April 2006, Vol. 16, No. 2

Table of Contents

CCE Recognition by USDE Set to Expire • CCE Response Spurs Follow-up Complaint • Differentiating Neuromuscular from Musculoligamentous Subluxation • Chiropractic Pioneer Passes Away • Early Life Infections Improve the Function of the Immune System • European Spine Journal Publishes PosturePrint® Study • ICA Defending Chiropractic from PT's • Immunization • Letters to the Editor • Life University Teaches CBP® as an Elective • The Ineffectiveness of Over Accommodating • Parker College and Seminars Begin Celebration Preparations • PosturePrint® Used to Determine Stability of Upright Posture • CBP® Hits 91 Publications • Thanks for Helping Your Local HMO Grow! • The Perfect Chiropractic Storm • Three Keys to Practice Success • Building Wealth Securely: Maintenance, Not Pain Relief •

back to front page

Thanks for Helping Your Local HMO Grow!

Why Have We Been So Stupid?

by John Gartner, DC

           In the most colossal show of generosity in American health care, about 80 percent of US chiropractors signed onto HMO panels in the 80’s and early 90’s. We were told that by participating we would see more patients, keep from losing our present patients when they signed on to the HMO’s, and make more money from treating all these newly covered folks. God, it was thrilling. At last, equitable insurance coverage. A dream come true. Some of us even paid anywhere from $150 to $2,000 or more to sign on to these wonderful “panels” of doctors who were predicted to have all the business within a few years. Our State and National Associations kept a respectful distance out of fear of anti-trust violations. But they bought into the concept that Managed Care would control most health care in the future. They saw nothing harmful in their officers working as representatives to various HMO’s. The thinking then was: “We can work from the inside to guarantee a better benefit.” What a wonderful rainbow to chase.

            Well where are we now? Our incomes have been sharply reduced. Chiropractic fees are less than they were 10+ years ago. Old guys are quitting practice, younger docs are having a hard time paying the rent. Many of them unable to get onto HMO-PPO panels — that were closed before they graduated from school! Somehow they don’t close panels as easily on the medical docs, just chiropractors. Must be because of our enormous utilization.

            In a sharp change from what used to be when chiropractors competed in an open market — patients no longer come to us because we are “good” or because we can help them when ordinary medical treatment failed. No, now the only criteria is if we are “covered.” As a bonus, the “covered” doctor gets to spend quiet week ends in the office, away from the press of family commitments, to create longhand paperwork for additional visits, usually far fewer than the patient’s condition rightfully deserves. Nobody seems to get the amount of treatment they need any more. Nobody is getting paid what we used to get paid. A logical consequence of our sharply rationed treatment is that our clinical results are dropping off. Either we get a “cure” in the HMO average of 6.8 visits or we have to tell the patient we can’t afford to work with them any more. That’s either because we can’t live on $20 - $25 co-pays — or because the contract we signed prevented us from treating covered patients privately once the HMO “allowance” was used up. The result is that many patients are forced to go the medical route and wind up taking Celebrex, Vioxx (forever) for complaints that the chiropractor was either controlling or reducing. And if (when) the drug treatment of these conditions happens to cause more serious side effects, advanced (read expensive) medical treatment for those will be covered by the HMO. Clearly there is a double standard.

            Our chiropractic service has become so rationed, so increasingly difficult to justify with ever more documentation, that hardly one in a hundred patients gets the kind of treatment s/he used to get before we signed up. In some cases, our HMO patients get notices that any treatment beyond the HMO allowances are “unnecessary.” Like it or not, such a letter to a patient paints us as either as over-utilizers or lousy doctors. It puts us in a no-win position.

            So today, instead of exercising the competence we earned by going to school and getting licensed, we have been reduced to playing “Simon Sez’ chiropractic, relying on the opinion of some former tire salesman as to the amount of chiropractic treatment our patient’s receive. This is a profession??

            As the HMO’s have grown and prospered, the chiropractors have seen their gross receipts shrink - markedly. Clearly, we have been “roped in.” It is now abundantly clear that Managed Care was a Trojan Horse. Do I have your attention?

