Donald M. Petersen Jr., BS, HCD(hc), FICC(h), Publisher
It has been almost a year since I reported to you on my work in the managed care organization known as MDC (please see "New Challenges" in the May 20, 1996 issue). That column described the effort undertaken towards full integration of chiropractic into managed care. It is now time to give you a report of the progress made and the lessons learned along the way.
To prevent any semblance of using Dynamic Chiropractic to advocate managed care, MDC has not been written about or mentioned in this publication since that article in 1996. This report is not intended to be any kind of endorsement for managed care or any particular organization: that is a choice for you to make.
Managed care is not necessarily the best choice for every DC, but your ability to make choices may be enhanced by knowing the experiences of someone who has wrestled with the monster from the inside. And while an occasional lesson has been shared in the past, this is a full report.
The marketing departments of most managed care organizations have lobbied to include chiropractic, because it made them more attractive to their prospective policyholders: our patients. There is no doubt that chiropractic patients are demanding chiropractic coverage of some sort.
But chiropractic's standing in the managed care market is tenuous. Chiropractic is not part of the health care algorithm. We are merely an option, and our inclusion is isolated. No managed care organization to my knowledge is recording the effectiveness of chiropractic and comparing that to medical care. There are no protocols that direct the patient to chiropractic first, drugs second and surgery last. Chiropractic access in managed care is purely patient driven.
So here we are. The managed care companies have enrolled many of our patients. The patients are seen by a small group of member-DCs who are paid much less for the care than they would be in a private practice. The promise of access to greater numbers of patients was just that, a promise. Chiropractic is the chrome wheels of managed care: nice feature, but not necessary.
The reason for my involvement in MDC was to integrate chiropractic into managed care: to create a model that would demonstrate chiropractic's effectiveness inside managed care as an integral service.
Lesson 1: Nobody's Interested
This may not come as a shock for you, but it took over three years to get any major carrier to be interested in looking at an integrated chiropractic model. Even though they were interested in chiropractic, the idea of integrating chiropractors into the system was foreign to them. They were too accustomed to chiropractic being on the outside of health care.
Lesson 2: They Don't Understand Chiropractic
While managed care companies know that many of their policyholders want chiropractic, and they've heard about some of the chiropractic research, they have no idea how to include chiropractic except as an add-on service. They don't understand the potential financial benefit that chiropractic offers in terms of increased effectiveness and lower risk to the patient.
Lesson 3: You Have to Want to be a Managed Care DC
Managed care promises certain benefits, but brings with it definite liabilities: lower fees, fewer visits and increased paperwork. Yes, there are some DCs who have seen a windfall of patients after joining a managed care panel, but relatively few.
Most DCs choose to join a managed care panel to maintain patient access. While this might not sound like much, it prevents patients from being lost when their employers switch to managed care and provides access to them, their families and their friends. The value of this benefit ultimately depends on your ability to turn one patient into several.
And you have to be willing to play the game. You have to be willing to follow the algorithms and do the paper work. If you would rather avoid the hassle, managed care is not for you.
Lesson 4: Making Up for a Poor Start
In their zeal to be included in managed care at any level, most chiropractic MCOs were willing to settle for low reimbursement schedules, limited access and narrow practice policies. Some chiropractic organizations underbid each other down to a ridiculous $.08 per-member-per-month! It will take years of renegotiating contracts to bring chiropractic managed care reimbursement back up to where it should be.
Lesson 5: The Cost
Developing a functioning integrated chiropractic managed care model was not simple. This required the expertise of DCs, researchers, insurance administrators, health care futurists, orthopaedic surgeons (remember, this is an integrated model), business people, and attorneys. It has been three years in development and required a substantial personal monetary investment from those involved. And the implementation will be even more expensive. To gain the interest of any major insurance carrier, the model must have the ability to be tested on a national basis.
Progress: Model in Formation
One major national carrier has finally agreed to begin the formation of a chiropractic program that will ultimately be integrated into their managed care program. This carrier is extremely cautious, but is willing to investigate the benefits that chiropractic care can provide when integrated into their health care system. The project will require several more years of work, and will start regionally.
Unfortunately, the effort to fully integrate chiropractic into managed care will require a substantial amount of financing. This financing usually comes from a Wall Street type of organization that is more concerned with the "bottom line" than with the welfare of their providers.
Chiropractic's position in managed care is too important to place in the hands of such business people. This is why MDC has chosen to turn this effort over to the National Chiropractic Mutual Insurance Company (NCMIC), a mutual company exclusively controlled by more than 25,000 chiropractors (policyholders). NCMIC not only has the financial wherewithal to see this effort through, but has the best interests of the profession at its core.
By this report, you can see that chiropractic integration into managed care holds no easy solutions. The managed care monster must be tamed to include DCs as front-line, fully-integrated providers, not just add-ons.
DMP Jr.
