Articles by JCS
Problem or Solution?
JC Smith, MA, DC
As the American healthcare crisis continues unabated with escalating costs and questionable care, despite the control of government, HMOs and MCOs to regulate care and to cut costs, problems continue to surface. As the last major country of the world that has not completely socialized its healthcare delivery system, the US faces a cross-roads as to possible solutions. Some MCOs shun more governmental controls while consumer groups demand a patients’ bill of rights to insure some protection from the crass profiteering by insurance executives geared more to the bottom line than dispensing adequate health care.
Despite recent newspaper articles revealing the vast amounts of medical and pharmaceutical mistakes that lead to thousands of deaths weekly in American hospitals, very little is mentioned about an overhaul of the present system. Poor penmanship by physicians, untrained pharmaceutical techs and over-worked ER doctors and pharmacists may explain some mistakes, but the inherent problems with the US healthcare delivery system far surpasses these issues.
What is the solution to this massive problem of declining healthcare in the US? Some may believe a single-payor system is inevitable as costs rise and care decreases. Some in the medical cartel would prefer to leave the system just the way it is. Oddly, very few have suggested that the healthcare industry be subject to the same market forces as are all American industries—free enterprise in an open marketplace.
If one subscribes to the ideals of free enterprise—that open competition on a level playing field will create better services/products at lower costs—than the obvious solution of this healthcare mess starts with a return to this premise. Although the antitrust court decision in the Wilk et al. v. AMA et al. case showed the monopolistic control of the medical society in American hospitals, this victory was hallow in that nothing came from it to stop the boycott of non-MD services from inclusion into the American healthcare system. This begs the question: Is it even possible to de-regulate the healthcare industry and let market forces prevail to correct the present abuses?
The lack of quality medical care, the attempt to cover-up mistakes, the huge amounts of money involved, and the resistance to open the healthcare marketplace to competition all reeks of a perverse medical system with its own ills.
While the powers-to-be negotiate their band-aid solutions to this enormous problem, at the basis of this problem rests an ideological clash between free enterprise and a quasi-socialistic/oligarchy system where government and the medical cartel work together. Perhaps no one sees this clash better than the chiropractic profession. Although a minor player in this debate for its first one hundred years of existence, chiropractors have long been cut out of the loop of government healthcare and MCO programs, forced into the realm of free enterprise.
Realistically, however, the American healthcare system is so intertwined between governmental regulations and subsidies, hospital and medical monopolies, along with the enormous financial clout of the pharmaceutical and insurance industries, a clearer picture of the present American healthcare scene is that of a government-endorse medical cartel quickly evolving into an oligarchy as government takes a stronger position within this cartel.
Is this the inevitable future of healthcare in America? Will we see an medical oligarchy that resembles a public-financed medical “utility” combined with the restricted-enterprise of monopolistic prices void of any real competition? Is a return to an open marketplace with free, unencumbered enterprise even possible any longer, or does this suggestion send a panic through the present medical cartel? Would the profit motive add to the problem or move us closer to the solution?
Perhaps a closer look at the American healthcare system will give us a clearer picture of the underlying problems and a possible answer.
The Ills of Hospital Care
A recent editorial in The New England Journal of Medicine by Woolhandler and Himmelstein, “When Money is the Mission—the High Costs of Investor-Owned Care,” is very critical of the profit motive in hospital care. They showed the higher costs of care in for-profit hospitals range 3 to 11 percent more than in not-for-profit ones. They also spend less on personnel, avoid providing charity care, and shorten stays. A recent study found that death rates for seriously ill patients were 7 percent lower at not-for-profit non-teaching hospitals than at for-profit non-teaching hospitals. Major teaching not-for-profit hospitals had 25 percent lower death rates according to their article.
They also mention that Silverman et al. reported that Medicare spending in 1995 was $732 higher per enrollee in for-profit markets and $459 higher in mixed markets than not-for-profit markets. These higher expenditures translate into $5.2 billion in excess Medicare costs. By extrapolation, had all US hospital been for-profit in 1995, Medicare’s annual tab would have been $24.3 billion higher than if there had been no for-profit hospitals.
Woolhandler et al. explain how investor ownership increase hospital costs principally by the princely rewards of executives. For example, the CEO of Columbia/HCA, the industry leader, resigned in the face of federal fraud investigations, but left with a $10 million severance package and $269 million in company stock. Incentive bonuses averaged 41.5 percent of administrators’ pay at for-profit hospitals, as compared with 19.7 percent at not-for-profit hospitals. In 1995, 25 percent of Columbia/HCA’s administrators received profit-related bonuses that amounted to at least 80 percent of their salaries; many who did not were forced out of the company. Obviously for-profit hospitals are cash-cows for administrators at the expense of patients’ care, medical personnel, housekeeping and charity work.
Whence Market Corrections?
