Many Chiropractors Unprepared to Survive Brave New World of Health Care Reform

By Brian Koslow
Editor's note: While this article was submitted for publication before the president's health care proposal was introduced to the country, the article its still timely and pertinent.

Action Steps You Should Be Taking Now

As a practice management consultant, I've helped thousands of chiropractors nationwide to build emotionally and financially rewarding practices. In the process, I have formed many close friendships with DCs. My wife Meryl is also a chiropractor.

It is on this basis that I have chosen to write this article. Like a fire bell clanging in the night, I feel compelled to warn my chiropractic friends that many of you, given your present business practices, are ill equipped to survive the Clinton administration's coming health care reform plans.

Details of the Clinton plan are sketchy. But the coming reforms I believe -- once the smoke clears and are fully implemented -- will obsolete almost all of the practice knowledge you have either learned hands-on or from consultants. And I fear many of you will wind up seeing fewer patients, earning lower reimbursements and practicing within large, impersonal collectives when everyone but chiropractors will be making musculoskeletal decisions.

I am determined to do everything I can to keep you from losing your patients, your practices, and the lifestyles you've worked so long and hard to build for your families. But, to help you do so, you must first confront the enormity and scope of what is being discussed in Washington today:

1) Under Clinton, fee for service may be history. Present plans call for the creation of large regional cooperatives to buy quality care at rock-bottom prices. This view coincides with the HMO approach to health care, because HMOs contract with doctors and hospitals at discounts that range from 10 to 40 percent. And big HMOs get even bigger discounts.

Says Money Magazine (May 1993): "There will be a little room in this new world for today's dominant health-care provider, the independent, fee-for-service, fatherly Dr. Welby."

2) Hillary Rodham Clinton has announced that the administration plans to fold Medicare, Medicaid, workers' compensation, and the medical portion of automobile insurance into a single, comprehensive, HMO-style health care system.

How will this effect your practice? Here is the view of Dr. Ronald L. Plamondon, the American Chiropractic Association's director of member services, which appeared in the ACA/FYI newsletter, March 1993 issue, page 2:

"States' workers compensation, managed care, and the president's proposed health care plans are all being geared toward cost effectiveness without much regard to either patients or providers. the possibility of chiropractic losing large chucks, or all of their portion of the health care pie, such as it is looms very large indeed."

3) Managed care will kill long-standing patient relationships. Patient choice will boil down to either accepting HMO-type care or absorbing high, out-of-network costs. This trend is already occurring right in your office. How many of your inactive patients have returned, only to learn that their new HMO or managed care program doesn't cover your services?

This problem is also occurring at the state level. Here in New Jersey, the recently enacted Health Care Reform Act was designed to broaden health care coverage, instead it's wreaking havoc.

One of the first managed care programs presented under the Reform Act was for a new Blue Cross hospital network. Under the plan, Blue Cross subscribers are reimbursed only if they have been treated by a doctor affiliated with a network-participating hospital.

New York also recently adopted a health care package that also includes some of the proposals being discussed in Washington. The changes are considered so revolutionary that nine health insurers have already left the state.

4) The system of managed care depends heavily on gatekeepers who do not understand or believe in chiropractic. If you can't beat the networks, you can always join 'em, right? Presently, there are two HMO plans that "cover" chiropractic. Here is what you have to look forward to as a chiropractor within an HMO network:

Under one plan, patients must first see their "primary care physician" -- a gatekeeper medical doctor -- to obtain a referral to see a chiropractor.

"It's normally a battle for patients to get their primary care doctor to refer them to a chiropractor," says one New Jersey chiropractor. "If the patient is insistent enough, the gatekeeper will approve a limited amount of care, like two visits."

Says a Long Island chiropractor: "They just pre-certify a number of visits, like two. If the patient needs more, they request that you write a letter to the gatekeeper doctor. You write the letter saying that so and so needs 30 visits, and the gatekeeper says "No," and that's the end of it.

"HMOs are very frustrating," he says. "They are too closely managed with regard to chiropractic. You join one of these networks thinking you'll make up for the limited office visits by getting more referrals. But maybe I get one referral a year. They have no concept of what we do." Under the second type of plan, the HMO will reimburse under a strict fee schedule and a limited number of visits. "I get paid more from Medicare than I do from this network," says one New York chiropractor. "It's ridiculous."

