More Pieces of the Health Care Reform Puzzle

As several recent ChiroPolls indicate, the majority of chiropractors don't know enough about the Patient Protection and Affordable Care Act ("Obamacare"), and the majority also believe the legislation will negatively affect their practices. What do DCs need to know – and what opportunities lie in store that actually may benefit their practices? Get the details in part 1 of this two-part interview with Dr. Gerry Clum, reprinted with permission from the July / August issue of Cleveland Chiropractic College – Kansas City's online newsletter, Health Insights Today.

The first president of Life Chiropractic College West (1981-2011), Dr. Clum is now presidential liaison for external affairs at Life University and director of The Octagon, a think tank sponsored by Life University. In addition, he serves as a consultant and expert witness in matters related to chiropractic practice / care.

In recent years, Dr. Clum has spoken to numerous employer, insurance and health-industry groups on behalf of the Foundation for Chiropractic Progress, providing powerful, fact-based presentations on the positive effects chiropractic inclusion can bring to both new and traditional forms of health care delivery. He is among the most knowledgeable people in the profession on issues related to the Affordable Care Act and the potential for chiropractic participation in the new entities (Patient-Centered Medical Homes and Accountable Care Organizations) being developed as part of health reform.

Major Changes Right Are Around the Corner

What recent trends and changes in the health care landscape are most likely to affect present and future chiropractors? The major components of the Affordable Care Act, which will change things on a broad scale in the United States, go into effect on Jan. 1, 2014. So we're in this ramp-up with several months to go, and it's going to be fast and furious because there are many brand-new structures that have never existed before. There's no template for them, so everything is being created out of whole cloth. It's going to be bumpy and chaotic.

The first thing I would tell people, and I don't want to offend anyone politically, is to not pay any attention to [news outlets such as] Fox News or MSNBC. Be careful where you get your information; get your information from trusted sources about what's going on relative to health care reform. Check the website Healthcare.gov. There is much to be learned from the Q&A on the site.

That being said, the next round of activity that's going to be very important for the profession is that we've got 25 or 26 states that have chosen not to implement the legislation.

In terms of choosing not to set up a state-based insurance exchange or marketplace? Yes. At some point, somebody's going to have to say what's going to happen in those states. The conventional wisdom up to now has been that these states will have the federal options imposed upon them. That is, as a result of their inactivity they will default to the federal option. The curiosity is that it's mainly Republican governors who are complaining about federal intervention, and by not setting up their own exchanges they are defaulting to greater federal intervention, with less control over their own domain.

So, it's an odd situation. How those states sort out is going to be a very important issue along the way, because that is going to determine what the essential benefits package is in those states. In the remaining states, the essential benefits package has been defined.

In some states, it looks very good for chiropractic and in other states, it doesn't look very good at all in terms of the basic benefits package. California, for example, doesn't look good at the moment. The plan [Kaiser Permanente] that has been used as the benchmark, as the basic benefits package guideline [that other plans must match or exceed], does not include chiropractic services.

Nondiscrimination and Essential Benefits

That would seem to be a clear violation of the nondiscrimination clause in the Affordable Care Act. Absolutely. Section 2706 of the law, written by Senator Harkin, addresses nondiscrimination based on provider category or class. That provision is intended to specifically protect practitioners such as chiropractors. Now, there's a version of this argument you have to follow through to the end, which is that it's based on services to be provided, rather than providers who provide services. So, when we're looking at it based on services to be provided, if there are services to be provided for whiplash injuries, for other musculoskeletal problems, for things that fall within the realm of the chiropractor, then they should be billable by a chiropractor under the system.

We, as chiropractors, want the protection to say that we are specifically included in the basic benefits package for A, B and C up to X, Y and Z. In some states, we're going to get that. In a majority of states, we're not. The question then is, if a chiropractor can legally and rightfully provide care in a given set of circumstances in that state, and those circumstances are covered under the provisions of the basic benefits package, then why can they not be covered if provided by a chiropractor? That interpretation is consistent with 2706.

So, in the states that have chosen a benchmark plan for essential benefits that does not include chiropractors – and it's a small number of states, but California is by far the largest state – does it appear that there's a longer battle brewing and that resolution of this issue may require action by a state insurance commissioner or legal action in the courts? That's true. There are lots of players that could be involved. The secretary of HHS could get involved or the district director of HHS could get involved. They could tell the state that under Section 2706, if a chiropractor is licensed to provide these services, then a chiropractor can provide them, period, and insurance companies need to pay them for it.

Shifting From Quantity to Quality

In the U.S., there are now major efforts to gradually shift the main emphasis in health insurance reimbursement away from the traditional volume-based system to one where reimbursement is based on quality outcomes. What's your understanding of how quality is defined?

Quality is kind of a "handful of mercury" issue: it's pretty tough to get hold of. But there are certainly measures. If we look at the hospital world, quality is measured by the frequency of readmissions after discharge for a given procedure, the number of hospital-acquired infections, the number of drug delivery errors during the period of confinement, and so on.

In our [chiropractic] world, they are likely to be more performance-oriented. They're probably not going to be radically different from what we would do today. We'd look at an Oswestry, an SF-36 or an SF-12. Or we'd look at measures of quality of life or activities-of-daily-living indices as a part of our care.

The idea that we can continue to see patients for X number of visits over Y period of time – without periodic evaluations that show progress in their functional improvement – is long gone. Probably the biggest change for chiropractors is that we need to start thinking about what we can do to demonstrate that between point A and point B, Mrs. Smith has improved. And the fact that I find greater joint mobility at her C6 and C7 is nice, but it doesn't answer the question.