Woolhandler et al. pose the question: “Why is it that the market does not weed out firms that offer inferior products at inflated prices?” Incredibly, they answer their own question with the belief: “The simplest explanation is that the competitive free market described in textbooks does not and cannot exist in health care for several reasons.”
While a competitive free market does not exist in health care presently, whether or not it cannot ever exist is a conclusion that poses a strong dilemma: Why do antitrust laws and free enterprise principles reign in all other industries except health care? Moreover, why would free enterprise and open competition be incompatible with healthcare?
First, they explain, many hospitals exercise virtual monopolies. Second, an informed choice by consumers, which results in greater efficiency according to market theory, is an mirage in health care. Many patients cannot comparison shop and thus rely upon their physician’s advice. Third, if purchasers cannot accurately appraise a product, they cannot determine whether its price is fair. Efforts to evaluate care are no match for profit-driven schemes to misrepresent it. Exploiting loop-holes is more lucrative than improving efficiency or quality, and creative cheaters have a decisive market advantage. Finally, neither patients nor employers pay for most of the costs of health care: government does at the rate of $2,500 per capita, including insurance premiums for government employees and tax subsidies for private insurance, and exceeds total per capita health care spending in every other nations except Switzerland.
As Woolhandler et al. conclude, “It is an odd free market that relies largely on public dollars.” Indeed, it also is an odd market that fails to give patients information about options, especially non-medical solutions to make an informed decision. Just as odd is the lack of comparison shopping, thus relying upon blind faith and the sole discretion of their physician. Also misrepresenting options or devising schemes to defraud payers instead of improving quality care reeks of scam mentality. As Woolhandler et al. summarizes, “investor ownership marks the triumph of greed…with for-profit hospitals, the money is the mission; form follows profit.”
Rather than calling for free market forces to prevail to offer better services/products at lower prices as in the rest of our society, Woolhandler et al. disagree despite the obvious problems in the present restricted marketplace of healthcare. “In our society, some aspects of life are off-limits to commerce… health care is too precious, intimate, and corruptible to entrust to the market.”
“Too precious” is interesting considering it took a federal law to allow birthing mothers an extra day overnight in hospitals to recuperate. And, considering the high-volume practices with low-contact time with patients done by most physicians, it’s difficult to understand their description of an “intimate” relationship exists nowadays in any hospital. “Corruptible” is also an interesting choice of words, but considering the huge amount of medical fraud that exists along with the over-blown costs of medical care, perhaps “corruptible” is painfully accurate.
The Medical Cartel
Oddly, their comparison of for-profit versus not-for-profit hospitals itself is not a true evaluation of actual free marketplace forces versus a sham marketplace because all hospitals are excluded from real market forces. What actually exists are two sham markets—one is just more profit oriented than the other. But a true free market simply does not exist in any facet of medical care nowadays; only “alternative” health care professionals such as chiropractors, homeopathic practitioners, nutritionists, herbalists and such have endured in an open marketplace outside the insulated world of insurance coverage. While they may not enjoy the princely salaries of their medical counterparts, they certainly have survived without the artificial support of insurance coverage.
On one hand, Woolhandler et al. acknowledge the sham marketplace of medicine, yet they attribute the ills to a free market which has never existed in the truest sense of the term. There has never been during the past half-century an open marketplace with free enterprise where all competitors can compete on a level playing field. The American health care delivery system is an cartel controlled by medical and hospital associations, sanctioned by state and federal government agencies controlled by medical appointees and influenced by medical political action committees, and subsidized by private and public health insurance programs and the powerful pharmaceutical industry. To suggest that a free market system exists in medical healthcare in America is ridiculous. Woolhandler et al. fail to address the real problem causing the abuses they decry—the medical cartel and lack of free enterprise.
The sham marketplace of medicine is obvious to its competition. Hospitals routinely deny chiropractors from managing their back cases which represent the third leading reason for hospital admissions and surgeries. They deny patients other options as well, such as chelation therapy in lieu of heart surgeries, another huge money-maker. Not giving patients a freedom of choice is the greatest evidence of the sham marketplace in healthcare, and one of the leading causes of higher costs. For instance, if only one in 100 back surgeries are helpful as the AHCPR report on acute low back pain in adults reports, offering spinal manipulation in lieu of surgery would represent a loss of substantial income for surgeons and hospitals. While spinal manipulative therapy may be good for patients, it’s bad for the business of medicine.
If a true free enterprise system existed in healthcare, there would be no interference from third-party payers, or Personal Injury or Workers’ Compensation adjusters, or Medicare or the government. If a true free market existed as in the rest of our economy, there wouldn't be any price-supports called health insurance or government dollars or tax subsidies, or exclusion of competition within hospitals under the guise of staff "privileges", i.e., discrimination against minority providers like chiropractors.
