18 Chiropractic's Future in Managed Care
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Dynamic Chiropractic – December 3, 1993, Vol. 11, Issue 25

Chiropractic's Future in Managed Care

By Stephen R. Seater
Arlington, VA -- Recently in the Washington Post, John Erb of A. Foster Higgins & Company, an employee benefits consulting firm, cautioned, "It's felt that there's an unlimited demand for chiropractic from people who use it. They would go every day if they could."

To remedy this situation, Erb said employers are increasingly assigning a physician (read allopath) in the role as "gatekeeper," with responsibility for deciding whether to refer patients to specialists, including chiropractors.

"That's where the rubber will meet the road," he said. "That's where the chiropractors will have to convince the allopathic doctors that their treatment is effective and that they can provide quality services."

The Dangers of Specializing

Chiropractors are musculoskeletal specialists, according to Erb, and medical gatekeepers will control the flow of patients to them to limit costs. This is what organized medicine, many insurers, and the big consulting firms envision for chiropractic. Specialists of all kinds will take a big hit in the managed care environment of tomorrow.

That's why the American Academy of Orthopedic Surgeons recently passed a resolution stating that they are "the most appropriate, highly qualified and cost-effective first contact physicians for the full spectrum of musculoskeletal diseases and injuries." That's right, orthopedists, one of the most narrowly specialized and most costly groups of physicians, are trying to position themselves as generalists and gatekeepers for all musculoskeletal conditions. They clearly see the handwriting on the wall and what is in store for specialists -- reduced incomes due to stringent cost controls and fewer patients being referred.

And what of chiropractic? Can it beat out the orthopods and other allopaths as musculoskeletal gatekeepers? Perhaps, if it can muster enough data to show that chiropractic interventions are less costly than medical treatments for musculoskeletal disorders. But even if it can succeed in doing this, there is no assurance that chiropractic can succeed in pushing the orthopedists aside and assume gatekeeper status for musculoskeletal complaints! After all, medicine has enormous resources and has waged unremitting warfare against chiropractic for decades. Its specialty groups, such as orthopedics, physiatry, etc., are presently very strong and well heeled. They will fight hard to keep chiropractic from obtaining its slice of the pie. Even in chiropractors become a part of managed care on a national scale, they could lose out if they are relegated to specialist status and become subject to allopathic gatekeepers.

The Need for Gatekeeper Status

Chiropractic must attain gatekeeper status, the question is how to do it. FCER believes the best way to achieve this goal is not as a specialist in back and neck pain or for all musculoskeletal conditions per se, but as a generalist, a primary care provider. This position forms the cornerstone of FCER's strategic plan and is the subject of the booklet, Chiropractic: A Primary Care Gatekeeper, by Arnold E. Cianciulli, MS, DC.

Chiropractic has never officially been a specialty, although many doctors now practice as if they were specialists. Most ads in the Yellow Pages proclaim chiropractors to be low back or neck pain specialists. But chiropractic was never conceived as a specialty, but rather as a complete, holistic approach to health care; it as different from medicine as 7UP is from cola drinks. The enormous marketing success of 7UP is not due to mimicking Coke or Pepsi, but rather to setting itself apart from them as the "uncola." If chiropractic intends to succeed in obtaining gatekeeper status, it must return to its original vision as a preventive, nondrug, nonsurgical, holistic,, whole body, primary care profession that does not duplicate allopathic medicine.

The time is right for chiropractic to assert itself as a primary care gatekeeper. Medicine in its quest for ever more technology and "wonder drugs" has produced far too many specialists and far too few primary care doctors. The shortage in general practice and family practice medical physicians is astounding and very serious for public health. Furthermore, medicine has become more and more impersonal. A disillusioned public is now turning its attention towards alternative care practitioners. Acupuncturists, herbalists, nutritionists, massage therapists (and other body-workers), and chiropractors are now in demand as never before, as was recently documented in the New England Journal of Medicine.

Are Chiropractors Prepared for Primary Care?

Chiropractic is the only one of the alternative groups that enjoys the professional degree of doctor. Osteopathic medicine has been largely subsumed by allopathic medicine. As doctors, chiropractors are trained to diagnose and care for the human body, and to consult with and refer to other doctors and allied health professionals, such as physical and massage therapists, acupuncturists, etc. None of these nondoctor groups however are trained to diagnose. Not one is at the same decision making level as the doctor of chiropractic. This fact, when coupled with both the primary care shortage and the public's desire to visit alternative care practitioners, means that a window of opportunity has opened for chiropractic.

A new report on the role of the doctor of chiropractic in the health care system by the Center for Studies in Health Policies, Inc., states: "The DC can be considered a generalist in the provision of primary health care services." The report says that DCs may be considered primary care gatekeepers and portals of entry to the health care system.

Positioning the Chiropractic Profession

To achieve primary care gatekeeper status, chiropractic must position itself properly in the public's mind. Positioning, as a marketing concept, is the attempt to win over the mind of the consumer. In the case of chiropractic, the mind of the health care consumer is not necessarily limited to individuals. To succeed, chiropractic must alter the public's current perception as the back and neck pain profession and publicly embrace a wellness/prevention, whole-body care position. We must emphasize our differences from allopathic medicine, the high degree of patient satisfaction we enjoy, and the safe and natural approach to health care. We should always emphasize our uniqueness and never engage in public debate with nondoctors, such as physical therapists, about who treats backs best. Doctors of chiropractic diagnose and treat the whole person, PTs do not.

Furthermore, chiropractic must recognize that it is at war for market share. All businesses, whether they admit it or not, are at war for market share. Chiropractic is a business just as medicine is a business, and as the great military genius Karl Von Clausewitz said, "War belongs to the province of business competition, which is also a conflict of human interests and activities."

As in all wars, a strategy is needed to win or at least to avoid being overwhelmed. Chiropractic needs an offensive marketing strategy, which should follow the three principles outlined in Marketing Warfare by Al Ries and Jack Trout:

  • "The main consideration is the strength of the leader's position." For chiropractic, this leader is medicine.


  • "Find a weakness in the leader's strength and attack at that point." Medicine's costly, crises-oriented, impersonal, high-tech, low-touch approach to patient care.


  • "Launch the attack on as narrow a front as possible." Medicine's failure to serve the public by providing adequate numbers of primary care practitioners is an appropriate "front."

The Next Step

The chiropractic profession is at a crossroads. There is a clear need for primary care gatekeeper status if the profession is to thrive. To accept the mantle of back care specialists will endanger the future of chiropractic and will limit patients' access to needed chiropractic care.

FCER is actively involved in helping to secure primary care gatekeeper status for the chiropractic profession through research and education. Members of the Foundation support this goal and receive a full spectrum of membership benefits. For more information, please contact: Diana Stevens, 1701 Clarendon Blvd., Arlington, VA 22209 or call (800) 637-6244 or (703) 276-7445.

Stephen R. Seater, CAE
Arlington, Virginia

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