           With rationed care and a more limited response to treatment, there is no doubt that our patient satisfaction surveys will be less favorable than they used to be in the 70’s and 80’s. Given their proven tendency to further restrict our service, it seems me that it is only a matter of time before the HMO’s data will prove that chiropractic is not effective enough to be a covered service.

Are we getting anywhere?

            From where I stand, it seems like everyone is taking a hit — everyone except the HMO’s, PPO’s and the carriers that utilize them. Insurance carriers and HMO’s continue to post healthy profits. Insurance executive salaries and bonuses are in the millions. In spite of that, they seem able to keep raising rates year after year. They blame it exclusively on increased utilization.

How can HMO utilization be so high when we are seeing patients less and less all the time? How can premium rates climb when payments for our services are at the lowest level in years?

            Something is wrong with this picture. What’s wrong is that we are not really a part of this program. We are tolerated and limited, clearly not effectively utilized. It is also clear that our colleagues working “inside” the HMO’s have done us more harm than good. Our treatment is often limited to conditions that are substantiated with evidence. Extremity problems, Otitis Media, visceral complaints are strictly taboo. It’s spine only with emphasis on non-surgical low backs. The fact that the anecdotal evidence supporting our treatment of spinal complaints is actually better than the anecdotal evidence supporting treatment with pain meds or spine surgery means nothing. It is obvious that they are not interested in a chiropractic benefit. Saving money is the last thing on their mind.

            At least ten times per day we hear media messages about is the high cost of health care. This is no accident. Isn’t it time to ask where exactly the ever increasing cost comes from? Clearly not from the “managed” treatment chiropractors provide. Nobody mentions it but a fair amount of the cost comes from the management of the HMO’s themselves. A good example is a Buffalo NY HMO, named “Americare” that was started about 15 years ago. The first thing they did was spend a million dollars of our premium money to name the local baseball stadium “Americare Park.” How exactly did that reduce health care costs? Look at the buildings HMO’s have been putting up across the country. It quickly becomes clear that either they aren’t starving or they have a cousin Vinny. In spite of increased utilization, the buildings keep going up - getting more regal — even while they tell the regulators that they have to raise rates because utilization is so high. Nobody seems to be mentioning the scandals, like the Health South fiasco where the CEO (Scrushy) had to refund his 47 MILLION dollar Bonus. In February, 06 Insurance giant AIG was hit with a record 1.64 BILLION fine for FRAUD! These are the very people who spend our premium money to pay for commercials telling US to fight insurance fraud! Ironic eh?

            There are lawsuits against HMO’s all over the country (go to Google.com and look under HMO Lawsuit Watch). One soon realizes that many of the HMO’s — who demand such scrupulous documentation to make sure we are honest are themselves run by people who not only appear to be less than honest, they are found guilty of FRAUD! Clearly these folks aren’t sharing any of the pain. Instead, while we work for less and less, they are sharing record salaries and bonuses. These are our advocates?

           How did this happen? Simple. Because we allowed it to happen. And we keep allowing it to happen. History proves one thing: These companies need ever more money. They never get enough. They use our patients and US to improve their profitability.

           After about 10 years of this nonsense, our professional associations started getting the picture. It has gradually sunk in — we are the victims of a world class shakedown! Our leaders now tell us we must sue these HMO’s for a better chiropractic benefit. We are told that these lawsuits are vital to our survival; that we can’t walk away from this fight. We’ve got to sue them for a better benefit. And just as we willingly finance the HMO’s profits, we get an equal opportunity to finance the lawsuit(s) that seek an equitable benefit - from the same people who all but promised us the moon just 10-15 years ago! Unfortunately, this expense falls on our shoulders just when today’s chiropractors find themselves a little short of cash.

           It is plain by now that if we want to practice like real chiropractors, we will have to look elsewhere. Today’s HMO is not our model. Never has been — never will be. The managed care industry has had some two decades to study our work and reward good practices etc. It hasn’t happened. There is simply no basis for optimism. Nobody’s happy. It’s time to move forward.