As long as there exists a Golden Goose called Medicare and health insurance to subsidize medical care, abuses, over-treatment, fraud and turf warfare will continue. Without price supports from insurance, the moral hazards of over-treatment and unnecessary services would cease and insured patients are not as likely to overuse the system. Since clients do not pay the cost themselves in many health care programs, providers of care have an incentive to over-treat with too many visits, hospitalizations, tests, etc. While some disgruntled medical providers decry any restrictions, much of the huge costs of health care stem from the vast amounts of unnecessary surgeries. Too much, too late and too costly describes much of medical care in the last stage of most patients’ lives.
It seems daily new revelations are forthcoming about the dangers of medical and hospital care. Whether it’s adverse drug reactions that affect over 2.2 million patients annually and kill over 100,000, or botched surgeries that kill 5,000 patients per one million procedures, or the fact that combined, medical mistakes kill 3,000 patients weekly in American hospitals and are now considered the third-leading cause of death in the United States, only behind heart disease and cancer, the facts clearly show that medical care is risky business.
Allthewhile Americans are spending over one trillion dollars for medical expenses as managed care organization find new ways to restrict or deny treatments to enhance their own profit—“Squeeze care to expand profits.” This equates to over $4,000 per American, not just for sick patients, but for every man, woman and child. And the unfortunate problem with this expensive, dangerous medical system is that it’s only getting worse. Despite the advent of HMOs, in fact, there are very few procedures in the medical arsenal that prevents the onset of chronic, degenerative diseases. Indeed, a medical Health Maintenance Organization is, at best, an oxymoron and, at worst, a fraud perpetuated on an unsuspecting public.
But it’s not as if there aren’t viable alternatives to this medical mess. Just because expensive medical exams, drugs and surgeries have not stemmed this onslaught of chronic illness doesn’t mean there aren’t other solutions that exist. Unfortunately, the medical dominance of the American healthcare delivery system has stymied, but not completely eliminated many alternative healthcare methods.
In fact, Dr. David Eisenberg of Harvard’s School of Medicine revealed in his surveys that Americans made more office visits to non-MDs than they did to MDs. His shocking surveys revealed Baby Boomers made 427 million office visits to non-MDs in 1990 compared to 388 million visits to MDs, then his follow-up survey in 1997 revealed that the numbers to non-MDs rose to 629 million while the numbers to MDs went down to 386. As he mentioned, maybe "alternative" isn’t so alternative anymore.
Despite this trend to alternatives, the medical cartel has resisted any changing of the guard. Most hospitals still deny staff privileges to these licensed non-MDs. Many health insurances still deny or greatly limit alternative care. Workers’ compensation programs still deny chiropractic care even though it is legally covered. Indeed, a medical bias still haunts our healthcare delivery system despite the public’s obvious usage, despite research and studies showing the cost and clinical-effectiveness of chiropractic care over medical methods.
Dr. Pran Manga, Ph.D, medical economist and Professor Doug Angus, Director of Masters Program in Health Administration at the University of Ottawa, concluded in their report that the exclusion of chiropractic services from mainstream medical services has caused increase costs to taxpayers and patients alike. Furthermore, they discuss the concept of distributive justice as a factor in improving health care:
"We would argue that the principle of distributive justice, and a parallel principle of equality of opportunity, require that the government implement all cost-effective substitutions; failure to do so results in unfairness to the taxpayers and unfairness to certain health care professions…. The monopolization of the health care services turf is also inequitable from yet another perspective. It denies some professions equal opportunity to earn income commensurate with their ability…Curiously, the professions that have and still suffer the adverse effects of the inefficient use of our health manpower have not used this argument forcefully enough to encourage and urge the desired reforms. They should."
The fact that chiropractic care for LBP cases is proven to be faster, safer, cheaper with longer-lasting results and three times the patient satisfaction rate than medical methods belies the discrimination chiropractors encounter in many facets of health care—hospital privileges denied, insurance limitations, workers’ compensation bias, to name but a few of the hurdles DCs face daily. Not only are chiropractors suffering from this professional bias, but patients also suffer from this discrimination when they are forced into back surgeries and denied viable options to their care. Taxpayers also suffer by paying outrageous taxes for funding Medicare and Medicaid programs using expensive medical services that are avoidable in many cases of LBP. Insurance policy holders also suffer increased premiums with the exclusion of cheaper alternative services.
Chiropractors, as taxpayers, should also be outraged by this distributive injustice. Our taxes pay for public hospitals, yet the medical cartel has effectively monopolized these facilities by excluding any competitor they wish. Before the recent research that verified SMT for LBP, these professional bigots justified their boycott of chiropractors by claiming there was no proof. After the proof came from the RAND Report, Manga I and II, the AHCPR study, and the British study headed by Meade, to name but a few, it silenced these criticisms, but didn't change their discriminatory policies.