Says another New York chiropractor: "They tell you their medical department will evaluate your treatment plan, but actually they have standard guidelines they follow so they can say they are cost effective. I did an experiment where I wrote three different treatment plans for three different patients and they called me and said, "Okay, we're going to allow nine visits for each patient. My fee-per-visit average is lower now than it's been in years."

"Managed care and crisis care are one and the same," says a New Jersey chiropractor with extensive experience working with HMOs. "That's why, based on my experience, if we don't start educating people today about chiropractic, 60 to 75 percent of our practices in the next three to five years will be gone."

Nowhere to Run and Hide

Ignore the evidence if you wish, but the trend toward HMOs and managed care in both the private and public sectors are clear. A Blue Cross spokesperson says that traditional indemnity health coverage, which currently accounts for 85 percent of Blue Cross/Blue Shield plans, will shrink to 30 percent.

And if the administration tilts the balance completely toward HMOs, traditional insurance could dry up entirely. Aetna, MetLife, Travelers and Prudential have formed a group that has been meeting with President Clinton's top health care advisors and advocating the HMO approach.

Of course, the Clinton campaign to revamp health care could also flounder or be reworked in Congress. But the pressures to control skyrocketing health care costs are enormous, and the president and his wife have staked so much on the issue, that fundamental change appears inevitable.

On May 11, 1993, the New York Times reported that "Lawmakers have expressed confidence that Congress will, within 18 months, pass landmark legislation meant to control health costs."

The Time to Take Action is Now

Comprehensive health care reform is coming. It will challenge us as never before. At a minimum, we recommend you immediately implement some or all of the following strategies:

  1. Get in on the Ground Floor: Don't wait for patients to ask you to join their new HMO plan ... or risk losing them. A proactive approach will give you time to explore HMO packages, having your attorney review all the fine print and enable you to sign on with only the best. And if the best ones are not currently accepting more DCs you still want to get on the wait list now. If Clinton's core package includes chiropractic, HMOs will be required to meet minimum standards, such as a certain number of chiropractors per area. They will probably use their lists before advertising to providers.


  2. Get Serious About Patient Education: The survival of your practice will be based on capacity -- your ability to get people into your office, devise a treatment plan, and carry it out, even if initially they are allowed only a few visits. That means educating your patients each and every visit, better than ever.

Why? If patients are only allowed two visits, by the time of the second visit, they will either understand what the problem is, how chiropractic will treat it, and why they should set up some alternative payment plan, or they will be gone forever.

In addition, if your practice is only about treating neck and back pain, after two visits the patient may be offered a referral to an osteopath, where spinal manipulation may be completely covered. Once a patient is in your office, it's up to you to set the agenda -- or some managed care gatekeeper, who couldn't care less about your patient's health, will be setting it for you.

3) Switch to a Cash Practice: Insurance companies are becoming less reliable sources of payment. Mrs. Clinton, in fact, has spoken with relish about the possibility of hundreds or even thousands of health insurers going out of business once health reform is fully implemented.

Our firm has been offering low-cost educational seminars across the northeast to teach chiropractors the step-by-step methods needed to build a successful cash practice. It is critical that you invest in training seminars to teach you and your staff how to correctly and effectively handle cash and setup these programs.

4) Document Everything and Offer Frequent Progress Reports: In my experience, very few chiropractors actually document everything they do. That's a mistake, because in some cases, an HMO will allow up to 40 visits a year where detailed progress reports are submitted at frequent regular intervals. We have seen, over the years, increases in utilization, peer reviews and paper reviews. The writing is on the wall. Those that formulate good habits of documentation of everything, will get paid. The key is to know how to set this up in your practice efficiently so it does not slow down your procedures or growth.

The Clinton administration's program will not change the fact that people will still need chiropractic care. Swallowing painkillers and undergoing unnecessary surgery won't work any better tomorrow than they do today. History has taught us that in spite of adversity, the public will always want results. The change will come in how you are paid for those results. It will require innovative thinking and nonlinear solutions.

Brian M. Koslow
Ramsey, New Jersey

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