JC Smith, MA, DC
While attending the recent COCSA meeting in San Diego, among the many excellent speakers, one in particular caught my interest. 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.
bviously, 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 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:
- 1. It must be legitimate
- 2. It must be a shared vision
- 3. It must stretch beyond reality
- 4. It must have high aspirations
- 5. It should be achievable within a specific time frame
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 prez 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.
At the COCSA conference, in casual conversation with ICA and GCC reps, I asked them when will the two associations unite into one? After their mouths dropped to the floor, their responses seemed more one of frustration than antagonism. The ICA rep, Dr. Tom Klapp, said that he tried to unite the factions in Michigan, but the ACA side wasn’t interested. The Georgia Chiro Council prez, Dr. Bob Porter, mentioned that until a few egos were gone, it probably wouldn’t happen even though political unity was necessary. Dr. Larry Stemp mentioned to me that he was able to unite the three factions in Washington state, so maybe there’s hope after all—we just need to do it in every state.
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.
But, what do I know? I’m just a country chiropractor wondering when our profession will mature and unite to create our vision into reality.