Now the problem with integrating chiropractic into hospitals and mainstream healthcare is, oddly, that SMT is too cheap. Apparently hospital administrators want the most expensive procedures to profit by, not the cheapest. Workers’ compensation programs also dislike chiropractic care because it’s too cheap. As I was informed by a workers’ compensation rep, "If we pay out less, we have to charge less. But if we pay out more, we can charge more in premiums, so there’s more money for everyone." Yuk, yuk, wink, wink.
So, what will it take to overcome this distributive injustice? The powers-to-be are resistant to charge less money for medical services in hospitals, so we can forget their voluntary cooperation. The workers’ compensation programs also dislike us because we’re too cheap. Politicians ignore us because our PACs do not have as deep pockets as the AMPAC.
I believe our only hope will be through the courts. Perhaps the lack of informed consent will force hospitals and surgeons into telling patients of all their options. Perhaps public outcry to include alternative health care into the mainstream will be an avenue. But as long as the insurance/medical/hospital cartel is profiting greatly from the present system, I doubt meaningful change will occur. It’s just too profitable to be a monopoly, and where capitalism rules, the folks with the most money win.
Bill Clinton recently spoke at the United Nations about maintaining open markets despite the downturn in the world’s economy. He implored that by not restricting the markets, the US was able to prosper unlike other countries. I wondered if an open market is so great, just when will we see this in healthcare to bring down the outlandish medical costs? Without an open market to allow free and unrestricted competition, market forces cannot prevail to allow the best services at the lowest prices. In fact, the sham marketplace of healthcare is the primary reason why the medical cartel prospers while they stymie all other forms of healthcare.
I concur with Dr. Manga when he mentioned in his report: “Curiously, the professions that have and still suffer the adverse effects of the inefficient use of our health manpower have not used this argument forcefully enough to encourage and urge the desired reforms. They should." Just when will chiropractic follow his suggestion and argue to the press and politicians his point of “distributive injustice” and its impact on the sham marketplace of healthcare and the astronomical costs of medical care? When will there be an open market and free competition in healthcare? Or are we relegated to second-class status fighting for the crumbs of the medical world’s failures?
The Final Solution: An Open Marketplace
One answer is to eliminate the medical cartel and return to an open marketplace. It's that simple. Re-introduce the same dynamics in healthcare as in the rest of our economy—free enterprise, open competition, and fewer government regulations.
The chiropractic market changed from being a basically free enterprise without insurance coverage characterized by a cash practice consisting of a high-volume, low-service care typified by chiropractic adjustments alone. Patients paid in cash before insurance began coverage of chiropractic services, and although most DCs did not live in great wealth, many made moderately good incomes.
With the inclusion of insurance coverage, chiropractic practices changed to more emphasis on selling additional services, i.e., more exams, office visits and modalities, along with an increase in insurance fraud with runners, NOOPE, TWIP and higher fees. With the focus on revenue, many DCs aim today not at a professional health relationship between patient and doctor, but on monetary reward instead. Indeed, the negative effects of creeping capitalism in healthcare can be seen in both the medical and chiropractic professions.
Bait-and-switch advertisements combined with NOOPE are moral hazards that seduces patients into care with no responsibilities such as co-pays, deductibles or concerns about over-treatment. Instead of patients looking for the best chiropractor to meet their needs, the focused has now changed to which DC is the cheapest. MCOs have also changed the link between doctors and patients from personal reasons to financial ones.
Creeping Capitalism vs Creeping Socialism?
New paradigm shift in chiropractic care due to new financial forces in marketplace with inclusion into insurance programs illustrates what creeping capitalism can do to any healthcare profession. From its initial roots as a ‘hands-on’ healing art along with intense ‘people-skills’ needed to re-educate patients to chiropractic principle of joint dysfunction rather than the medical model of ‘pulled muscles’ or ‘slipped discs,’ chiropractic care today in many instances resembles many medical practices with shorter office visits, less ‘hands-on’ care, less efforts to re-educate patients, and more insurance fraud than ever before.
Obviously it’s the motivation and not the class of providers that determines its viability to offer quality care at fair prices. While the medically dominated system we presently have illustrates the excesses of a cartel, it’s unlikely that their grip will loosen to allow for more competition to enter the current system. It would be naïve to think there’s room for other types of providers on the medical pedestal.
Whether its the downside of creeping monopoly capitalism motivating doctors by greed or creeping socialism in healthcare removing motivation for industrious doctors since no financial rewards exist, neither system seems appealing. The conflict between giving patients too little care as the MCOs would have it, or too much care as the monopolistic fee-for-service system encouraged, both healthcare systems appear to be flawed in terms of giving patients proper care at a fair price.
Free Enterprise in Healthcare
Somewhere in the middle lies the answer, but in a free enterprise society, it is difficult to rationalize why every other facet of our economy is regulated by free enterprise except for healthcare. The logical answer seems to be instituting an open marketplace within healthcare to allow free enterprise to prevail. Stop with the monopolistic control of the medical cartel by opening all public hospitals to any licensed provider. The sham explanation that staff privileges are to protect the public from charlatans is a smokescreen for anti-competitive restraints.
