especially the director of workers' compensation who had been charged nearly $800 by a DC for an initial visit to treat an acute torticollis) regarding their belief that there is widespread abuse and over utilization in the workers' compensation system, the governor was finally convinced that we (chiropractors), as a profession, do not condone either of those kinds of behavior.

The governor was also made aware of the fact that chiropractic needed to establish standards and begin to determine the need for care based on the level of services required by the patient's condition: and should not be based on what the provider needed in his pocket, nor what the insurance company needed by cutting the bill. But rather, coming to a point where the chiropractor's responsibility was to see that the need was met with the appropriate level of care. As we left the goveror's office, he advised his staff, "I want Dr. Herring to be happy with regard to utilization review."

Later, Steve Cavanaugh, the state workers' compensation director who had initially been the greatest opposition on the governor's staff, invited me to be on his Workers' Compensation Advisory Council. At the request of Mr. Cavanaugh, the Chiropractic Association of Louisiana is developing standards of care in Louisiana for the workers' compensation office and we're standardizing the examination procedures that are to be used in that process. Thus, when IMEs are done, and consultants review the claims, they are going to be comparing apples to apples. They are going to be looking at the exact reproduction of the same test done by the IME practitioner, that was done by the treating physician, and thus, we are going to have the same kind of test results. It's not going to be a maximum test procedure; it's going to be a minimum test procedure.

Through that involvement, I was asked to take part in a forum in New Orleans, for the southern division of the International Association of Industrial Accidents Boards and Commissions (IAIABC), which is made up of representatives from all the workers' compensation boards from every state). It is my opinion that the IAIABC is important due to the fact that one of the functions of this group is to share information about what is happening in each other's states (such as Oregon), with regard to their successes and failures in attempting to control health care cost in the workers' compensation arena, and to then try to formulate model pieces of legislation in order to take stands on certain issues.

Another one of their functions is to encourage states to take action that have apparently begun to prove successful in one or more states. The goal is to define those actions that have had the effect of driving down the cost of health care for the injured worker. For this reason, the actions of the members of the IAIABC are going to be very critical to chiropractic because they weave their web throughout the entire nation. They have a communication system and a common interest in holding down costs.

These are the people who are going to be the movers and the shakers of what happens to us and to other health care providers in the future, because they are under the pressure of the cost of workers' compensation by business and industry groups who are paying for the rising cost of health care. Fortunately, (for myself but more importantly for our profession) I was asked to join the IAIABC as a consultant member and am currently the only chiropractor who is a member of the IAIABC. I was appointed to their medical care committee, which is focusing its attention on methods cost containment.

Other IAIABC consultant members include the director of insurance and employee benefits for General Motors, the medical director for AETNA (who is an MD), the president of the National Association of Workers' Compensation Insurance Carriers, the American Bar Association, various private acturarial firms, several MDs who are in private practice, and there is even a physical therapist who actually works for one of the state departments of workers' compensation.

We had the opportunity to meet and discuss data collection procedures with several actuaries who sell computer programs to states. We discussed the method in which data will be collected, assimilated, and reported -- issues that are very critical to the chiropractic profession. Every study I've seen, thus far, comparing the cost of medical doctor charges, chiropractic charges, and physical therapy charges, has reported only those costs that are billed directly out of each provider's office, and not any costs that are ordered and billed from another source. For example, all diagnostic procedures done by independent labs or hospitals, plus all therapeutics done by the physical therapist, pharmacist, hospital, and rehabilitation agencies are not included. Also, there is no combining of the medical doctor costs when accessing physical therapy costs. They do not even include the hospital and surgical costs in their calculations. This is just not right.

While I was at the IAIABC conference, we presented a panel discussion of what we called the "Louisiana Experience," --- what we had done to change the law in Louisiana which included, utilization review, administrative judges and a fee schedule. I was asked to discuss, in front of that audience, my feelings about IMEs and reviews done by someone other than a doctor of chiropractic to determine the need for and level of chiropractic care.

I had to debate this ultimately, with the president of the Louisiana Medical Society (an MD) who was on this panel also. When asked the question why I felt it was so imperative that chiropractic utilization reviews be done solely within the chiropractic profession, my reply was that the MD was neither capable nor qualified to determine the need for chiropractic care. With this statement, he began to expound on his philosophy that it is the medical profession which is the overall profession and everything else is a subset; therefore, they should be able to sit in judgement on all of the health care disciples.

By asking him a series of questions about basic chiropractic terminology and treatment procedures, it was possible to prove to the audience that the MD had no knowledge of chiropractic. For example, when asked about a joint fixation, he had no idea what it was, how to determine the line of correction required, or how to find it in the clinical setting.

