Is Managed Care Our Enemy?

By Craig Liebenson, DC

The first wave of managed care has swept through chiropractic practices from Oregon and California to Minnesota and Massachusetts. Cost containment, not quality assurance, has been the diet of the successful managed care organizations (MCOs). By keeping tight reigns on consumers' access and panelists' freedom, costs have indeed come down. Has quality been sacrificed in this pursuit of lowering costs?

Do we know what quality treatments or outcomes are for the conditions we commonly treat? Can we identify those patients who require more intensive or longer duration treatment programs? In fact, there is a wealth of evidence about what treatments are proven to work, what outcomes are sensitive and responsive to the conditions that we treat, and what the risk factors are of a prolonged recovery. In future columns I will describe what we know and show how this can be incorporated into a quality assurance approach to chiropractic practice.

The odds are that MCOs are here to stay. This needn't be a bad thing if we can switch the emphasis from cost containment to quality assurance. In the long term, unless such outcomes as patient satisfaction and pain related impairment or disability are figured into the equation, groups which are buying health care from MCOs will seek it elsewhere.

Chiropractic has an excellent opportunity to assert that it is part of the solution to the cost epidemic of musculoskeletal syndromes. There is a revolution occurring in the management of pain syndromes. The revolution necessitates a new management approach recognizing the following features:

1. and chronic pain are entirely different.


2. relief strategies are essential in acute management.


3. restoration and behavioral strategies are essential in chronic management.


4. findings correlate poorly with symptoms in most cases.


5. biopsychosocial approach is necessary for treating, and more importantly, for preventing chronic pain syndromes.

To move your practice in the direction of quality assurance, you will want to follow established critical pathways of management:

1. triage of patients into the following classifications: "red flags" of disease; nerve root pain; and mechanical pain;


2. of the +ve prognosis and establishment of functional goals or end points of care;


3. about activity modifications;


4. and other modalities for pain relief;


5. from passive pain relief modalities to active rehabilitation protocols within the 1st month of care;


6. of outcomes measurement every 2-4 weeks;


7. reassessment if lack of measurable progress within 4-6 weeks.

If we begin to practice in a quality assurance manner, then we will find many new sources of referral for our practices. In particular, we can confidently market our practice to MDs and attorneys.

What patients should we be seeking from medical referral? Acute or chronic pain patients without underlying organic pathology can be referred for chiropractic care.

1. acute pain patient who fails to achieve substantial pain relief with medication within one week. Rx: manual therapy, activity modification advice, and reactivation.
   
2. chronic pain patient. Rx: course of manual therapy; identification of functional capacity deficits; functional restoration; operant conditioning with behavioral medicine specialist.

This modern, biopsychosocial approach encompassing critical management pathways and ongoing outcomes assessment is the future for quality care dispensed by chiropractors. It is the most defensible care in personal injury or workmans' compensation cases expected to involve documentation, deposition or testimony.

Upcoming columns will address the evidence regarding:

• What treatments are evidence-based?


• What outcomes are reliable, responsive, and valid?


• How can we identify those patients who require more intensive or longer duration treatment programs?

Craig Liebenson, DC
Los Angeles, California

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