Open insurance coverage to any license provider rather than only MDs. Eliminate medical gatekeepers for HMOs since their gate remains closed to non-MDs. By injecting an open marketplace in the healthcare system, the cream will rise to the top once again. No longer will patients be forced into one type of treatment because their insurance discriminates or their MD fails to provide adequate information about all treatment options to allow the patient to make an informed consent.
As well as removing anti-competitive forces in healthcare, another solution is to eliminate mandated group health insurance and allow for medical savings accounts (MSAs). If people want to save for impending costs of medical services, they can always take the $400/month for insurance premiums that the average family spends and invest it themselves into MSAs. If they've taken care of themselves and not had to use it to pay exorbitant medical costs, they can keep the rest for themselves (as opposed to the insurance companies keeping the balance).
Another benefit of a free enterprise healthcare system would be the lowering of costs. Most people don't have $50,000 for a bypass surgery or $20,000 for a back surgery. Surgeons would have to lower their prices to a reasonable rate, or else they would price themselves out of business--just what a free marketplace is designed to do. For those patients with no money, a single-payer safety net system like Medicare would still be there to help. But for the majority of people under 65, a free marketplace would create better services at lowered costs.
No longer would a Golden Goose exist to supply huge payments for relatively little work--which is exactly what the MDs now have. Since most adults are covered by group health insurance, the medical profession continues to charge exorbitant prices. In fact, they have the consumer “over a barrel” in that you have to have medical insurance to protect oneself from their high costs. However, if a free market prevailed, better services/products at lower prices would occur, thus lowering the cash price of typical medical procedures, just as the chiropractors have done for many years.
Another aspect of a free marketplace in healthcare is the lack of guarantees or warranties as in manufacturing. Lemon laws and warranties will guarantee the consumer if the product fails, they have the recourse to a new product or their money is refunded. Only in the sham marketplace of healthcare do we hear the proverbial medical excuse of a botched procedure: “The operation was a success, but the patient died and here’s a bill for $50,000” as too many people have been told after an ineffective surgery. A no-pay for no-results policy would drastically cut down on the presumed 80-90 percent of surgeries that are deemed unnecessary because doctors simply wouldn’t take the gamble if they stood to lose money. As long as insurance covers for any outcome, including bad ones, the only risk is on the patient.
If guarantees in healthcare were used, many unnecessary/ineffective surgeries would never be done in the first place. No surgeon would gamble on a risky outcome, especially if he was held financially liable on every case and not just when a lawyer proved malpractice. By definition, a failed procedure ipso facto is malpractice. Why are patients/payers asked to pay for a failed service? No where but in medical care is this done. Instead of experimenting on patients with medications at will, if doctors were liable for drug reactions and interactions, let alone failed results to control symptoms, fewer drugs would be prescribed and the 2.2 million cases of adverse drug reactions annually would be greatly diminished.
Another glaring problem with public hospitals is the ability of the medical society to exclude any competition they so desire. The reigns of control over who is allowed on staff is solely in the control of the medical staff, so any practitioner of another profession such as chiropractic finds it virtually impossible to gain staff privileges. Presently of the 5,000+ hospitals in the US, only 200 have chiropractors on staff.
Patients in hospitals are routinely denied access to chiropractic care and other forms of non-allopathic treatments due to this monopolistic control. Although the Wilk antitrust suit won by the chiropractic profession ruled against discrimination to boycott chiropractors, obviously very little has changed. Until each hospital has DCs on staff, patients will be denied a freedom of choice and chiropractors will be denied distributive justice—the right to compete for business.
Imagine if the Atlanta airport was taken over by Delta Airlines because it was the largest server and then they kicked all other airlines out. The uproar would be huge, to say the least. But when a similar situation occurs in our public hospitals, nothing is said. Obviously the sham marketplace of hospital medical care has become so well ingrained into our society that few people complain about the lack of open competition in a free enterprise system.
Double Standards for the Business of Healthcare
Whenever I hear legislators bellow the benefits of the free marketplace, I ask why don't the same rules apply to healthcare business? I've never gotten a response, ever. The examples of an unleveled playing field in healthcare are abundant. For example, I don't understand why a public hospital is taken over by the medics, then they declare it's a "privilege" to be on staff, determined by them alone. That's equivalent to a public golf course being taken over by one group to the exclusion of all others, only to be told it's a privilege to be doled out by the powers-to-be. What's wrong with this picture? At the golf course it would be considered discrimination or racism, but in the hospital, it's a privilege.
All I can imagine why politicians are against a free marketplace in healthcare is because they understand it's a huge, powerful and vindictive cartel that is out of control. Look what happened to Clinton’s Health Care Reform Act--shot out of the water by the insurance companies, medical society and other medical alliances. Why would they want to reform their own virtual monopoly? And since they own most politicians with their PAC contributions, their lobbyists, and their under the table dealings, the insurance/medical world is safe from being forced into the free enterprise system.