After asking him eight or ten questions of that type, I then said, "I rest my case --- you know nothing about my profession. You don't know when it should be administered, when it should be withheld, nor how it should be administered. Therefore, you are neither competent nor qualified to make those decisions, no more than I am competent or qualified to determine when surgery should or should not be done, and in particular, how it should be done." In the end, the MD agreed. Now the Louisiana Medical Society seems to have softened on this issue; but, don't be fooled by this story, they still believe that they know all there is to know about what we do as doctors of chiropractic.

Ultimately, I was asked to speak at the International Convention of the IAIABC last September, in Baltimore. The topic of my speech was, "Chiropractic Cost Containment---When is Enough, Enough?" The basic philosophy behind the speech was that a practitioner should not be paid for his services if he cannot justify the need for them. We also spoke about standards of care and about determining the need for chiropractic care based on the objective findings of the treating DC and not on some arbitrary standard that some claims reviewer pulled out of a hat.

What happened in Oregon is typical of what we will see happening in other states around the country, simply because all of the other workers' compensation boards and directors are very aware of what happened there (and why it happened). If they are not aware of the details, then when they meet in the future, they will discuss what went on, the statistics, the numbers, the justifications used, and all other reasons behind what happened. As this information and other information like the Utah and Minnesota studies are discussed, and this data begins to become a bigger and bigger mass of derogative information towards our profession, we are going to see these kinds of problems cropping up all over the country .

This is one state. Who is next? I'm not sure, but it will happen, I believe, because of the interplay of these people. That's all they do -- stand around and say things like, "Well, what did you do about this situation in your state? Well, did that work? How did that profession react to that? All of this discussion will help them to develop schemes of dealing with these issues.

Each state, of course, has its unique legislative process, and some states have boards or commissions and others don't. But the same thing can happen in your state. The high costs of health care in workers' compensation will continue to motivate business and industry groups to exert pressure and attempt to influence policy and law makers to do those things which they believe will lower the premium costs of workers' compensation in this country---because the increasing health care costs to employers are astronomical!

So what can the chiropractic profession do to offset the tremendous flow of anti-chiropractic information that seems to point us out as the most expensive, most extravagant, least effective group of practitioners? Well, there are probably multiple things that we need to do, but they all start from the point that we must begin to develop credible data on the chiropractic profession.

We need to begin to prove that chiropractic is cost effective but at the same time we also have to look at the abusers that we have in our profession. They are costing us our reputation across this country because of high fees and overutilization and the repetitive use of their services over long periods of time. Additionally, these abusers are using diagnostic services that are often not indicated by the patient's history or examination.

I believe that we are seeing these abusers giving the insurance industry the ammunition they need to draw attention to the chiropractic profession and make us an easy target. We are one of the weaker professions because we are smaller and because there always seems to be somebody who is an MD on the inside, advising and criticizing us. Our abusers have given them the bills to use as examples. We are getting the rocks thrown at the entire profession and the insurance and business industries are not singling out the individual abusers. We have become a target, in part, because the actions of a few members of our profession have given them a lot of reasons to throw rocks.

We must now begin to clean up our profession and police our own ranks, or someone else will do it for us. Our advertising schemes of attracting new patients into our offices on a monetary basis are harming our public reputation. We are giving the public an impression that we are more interested in the dollar than we are in the patient care we provide. We must now begin to address advertising and overutiliation if we wish to project a better image.

Finally, we must begin to collect credible data that will demonstrate the cost-effectiveness of chiropractic care. We must then make an all-out effort to disseminate that information across this country to the legislative libraries of each state, the American Legislative Exchange Council, and the IAIABC. This information can be cataloged and any time a legislator or administrator needs information on workers' compensation, Medicare, Medicaid, or health insurance, the information is there and it's available for their scrutiny to, hopefully, put things in a more positive light for the profession. In the right hands at the right time, information is powerful when legislators legislate and administrators make policy decisions and pass out administrative rules.

Because of the attitude changes in Louisiana's workers' compensation director, as opposed to that first day in the governor's office, I'm convinced that we can overcome all of these negatives. Mr. Cavanaugh now says, "Chiropractic bills comprise less than four percent of the total payouts in workers' compensation medical costs; therefore, I believe that they (chiropractors) are being singled out, to draw attention away from other areas of medical care, which is where the real cost problems exist." His opinion changed only after long hours of discussion to overcome his personal negative attitude (born out of his own bad experience) due to facts that he was able to obtain about chiropractic billings, and an individual DC who said that the profession does not condone overutilization of any kind.

The ACA, the Congress of Chiropractic State Associations (CCSA), the International Chiropractors Association (ICA), the state associations, and every individual chiropractor and student must begin immediately to amass information on chiropractic, so that state legislators and others who have need for information relative to the cost effectiveness of chiropractic can have this information at their disposal when they need it. If we don't have that information, then policymakers, legislators, and those who are going to impact us with their rules, procedures, and their laws, are going to base their decisions on the biased opinion of what is being printed now -- and that misinformation is gradually going to destroy our profession.