How Chiropractors Can Avoid the Impending Bureaucratic Abyss
Dear Editor:
When everyone in chiropractic was clamoring for inclusion in Medicare and private insurance, it was seen as more of a fairness issue than a money issue. Third-party pay was less common then, and is a relative newcomer to health care, yet if one asks 100 people to come up with a solution to the health care "crisis," virtually everyone's solution involves some form of third-party pay. Even though all of us have been personally affected by the intrinsic flaws of third-party-pay systems, we rarely hear doctors advocate eliminating this inefficient, complicated, profit-driven system. Maybe that's because these systems were already in place by the time most docs started practice.
I was fortunate enough to practice several years before third-party-pay systems became so pervasive, so I was familiar with the dynamics of a cash practice. In contrasting the two paradigms, it becomes apparent where third-party-pay systems fail:
- They are the ultimate deciders of which procedures to perform (the ones that pay), despite having no expertise regarding the activity being overseen.
- Third parties have no direct participation in the relationships that they control.
- They have no understanding or regard for the erosive effect they have on the doctor-patient relationship.
- Because third parties organize and codify every facet of treatment, the need to follow procedures and rules takes precedence over outcomes.
- Doctor-patient relationships are personal, whereas third-party relationships are completely impersonal.
- There is no code or allowance made for the art of what we do. This intangible can not be codified.
In short, both patient and doctor are eliminated from the decision-making process. When only a patient and doctor confer and reach an agreement about what each is willing to do, a contract is made. This contract is profoundly direct, simple and honest. Each participant knows what is expected of themselves and the other party. No third party profits from this relationship.
The pragmatic, yet brilliant Milton Friedman observed that spending one's own money was different from spending someone else's money, in that the former is accompanied by the expectation of acquiring something of value. This principle holds true in every facet of commerce including health care.
Currently in my practice, I accept no assignment from third parties. Patients are willing to pay for a service they value, even if they have health insurance. If you doubt this fact, you greatly undervalue your work.
Incidentally, England has been administering a national health care system for decades. Chiropractors are not included in that program, and after visiting with a couple of docs working there, I discovered that they are not at all unhappy about their professional status. They avoided the hassle associated with the bureaucracy and operate very successful cash practices. Had the leaders of our own profession been a bit more farsighted, we too might have avoided the impending bureaucratic abyss.
John Fausett, DC
Monahans, Texas
The Chiropractic Profession Has Missed Its Opportunity
Dear Editor:
Many opinions and much misinformation have been relayed to the chiropractic profession regarding the legislative changes that were part of PPACA. The most significant and disturbing is the presumption that Section 2706, which provides for non-allopathic providers to participate in ACOs (Accountable Care Organizations), means that chiropractors will be invited to participate.
With the re-election of Barack Obama, the rapid development of ACOs across the nation is creating new systems of reimbursement that make other systems not relevant. Many trade associations have banked on the profession being included in essential-benefit packages that would allow their inclusion in ACOs.
First of all, do not mistake that ACOs will be bound to legislative inclusion and insurance equality laws. That would be likened to demanding a hospital to have chiropractic services on staff. The focus on the inherently important piece of the puzzle, which was to become primary care providers, was ignored too long by our chiropractic organizations. Whether your philosophical pinnings are toward adjustment only or prescriptive rights, the one issue that could have guaranteed our position was the inclusion of differential diagnosis in all states' scopes of practice. Without the duties and responsibilities, there will be no rights or rewards.
Portal-of-entry providers have no position of authority in the new environment. Instead of focusing our attention on our opinion of what constitutes primary care, the profession missed an opportunity to address the players in the market that will make the decision. The medical profession, the academic institutions, the insurers, the legislators and the public are the groups that should have been queried regarding how the chiropractic profession could have filled the role of primary care.
Dartmouth began studying the health care professions six years ago. In fact, only certain allopathic physicians are included as primary care medical home providers. The model is family practice physicians, internal medicine and pediatricians. Ancillary allopathic providers that have been deemed primary care home medical providers also include physician assistants and nurse practitioners.
Allopathic specialists are dependent on the ACO directing patients for their care. Dartmouth also identified portal-of-entry providers that were deemed beneficial to the system including social workers, DPTs, optometrists and dentists.
Chiropractic was not deemed capable of providing primary care or being the center of a primary care home medical model. The chiropractor's only inclusion opportunity is to take an ancillary role as a provider of manipulative services in an ACO headed by one of the listed primary care providers. The Chiropractic profession will no longer function on an autonomous basis unless outside of the "system."
The long-term survival likelihood of the chiropractic profession is grim, as it will suffer a massive blow over the next five years. The erosion of independent contracting with insurers will occur as the ACO will assume the contracting entity position. If you're not in an ACO, you will not be part of the negotiation; and even then you are likely to receive a stipend in the total care of the patient. The chiropractors who will function in these organizations will be the ones who speak the medical language of diagnoses with a clear understanding of anatomy and pathophysiology of disease process.
The chiropractic schools will see significant enrollment declines as a consequence. The chiropractors who practice with certain philosophical pinnings will be relegated to competition for the provider willing to accept the lowest fee, and who is capable of seeing the most patients per day. Already in numerous areas of the country ,the cash price of the adjustment has fallen to $12-$19. This level of compensation is not commensurate with a professional degree or to maintain professional status.
Dean Willhite, DC, DABCI
Manitowoc, Wisc.