If the Golden Goose is starved from a lack of insurance money funneled to it, the system would collapse causing untold disasters for patients and doctors' incomes. While a transition would be difficult, in the end a free marketplace would in fact lower costs and improve services. We've already seen this with the breakup of AT&T, for example. Deregulation of the airline industry also proved successful. So why can't the government deregulate the healthcare system? End all subsidies; open up the public hospitals to all providers; allow MSAs to pay for services; and encourage an open marketplace with fair competition.
A Medical Utility?
Some would argue that the medical health care delivery system is considered a public utility rather than a standard business, hence they should not be viewed as participating in free enterprise. After all, public tax monies support the various elements that comprise the healthcare delivery system—build and support medical schools, public hospitals, fund Medicare and Medicaid, and so on. Just as public monies build and support our police and fire departments, some look at their local hospital in the same regard.
However, there is one huge difference between a true public utility and the medical system, that is, the police and fire departments don’t charge citizens ungodly amounts of money when they perform their services. Imagine your house on fire and the fire truck pulls up, but before they turn on their water hoses, the fire chief hands you a bill for $50,000 and asks for your credit card. Imagine a policeman before he enters your home to arrest a burglar asking for $20,000 to catch the thief. If these two cases occurred, we would be incensed knowing they were public servants.
So why does a public hospital operating on public funds charge inordinate prices for doing their public service? Is it ethical for these public servants to charge outrageous sums after being supported by public monies? It seems they have the best of both worlds—public and private. Public monies put them through med school and build and support their overhead in hospitals, then they are allowed to charge for their services.
The Trend to Alternatives
Another glaring omission in the present healthcare delivery system is the lack of prevention. While HMOs lay claim to this intent, a medical HMO is an oxymoron—in no way does any drug or surgery prevent chronic, degenerative diseases. At best they may be early interventions, such as pap smears and mammograms, but none of these procedures prevent the onset of disease. Good health is not a function of taking more drugs or having more surgery; good health comes from healthy habits and preventative measures found mostly in the “alternative” health care professions. In effect, we have a medical system with no “toothpaste”, if you will.
Obviously, the “ounces of prevention” are not as lucrative as the “pounds of cure” for the medical cartel. After years of ridiculing any and all forms of natural alternatives, the medical profession was stunned by David Eisenberg’s study on usage of alternative care by Americans. He found that 40% of adults regularly used some type of alternative care; most users are college-educated baby boomers; and more stunning was the huge number of users—his 1990 study revealed 388 million office visits to MDs while there were 427 million visits to non-MDs. Seven years later, his follow-up study showed a 50% increase of alternative care usage to 629 million visits while the use of medical care decreased to 386 million office visits. Additionally, much of this expense to alternative providers was paid out-of-pocket by the patients, indicating their willingness to go outside the prevailing medical cartel. Obviously, this study supports the contention that quality health care at reasonable costs are affordable and sought by the public despite the lack of third-party payment.
The New Value System of Healthcare
Woolhandler et al. conclude their article with a very interesting comment:
“But our main objection to investor-owned care is not that it wastes taxpayers’ money, nor even that it causes modest decrements in quality. The most serious problem with such care is that it embodies a new value system that severs the communal roots and samaritan traditions of hospitals, makes doctors and nurses the instruments of investors, and views patients as commodities.”
While their sentiments are well-taken, these features of the present medical system can also be viewed as a direct result of a cartel—no competition to force better services at lower prices; huge financial incentives to motivate hospital administrators and providers to over-utilize services leading to huge amounts of unnecessary surgeries or to find loopholes for fraud and greed, e.g., the Columbia/HCA fraud. The huge monetary incentives also attract people into the healthcare field whose main goal is financial rather than samaritan, thus patients are viewed more as commodities rather than as people with whom doctors are supposed to develop a healthy relationship—the present 28 second average office visit doesn’t allow for anything much more than a high-volume, low-service format for providers.
But, is this situation a result of doctors being forced into such inadequate behavior by greedy HMOs or for-profit hospital administrators, as Woolhandler would argue, or is it also a function of greedy doctors’ own zeal to make their average income of $200,000? Many doctors have walked away from this HMO model of care to re-invent their practices. Many chiropractors have long held fast to resist the high-volume, low-service model forced upon some by MCOs, thus explaining why Gallup polls indicate that chiropractic patients have three times the satisfaction rates compared to their medical counterparts. There does exist a choice for every provider—it simply depends upon the moral guideline that motivates each, and their ability to wean themselves from the lucrative carrots of the present cartel.
