Articles by JCS
"Too Many Notes, Mozart"
J.C. Smith, DC
Managed care organizations appear paradoxical, especially when they market themselves as health maintenance organizations whose goal is to promote wellness and thereby limit unnecessary medical expenses. Unfortunately, as we are learning, fact is much different than the fiction of advertising. While HMOs preach a principle - wellness - that many people want to hear, in fact, the term medical HMO is an oxymoron. Indeed, by its very nature, there is precious little medical science can do to prevent the onset of any disease. While expensive exams may serve as early detection and drugs or surgery may be helpful in crisis care, as far as I know, there are no drugs or surgeries that will keep you well or improve your health. The mistaken belief that more drugs and surgery are the keys to any health care reformation illustrates the delusion of many medical experts. The solution to this dilemma lies outside the world of medical care and rests in the world of natural, hygienic health care - chiropractic, nutrition, exercise - all outside the loop of most HMOs.
The inevitability of managed care was the direct result of the medical profession strangling their golden goose of insurance for decades. For too long, their carte blanche credit card spending have driven the costs of medical care over one trillion dollars, more than the entire economy of Italy! The U.S. spends more on medical care than any other country, yet we lead the world in every category of degenerative disease and rank only 17th of the 24 industrialized nations in regards to longevity.1 Obviously the medical solution to the management of disease has proven clinically ineffective although it has proven financially quite lucrative for doctors and insurance executives alike. Disease care pays well, much better than wellness care, and that's the inherent rub that makes medical management of "wellness" care a natural contradiction. In reality, HMOs are nothing more than the proverbial wolf in sheep's clothing.
Ironically, the insurance executives jumped on this HMO bandwagon extolling the blessings of keeping patients well to fuel the obvious need to change from expensive and often unnecessary disease care to wellness care in order to reduce costs. Their overt marketing pitch of wellness care has only served to camouflage their covert intent to maximize profits by squeezing care to patients. Doctors are now rewarded for denying care to patients. In many HMO capitation contracts, physicians are bonused for limiting care and boosting the HMO's image and enrollment. On the other hand, for each dollar of emergency care, the HMO penalizes the doctor up to 50 cents.2 When income is tethered to conduct that promotes corporate profits, the ethical issue of doing what's best for the patient becomes secondary. Even most HMO managers believe that large incentives to physicians compromises the quality of care, according to an editorial article, Extreme Risk - The New Corporate Proposition for Physicians, in The New England Journal of Medicine.3
After killing President Clinton's Health Care Reform effort with complaints of socialized medicine, the insurance executives decided it was their turn to squeeze the golden goose of health insurance. Doctors have proven they were incapable of regulating their carte blanche spending habits, so the HMO personnel have replaced the traditional fee-for-service which encouraged unnecessary exams and services with their version of managed care which puts the claims adjustor in the decision making position. This "middle man" of HMO now becomes the ultimate decision maker who determines what, when, and where any medical services will be done. Instead of greedy doctors exploiting the system, now we have a situation of bureaucrats deciding policy based on profits, not actual patient needs, and treatments given by the cheapest doctors available. The net outcome of the Health Care Reform has been the insurance companies' version of socialized medicine with them in control rather than the government.
Typical of this transition from MDs to insurance administrators exploiting the same situation, U.S. Healthcare, one of the largest HMOs, serves as a good example: the CEO pocketed $20 million in a single year and holds $534 million in company stock; the company makes $1 million a day in profits, adding to its $1.2 billion cash reserve; spending only 74.4% of its revenues on medical care.4 Apparently managed care has been very healthy for the pocketbooks of those operating in the insurance rooms rather than in the hospitals. "Squeeze care and expand profits" has become the guiding light of HMOs. "We can no longer tolerate patients with complex and expensive-to-treat conditions being encouraged to transfer to our group," according to the chief of a university hospital who admonished his faculty members for treating sick patients.5 Doctors punished for treating sick patients can only ring true in the wacky world of managed care.
Another sign of incongruence in health care involves the epidemic of back attacks. With the plethora of research lately that has substantiated the superiority of chiropractic care over medical management for LBP cases, the refusal of medical gatekeepers and HMOs to give patients access to chiropractors is nothing less than unethical and expensive. As an example of medical immorality in such cases, recently a lady patient badly injured in a horrific auto accident came to my office for care. Her insurance company was immediately notified of this Grade 4 - Severe case, and following the professional guidelines from the Chiropractic Rehabilitative Association, she was placed on a four month intensive care and rehab program. At the end of this period, the patient was still subacute and somewhat improved, but needed more care to reach her point of maximum therapeutic improvement.
