J. Michael Menke, MA, DC, PhD
"Circumstances make man, not man circumstances."
- Mark Twain |
Helping people get out of pain is the most immediate and palpable function of a chiropractor. Most people see chiropractors for pain. Whatever else chiropractors diagnose and treat, they usually treat along with pain and along with a skeletal component.
Health care insurance and reimbursement were invented in the 1930s to manage risk - to share financial responsibilities for illness when people really needed it. Malpractice also distributes risk in cases of medical mistakes. Medical physicians pay high malpractice premiums that are passed on as higher charges to insurers, consumers, and employers who cut benefits and raise the cost of consumer goods and services to stay competitive. Recent employee strikes were primarily due to a loss of health insurance benefits. Physicians and their services receive a hard look and inefficient ones are "encouraged" to shape up.
Making entrepreneurial physicians accountable sounds like the American free market at work. After all, it seems like physicians should be paid according to their contributions. In a cynical moment late on a December Friday night in a chiropractic office long ago, I decided to recalibrate my contribution to society.
A very fortunate patient came in that night, a woman who had walked with a cane for two years after slipping on icy steps in Kansas. As a nurse, she went first to her orthopedist and physical therapist (fair enough). But I dared to ask, "If a stranger said to you, 'I can remove your pain, but you must give me your house,' how would you respond?"
Please understand that it was the end of a long week, including four pages of an infamous ASHN Explanation of Benefits denying me hundreds of dollars in services, accompanied by a check for $5 in an envelope with $2 in postage. I was possessed by a lack of political correctness. So that night, I didn't care if it was me or the "Great Placebo" to effect change, but either way, "Good luck with my insurance!" wasn't going to cut it; and both placebo and I were going to get paid for helping her by 50 percent that first night and close to 100 percent in three OVs. I didn't want her house, though I made a point, and I had made a new friend. How much to get rid of your pain? Now we knew.
This was no new technique I could charge $1,399 for and certify for modules I through III. I just practiced solid clinical (integrative) chiropractic - universally good clinical tools. By asking, "Does this hurt?" a few times, I gathered "special" information. Everyone else needed images and blood tests, while the proximal cause - gluteal spasm - was never considered. No insight or genius here. No need to drag God into it (He is way too busy these days, anyway) or Innate, and nary a subluxation in sight. Not even a need to adjust; to turn anything on or off. She was just as allergic to gravity and old age as the rest of us.
Her insurance would have paid for a total hip replacement, while chiropractic is often not indicated and not reimbursable. If free market forces work so well, why doesn't what works get paid for?
Well, there are some big reasons, and they are not as simple as "no one likes us chiropractors." We know now that to buy cheap health care reduces quality, crushes incentives to improve delivery (HBR, 2004), and perverts the sacred patient-doctor bond. Insurance should compete on quality. A certain panel of physicians could have the best results with backs, ovarian cancer, or whatever. Then let consumers choose a plan by effectiveness, not price. Competing on quality would reduce costs in the long run, but today's game is shifting costs to hospitals, physicians, and patients.
Although premiums rise at 10 percent to 20 percent annually, your fees are not going up 10 percent to 20 percent annually. Insurance directs care by reimbursing it to the predictable outcomes, even if they are not necessarily good outcomes, or outcomes without risk. As my chiropractor friend Victor Hennig in Menlo Park, California, says, "When did insurance start directing health care decisions? And when did people believe health care was only what insurance paid for?"
Health insurance is not evil, but our addiction to insurance may be. Our passive expectation of insurance to pay all our sick bills, regardless of outcome, and our automatic and unimaginative willingness to let what is cheap or reimbursed become health care, have led to a crisis.
J. Michael Menke, DC
Tucson, Arizona
menke@u.arizona.edu