I fear until the medical cartel is dismantled, health care of all types in this country will only worsen--shorter hospital stays that become more expensive; doctors motivated more by greed than service; more expensive insurance with more restrictions on medical and alternative care; more dependence on the pounds of cure rather than the ounces of prevention; and more fraud and greed among hospital and insurance administrators. Until an open marketplace in healthcare based on free enterprise is established, we can expect only more of the same worsening health care at rising costs. Until a true healthcare reform occurs with a return to the roots of free enterprise, we cannot expect, as Woolhandler et al. complained, to "weed out firms that offer inferior products at inflated prices."
Chiropractic Future Scenarios
Dr. Clement Bezold of the Institute of Alternative Futures headed a group of researchers sponsored by NCIMC on the future role of chiropractic in the year 2010. IAF’s findings include four scenarios—good, bad, not-so-bad and transformed.
Scenario 1) More and Better Health Care: Managed care, outcomes and consumers drive health care. Chiropractic care is proven cost-effective for low back pain, headaches, neck pain, arthritis, scoliosis, asthma and repetitive stress injuries, and as supplementary therapy for cancer and other conditions where the disease or treatment involves significant pain. Wal-Mart creates “the back center” in its stores and expands access to low cost chiropractic care. There are 103,000 chiropractors, with average visits per week holding at about 120, with back conditions representing 50% of visits and wellness another 20%. Underemployment among chiropractors holds at about 15%.
Scenario 2) Hard Times, Frugal Health Care: Chiropractic is drastically affected by frugal universal coverage through managed care; outcomes limit manipulation to back problems. And 50% of spinal manipulation in 2010 is delivered by physicians, nurses and other health professionals. Chiropractic colleges close as only 68,000 chiropractors are needed in 2010. Many of those still practicing are forced to sell the “$10 treatment.” Wellness visits decline and underemployment grows to 35%.
Scenario 3) Self-Care Rules: Very effective self-care, including advanced home health systems and universal catastrophic coverage, make health care a buyer’s market. Individuals and families can do most of their care very effectively at home, lowering the need for all types of providers. Surplus providers exceed the 450,000 number forecast in the 1990s by the Pew Commission. Health care professionals who provide “touch” are in high demand but competition is fierce. Chiropractors are able to increase demand significantly by ensuring they provide care to 60% of those Americans with back problems (rather than 40% as in the 1990s). Chiropractors also expand the indications they can treat with proven efficacy as well as provide evidence that for many people wellness visits are appropriate. The success of chiropractors leads to 85,000 chiropractors in 2010 (about 20,000 fewer than anticipated in 1997), but they are doing well.
Scenario 4) The Transformation: Chiropractors’ clarified and expanded vision for the profession leads them to expand their contribution to health outcomes for their patients and their communities. Wellness and self-healing resulting from enabling the body to function effectively (the innate healing force) become much sought-after contributions of chiropractic manipulation—so sought-after that 50% of manipulation in 2010 is performed by non-chiropractors. Chiropractors broaden what they do with and for their patients and their communities. For their patients they combine intelligent information systems with high touch and assertive coaching. The wellness emphasis of health care and the success of chiropractors in treatment and wellness leads to 108,000 in 2010 with 10% of these chiropractors employed in non-clinical roles and only 6% underemployed.
Time will tell us what actually prevails in twenty years, but whichever rules, it may also be greatly affected by other motivations outside of these four scenarios if the present factors still exist. If the managed care organizations want to offer the most clinical and cost effective treatments, then chiropractic SMT would definitely be included since for the majority of back cases we are faster, cheaper, with longer-lasting results and higher patient satisfaction rates.
Unfortunately, being the cheapest isn’t necessarily a great attraction to many in the healthcare delivery system. Whether it’s attorneys looking for the highest meds via back surgery for MVA victims, or the hospitals wanting $20,000 back surgeries to fill their beds instead of $800 chiropractic-resolved LBP cases, or workers’ compensation railroading LBP patients in for surgery because, as I was told, “If we pay out more, we can charge more in premiums, so there’s more money for everyone.” Yuk, yuk, wink, wink.
Obviously, being the fastest and cheapest form of LBP care is a disadvantage in the greedy world of healthcare. Despite the call to lower healthcare costs, rarely has the MCOs looked at this paradox, nor do they question the high costs of the 90% of unnecessary back surgeries. This odd revelation is due to what Dr. Bezold termed “perverse motivations.” Incidentally, these perverse motivations were never factored into the four scenarios his IAF created.
Although a glaring problem, it seems the MCOs actually prefer higher costs so as to generate more money through higher premiums. While the rest of the world’s socialized healthcare systems are trying to save money, the American system actively uses the most expensive and least clinically-effective methods for the epidemic of back problems. Only in a for-profit system does such irony occur.
So, I’ve decided to create a few more scenarios for chiropractic based upon my experiences as a practicing chiropractor and as an observer of this profession’s many dynamics. Lest I be reminded I’m not a Ph.D. in research, please allow my professional observations to have some merit.