Her insurance carrier, State Farm, decided to send her paperwork off for an IME review, which arbitrarily determined she needed only 22 adjustments and should be on pain pills and muscle relaxers instead! Incredible decision in light of the fact this patient needed more care, not less. To make matters worse, the State Farm adjustor refused to pay much of her bill telling the patient that according to the faceless, nameless IME, her chiropractor gave her too many adjustments. Can you imagine how she must have felt to be told she had too much care when, in fact, she still was in pain and needed more care, and then was stuck with the bill! Apparently we had exceeded the insurance company's cookbook guidelines which called for half the recommended number of adjustments, no rehab, and no exceptions! Both the insurance adjustor and the IME doctor stood to lose their bonuses if this lady was given the right amount of care until she was out of pain and fully functioning again.
Another sad example of HMOs bureaucrats deceiving patients came to light recently when a satisfied "transformed" patient of mine told me her company had switched insurance programs to an Aetna HMO that covered chiropractic. But when she phoned the claims adjustor for authorization, she was rudely told her policy didn't cover chiropractic. Actually, the adjustor ridiculed her decision to use chiropractic: "Chiropractic is like cosmetic surgery, it's really not necessary. Why don't you have a back surgery instead." Can you imagine how this patient must have felt, especially when she finally discovered that her policy did in fact cover chiropractic care? Being lied to by her adjustor, being told she didn't have a freedom of choice, being ridiculed for using chiropractic care, and being insulted by the suggestion to have a back surgery instead! Unfortunately, this approach is standard in the operating procedures of most insurance companies - squeeze care to expand profits.
This situation is faced routinely by every DC and patients. While HMOs and most insurance companies seem eager to pay for unnecessary MRI exams and back surgeries, they use biased medical analysis to refuse or discourage more effective and less costly chiropractic care. On the other hand, I have never heard of any back surgery case being denied and sent to a chiropractor instead in order to save money and avoid unnecessary, ineffective surgery. The gall of medical gatekeepers to restrict cheaper, better, faster, and safer chiropractic care is enough to gag any DC. It reminds me of a situation that has been reported in the annals of classical music history. Apparently the great composer Mozart, after a monumental performance of new material, was reprimanded by a less-than-knowledgeable aristocrat who criticized his performance by saying that his work had "too many notes, Mozart." When I hear unethical MDs and claims adjustors tell me "too many adjustments, Dr. Smith," I can only think how Mozart must have felt. It's enough to make you scream in disgust!
Ironically, within a few short years of the advent of HMOs, the same MDs who once profited by giving unnecessary care in the fee-for-service system now have made a 180 degree turnaround and now profit by denying care to the same patients. As the NEJM editorial mentioned, "It is hard to be a good doctor. The ways we are paid often distort our clinical and moral judgement and seldom improve it. Extreme financial incentives invite extreme distortions."6 Not only are MDs swayed by financial incentives, now insurance bureaucrats are also swayed to make decisions that improve their own financial gain at the expense of patients. Squeeze care to expand profits is their new rallying cry. If profit is the main goal of HMOs and not servicing patient needs, the obvious question remains: when doctors all become businessmen, who will be the doctors and where will sick people go?
Although this comes as a new revelation to some within the medical world, we chiropractors have long known that financial rewards taint medical decisions. How else can one explain the epidemic of back surgeries that exists mainly in the U.S.? Even after the AHPCR mentioned in its Consumer Version of the new guidelines on Acute Low Back in Adults that only one in 100 back surgeries is helpful, the rate of back surgeries has not lessened.7 Even after Pran Manga, PhD., author of the Ontario Health Ministry's evaluation of low back pain, recommended that chiropractors be the gatekeepers for these conditions to save money and to offer more effective treatment, the insurance world has remained strangely silent.8 Considering LBP strikes 80% of all adults, costs nearly $100 billion annually, and that the average non-surgical medical back averages $7100 and a surgical back costs $14,000 according to MetLife statistics, one would logically think that these insurance executives would embrace chiropractic care with open arms.9 Unfortunately, that has not been the case because the medical powers-to-be are not interested in paying anyone but themselves for services, no matter how cost or clinically-effective chiropractic care may be for these LBP cases.
The nature of a monopoly is to eliminate competition and to offer a poor service at a high price, which is exactly what has happened in the medical industry. As long as expenditures remain high, so do the insurance premiums. The supposed answer to the soaring costs was the HMO concept to keep patients well. But medical care inherently cannot accomplish this goal, so premiums in HMOs are rising twice as fast as costs, patients' choice of doctors and treatments is limited, waiting times are increasing, and services are cut to the bone by the HMO policy to squeeze care to expand profits. HMOs are not "managed competition" as much as they are simply anti-competitive monopolies.10 And who says America doesn't have socialized medicine when both government and private insurance programs deny doctors a level playing field with open competition and patients a free choices to select the best service? Just where is the free marketplace in health care?