            We now find ourselves in the same position as a common junkie; afraid to quit our addiction to that meager HMO allowance for fear of the pain that is sure to follow without it. Could be true. However, more than a few of our colleagues have done just that. They responded to limited treatment allowances, week ends away from the family and decreasing gross receipts by gradually developing other work, with PI, with Comp, with private patients. They have developed innovative fee systems that regular folks can afford - and that put hard cash (not promises) in their pockets at the end of every day. They are biting the bullet and climbing out of their comfort zones by getting out of HMO’s that make their lives miserable, that keep them from enjoying their families. They refuse to work for peanuts. Rather than wasting their time doing dumb paperwork, they are developing their chiropractic skills, actively seeking new patients because they are better — not just because they are “covered.”

           Is it easy? No. Doctors who never got onto any panels had to develop a practice based on good doctoring and sharp personal marketing skills. Those who really applied themselves have prospered. Those doctors who simply sat in their offices waiting for a practice to fall on their heads have been disappointed.

            The hard truth is that eventually we each learn that there are better and worse ways to practice this fine healing art. It’s time for us to quit relying on the HMO to make our clinical and financial decisions and seek to improve our personal practice and bottom line. Rather than being an HMO robot, it’s time to become a true professional. Let’s get back to doing those things that have historically built thriving practices. Things like developing our chiropractic skills, our patient communications, our examining and treatment skills, our personal practice marketing; our involvement in our communities. The HMO “generation” has taken our attention away from these things. It has caused us to become “generic” practitioners, just doing what they pay for. This has hurt us badly. It’s time to make some decisions.

           Is there any help? You bet. It’s time to start doing what too few of us do —visiting with our local colleagues. Make the effort to spend some social time with some of your area colleagues who either dropped out of one or more HMO or who never got into them to begin with. These doctors have more than a few answers. Ask them what they would do in your position. The good ones will spend time with you — once! You can often get some great guidance from these doctors. More than a few of them have done some serious study about the practice of chiropractic. Of course, if all you want is to hear their story and not make any changes yourself, you may as well forget the whole idea and simply re-adjust that millstone around your neck.

            If visiting with your colleagues isn’t enough to set you on the right course, it’s time to look around for a good practice coaching organization. With all due respect to their detractors, these practice management organizations have generally gotten a bum rap from our profession’s leadership in the past. More than a few of our leaders who have castigated practice management organizations have been up to their ears doing IME?s or working for insurance or HMO interests.

            Practice management organizations operate in a free marketplace. The record shows that some have advocated procedures considered to be less than ethical. We aren’t talking about that sort of firm. The truth is that ever since the 30’s, chiropractic practice management firms have been helping practitioners improve their practice management and patient management skills. They alone have concentrated on what works best, what makes practices thrive in the environment of their times. Today’s ethical, sensible chiropractic practice management firms are an excellent source of help in today’s chiropractic marketplace. They will cost you some money but it’s usually worth it. Look for those who have been around a while; companies with a good track record. As with anything else, there are good ones and bad ones. Do your homework. Talk to their clients (and former clients) in your area. Look for the ethical ones that impress you. Just remember that they are not ALL bad, not by a long shot.

           The future is OURS doctor. It belongs to the chiropractic practitioners. It does not belong to our professional associations, the schools, the IME’s or our colleagues serving as IME?s or insurance company representatives. It belongs to each and every licensed practitioner! Given the shortage of funds all around the profession, it is clear that we practitioners, not our organizations — have to develop and grow the market for our individual services in our own communities, just as we always have. Impossible? Not on your life. Following such a course stands to become the turning point in your career.

            Bottom line: Don’t just sit there doctor. Get uncomfortable! Make some decisions and follow through. Think for yourself. Make plans. Make changes. Don’t wait for the crowd (which is usually wrong). Move! Challenge your ideas. Take charge of your future. Decide to be a professional instead of a robot. Do the thing, and you will have the power! We all should refuse to join these things (or if you are in them, get out!). Then they will have no coverage for patients and patients will ask for coverage elsewhere.