Scenario 5) For-Profit MCOs Reign Supreme: After killing Clinton’s Health Care Reform Act of 1994, lobbyists of the medical/pharmaceutical/MCO cartel take control of this trillion dollar industry. AMPAC buys most legislators and Republican presidents ignore pleas of consumers that healthcare insurance is expensive and inadequate, and kill any meaningful Patient Bill of Rights. Ignoring federal guidelines from AHCPR that spinal manipulation is preferable and that “Surgery has been found to be helpful in only one in 100 cases of low back problems,” hospitals, workers’ compensation and most all health insurance companies continue to exclude chiropractic care from its core benefits since it’s too cheap. Chiropractic remains on the fringe, out of the loop of mainstream healthcare.
Scenario 6) CAM Scams Increase: With an over-abundance of chiropractors graduating from diploma-mills, struggling DCs join CAM affinity programs which are out-of-pocket cash programs which offer huge discounts to consumers. Willing to work for 30-50% less, chiropractors develop turnstile practices where emphasis is placed on volume, not quality care. Wal-Mart begins a “Spines ‘R Us” franchise in its stores to capitalize on the CAM scam, and young grads with $100,000+ student loan debts flock to join.
Scenario 7) HCFA Prevails: After lengthy litigation, Sec. Shalala and HCFA prevail in federal court. Medicare MCOs actively recruit physical therapists to treat back pain, ignoring the “subluxation” diagnosis altogether—they simply treat “back pain.” Since PTs are willing to follow strict guidelines of care, unlike chiropractors who offer various versions of SMT, the public and MCOs are satisfied, knowing what they are buying. Chiropractic colleges see decline in numbers, and a few go broke due to profiteering administrators.
Scenario 8) Unity & Public Relations Prevail: After declining legislative victories and the loss of MCO coverage due to the HCFA defeat, the various chiropractic factions finally decide to unite and overcome their petty philosophical differences. Similar to the AFL-CIO merger, the ACA and ICA become the UCA, state associations also unite and garner strength in numbers by actively recruiting the many scab DCs by offering practice empowerment programs to teach ethical and effective practice management. A national television PR campaign to improve chiropractic’s image takes three years to become effective. It is paid from a $200 service tax on every practicing chiropractor despite the protests of a few ol’ time chiropractors who still obstruct unity and progress. Half the number of chiropractic colleges exist as in 1999, with stricter guidelines for administrators’ qualifications and higher entrance requirements for students. A few legitimate state universities include CAM and chiropractic in their curriculum, and many of the expensive chiropractic diploma mills go bankrupt.
While Dr. Bezold of the IAF may disagree with my four scenarios, nonetheless there is some validity of each. At his presentation at COCSA, Dr. Bezold mentioned that we chiropractors must “create the future you want by strength of your vision.” He listed five factors to create a lasting vision:
He mentioned that our collective vision must be “worthy of the field.” With such diversity of opinion in our field, I’m uncertain what “worthy” might constitute. But, as Dr. Bob Argyelan, former president of the California Chiropractic Assn., has mentioned repeatedly, we DCs must focus on our “commonalities,” not our differences. Until the factions put aside their philosophy/dogma/religious differences and focus on our political, economic, and sociological needs (unity, parity, and public relations), we will continue to wallow in our differences, allthewhile remaining weak, ineffectual, and wondering why. Golly gee, go figure.
So, is the future of our profession going to be the will of futurists concerned with a shared vision, or will it continue to be a function of obstructionists railing against unity for egocentric reasons? Can DCs see the value of a shared vision of unity, parity and improving our public image, or will we remain factions fighting a turf war amongst ourselves?
It’s obvious the need is to move forward with our common goals and vision. Do we have the courage to say good-bye to old issues of old autocrats who are strangling our present and will certainly kill our future unless the present generation revolts? Just consider these eight scenarios and decide which one you prefer. As Dr. Bezold said, we need a shared vision, filled with our highest aspirations that stretch our reality, and one that is worthy of our profession. If unity, parity and an improved public image aren’t goals of our collective vision, what is? More of the same old mess and out-dated rhetoric? I pray not.
 The Philadelphia Inquirer, Sunday, Sept. 12, 1999.
 Woolhandler S and DU Himmelstein, When Money is the Mission—the High Costs of Investor-Owned Care, NEJM, vol. 341, No. 6, pp. 444-6, August 5, 1999.
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 Eichenwald K, Gottlieb M. Health care’s giant: when hospitals play hardball; a hospital chain’s brass knuckles, and the backlash. New York Times. May 11, 1997:D1.
S. Bigos, et al., “Acute Low Back Problems in Adults, Clinical Practice Guideline No. 14,” U.S. Public Health Service, U.S. Dept. of Health and Human Services, AHCPR Pub. No. 95-0642, Rockville, MD: Dec. 1994.
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