Obviously the Republican call for more competition to lower costs and improve services doesn't apply to the medical cartel, even in light of the movement toward HMOs. While the lower expenditures of chiropractic management are well documented by many investigators (Koes11, Jarvis12, Wolk13, Schifrin14, Dean15), the millions of cases of LBP each year are still railroaded into ineffective medical management by MD gatekeepers and HMO adjustors who seem eager to drug and cut patients without any consideration given to chiropractic spinal care. Patients are routinely denied legal informed consent as to rationale alternatives. Apparently freedom of choice is a moot issue in health care as long as profits soar.
The late Robert Mendelsohn, MD, author of Confessions of a Medical Heretic, reportedly was quoted with this poignant statement: "Anyone who has a back surgery without seeing a chiropractor first should also have his head examined." I dare say the same sentiment can be applied to any insurance company that refuses to use chiropractic care: "Any HMO that authorizes back surgery without seeing a chiropractor first should also have their heads (and policy) examined." Once this new era of the wolf in sheep's clothing strangling the golden goose ends, if there is any life left in the poor goose, hopefully the public will have learned that medical HMOs not only are an oxymoronic concept, but that real health care rests outside the medical box of solutions. As patients ascend up the learning curve to better health with new-found knowledge about chiropractic care, nutrition, aerobics and nutritional supplements, the old medical solutions of drugs and surgeries will be left at the bottom of the curve. Indeed, the only hope for patients seeking health maintenance is to think out of the medical box and to discover the world of natural health care, which is the real realm of health maintenance.
The next time an IME or HMO curtails your care and cuts your fees with the alibi of "too many adjustments", keep in mind how Mozart must have felt when told he used "too many notes." Although it might be disheartening to be controlled by the ignorant and by those who profit by others' demise, at least we DCs can keep our heads high with pride to know we're doing the right thing. And certainly, we can rest assured we're in good company. I only wish I could have heard Mozart's reaction when he was told he used too many notes.
1. Sherrill, Robert, "The Most Expensive Health Care System in the World", The Nation, Sept. 16, 1995
2. Woolhandler, S, MD, MPH, Himmelstein, DV, MD, "Extreme Risk - the New Corporate Proposition for Physicians", NEJM, vol 333, #25, Jan. 21, 1996
3. Woolhandler, ibid.
4. U.S. Healthcare announces third quarter results and dividend increase. Press release of U.S. Healthcare, Blue Bell, PA., Oct. 23, 1995
5. Calif. hopsital under fire for seeking healthier patients. Modern Healthcare. Aug. 21, 1995:172
6. Woolhandler, ibid.
7. Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in Adults, Clinical Practice Guideline No. 14. AHCPR Publication No. 95-0642. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, US Department of Health and Human Services, December 1994
8. Manga Pran, PhD, et al, "The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low-Back Pain", Ontario Ministry of Health, 1993
9. Mushinski Margaret, "Average Hospital Charges for Medical and Surgical Treatment of Back Problems: United States, 1993", Statistical Bulletin, Apr-Jun 1995, Metropolitan Life Insurance Company, Health and Safety Education Division, Medical Department.
10. Sherrill, ibid.
11. Koes B.W., Bouter L.M., et al. "Randomized Clinical Trial of Manipulative Therapy and Physiotherapy for Persistent Back and Neck Complaints: Results of One Year Follow Up," British Medical Journal, 7 March 1992, vol. 304, pp 601-605
12. Jarvis K.B., Phillips R.B, et al. "Cost per Case Comparison of Back Injury Claims of Chiropractic versus Medical Management for Conditions with Identical Diagnostic Codes," Journal of Occupational Medicine, Aug. 1991, vol. 33, #8, pp 847-52
13. Wolk S. "Chiropractic versus Medical Care: A Cost Analysis of Disability and Treatment for Back-Related Workers' Compensation Cases." FCER, Sept. 1988
14. Schifrin L.G. "Mandated Health Insurance Coverage for Chiropractic Treatment: An Economic Assessment with Implications for the Commonwealth of Virginia." The College of William and Mary, Williamsburg, VA, and the Medical College of Virginia, Richmond, VA, Jan 1992
15. Dean D.H., Schmidt R.M. "A Comparison of the Costs of Chiropractors versus Alternative Medical Practitioners," University of Richmond, VA., 13 Jan. 1992