Because that isn't a patient-centered outcome? Yes. What does Mrs. Jones think about how Mrs. Jones is doing? And what have you done to collect that information on a consistent, ongoing basis, other than asking, "Are you better today, Mrs. Jones?" So that kind of an approach is something that we're going to have to standardize. We're going to have to agree upon specifics. We've got low back indices, neck indices, indices for everything under the sun. Their use is going to have to become routine. This doesn't have to be burdensome; they don't have to be multi-page. They can be single page, where the patient fills it out in the waiting room and then it's scored and popped into the record. And you make use of that as you go forward.

There are other aspects of quality — patient satisfaction with the outcomes of their care, your delivery of the care, the environment in which the care is delivered. All of those will become metrics that will become part of this discussion over time. But really, one of the biggest changes that is coming about in the Affordable Care Act in terms of funding, particularly in the Patient Centered Medical Home model or the Accountable Care Organization model, is the idea that there will be additional payment made when practitioners of all kinds, including chiropractors, do things to reduce the level of care needed and save the system money.

In the past, as you said at the beginning of this question, the only ways you made money in healthcare were that you provided more, or more expensive, services. And that was true for everybody across healthcare. They provided more care for more money; that's how it worked.  It is now understood that the system cannot continue to expand exponentially on that basis; that we've got to change the incentives so that practitioners behave differently. So now, practitioners will be compensated for providing care that produces a quicker and better result, rather than simply more or more expensive care, as in the past. 

This is a sea-change, a truly massive shift. We haven't seen this before. It's as fundamental as it gets.

New Models: Medical Homes and ACOs

The two mechanisms that you mentioned, the Patient Centered Medical Homes (or health care homes) and the Accountable Care Organizations, are essentially team-based health care delivery arrangements. Under the Affordable Care Act, these can include chiropractors but are not required to do so. What else should DCs know about these groups and about possibly seeking to participate in them? First and foremost, they need to know they exist. I don't say that jokingly, I say it very sincerely. I think there are a great many chiropractors across the country (as there are a great many medical doctors) who have heard these terms, but haven't got a clue as to what they mean. So the first thing I would do is start Googling "accountable care organizations," and I'd spend half an hour wandering through websites and reading until you get a sense of what they are.

Basically, they are vertically integrated environments that take a patient from a primary care environment to an end-of-life environment, and include everything in between. They seek to integrate across that spectrum of care, to coordinate on a team basis the activities of the providers involved, for the greatest good. You know as well as I do that today, any patient can walk into 20 different providers, get 20 different prescriptions for oxycodone, and take themselves out by the end of the day if they want, by taking the drugs. There's no integration in the system. A person can go out and doctor shop and get healthcare as many times as they want in a given day.

Well, this new system is intended to try to stop that, to stop the abuses, but also to refine and improve the normal or intended use of care. It is very much team-oriented and it's very much oriented to allowing people to practice at the top of their license.

What does it mean to practice at the top of your license? Surgeons drawing blood and taking blood pressure is a waste of time and money. Same goes for a chiropractor rubbing an ultrasound or ice on somebody; it's a waste of their skill. You want to work at the highest level of your skill. As a chiropractor, I think that's evaluating and adjusting patients as needed. If you want or need something else to be done in your office, let someone else do it. And let that person work to the level of his or her training and greatest skill.

In a vertically integrated system, there might be 20 practitioners who could tend to a particular low back case: a neurologist, an orthopedist, a physical therapist, a chiropractor, a massage therapist, an acupuncturist, a rheumatologist, etc.

Efficient Entry Into the System

But the question is, what's in the patient's best interest? What's the point at which to begin? The system would be designed to facilitate the most efficient entry into it. What percentage of these patients can we address with the greatest success, at the least cost, with the greatest amount of patient satisfaction, in the shortest period of time? Now if this model causes the group, the entity – the PCMH or the ACO  – to make more money by doing less, what we will see is that for the first time, there's an incentive to make more money by not doing more. Sea-change is the only word for it. That's really the big thing.

So, let's get back to where we began this question, with the ACO and PCMH products. Kaiser Permanente is a classic ACO. A PCMH is a building block of an HMO [health maintenance organization]. It's a group that agrees to work together to take care of a given number of patients.They refer to the hospital within the ACO; those types of involvements are coordinated. Again, records are integrated, tests aren't repeated unnecessarily, imaging isn't done repeatedly because they didn't get the X-ray from one office to the other. All those kinds of things, because they are handled electronically, become integrated and more efficient.

This is a free-market arrangement. Chiropractors can function anyplace they can inject themselves into the system. In this scenario, it is crucial that chiropractors understand the literature regarding cost-effectiveness and patient satisfaction associated with the care that we deliver.

Dr. Daniel Redwood, the interviewer, is a professor at Cleveland Chiropractic College – Kansas City. He is the editor-in-chief of Health Insights Today, associate editor of Topics in Integrative Healthcare, and serves on the editorial board of the Journal of the American Chiropractic Association. Visit Dr. Redwood's website and health-policy blog at www.redwoodhealthspeak.com.

Part 2 of this article appears in the Nov. 15 issue. It completes Dr. Redwood's interview with Dr. Clum regarding Medical Homes and Accountable Care Organizations, including Dr. Clum's thoughts on how DCs can participate and in so doing, expand patient access to chiropractic care.