March/April 1996

Any Willing Provider Laws

Are Any Willing Provider laws the White Knight chiropractors need to gain entry into a restricted "Managed Camelot" or a Trojan Horse designed by the insurance industry as its ultimate weapon?

The major theory behind managed care is that by controlling the number of providers it allows to service its contracts, insurance companies are able to control increases in health care costs. The emphasis is on the word "theory" because, to date, there has yet to be a verifiable study which confirms that any managed care plan has been successful in containing long term health care costs.

That does not mean that there has not been an effect on the health care system. Indeed, the managed care system has brought greater efficiencies to virtually every part of health care. Literally every procedure and operating assumption has been scrutinized to see if it could be performed in a more efficient manner. The savings, unfortunately, have not gone to the consumer. Every new managed care company wants to build its own clinics and administrative offices. In each of these buildings, management insists on the newest equipment and the latest technology.

For the most part, it has been the provider community and the public who have paid the price. The provider community, who has seen drastic reductions in its compensation; and the public, who has seen its access to health care significantly reduced. While insurance companies have shifted the financial risk of providing health care from its corporations to the provider community, they are reporting the same historical levels of profitability.

Provider/patient relationships

Providers have been particularly concerned with their inability to serve the needs of patients in their communities. Families who may have had a relationship with their family chiropractor for decades have suddenly been told that this relationship must end.

Why? Not because the doctor in question does not have adequate skills. In fact, he or she may have excellent clinical skills. Not because they are unwilling to work hard. In fact, these may be among the hardest working chiropractors in the community. And not because these doctors were unwilling to accept the financial terms offered by the managed care companies. Because, most often, these doctors are never even offered a contract by the managed care companies.

The managed care companies simply make a business decision to select doctors who met their criteria, and do not consider how those decisions will affect the lives of their policyholders. Because they restrict the number of chiropractors who are allowed to service a contract, the insurance company has already made one very large financial mistake.

When an individual has been seeing the same provider over a long period of time, that provider develops a unique understanding of the individual. The type of understanding that you can not obtain just by reviewing their health care records. The doctor who is going to take over the patient's care understands this. They know that it takes time to build an understanding of the patient. Moreover, because they do not want to incur the risk of malpractice, they will often subject the patient to a new round of examinations and tests "just to be sure" they understand every nuance of a patient's condition. The knowledge and understanding that the patient's previous doctor had acquired over years and years is wasted.

The patient is hurt because, at least initially, they will not receive the quality of care that they had been used to. They must also learn to overcome the natural anxiety that occurs until they develop confidence in their new chiropractor. Of course, in a managed care environment, that new relationship may be sort lived. Because there is nothing to prevent the insurance company from once again replacing their doctor as soon as the current contract has expired.

Potential of any willing provider language

Some believe that the solution is adding "any willing provider" language to the statutes that govern the selling of insurance on a state or national level. Under this concept, any provider that meets the credentialling requirements of the insurance company and is willing to accept its contractual terms would have the right to belong to the group. Providers see this as a means of insuring their right to develop and maintain their patient relationships. They also look at it as a means of avoiding the huge financial problems as a result of losing a significant portion of their patient base.

Managing cost by limiting access

During the initial rounds of state and national health care reform, the insurance industry has fought hard against these proposals. They believe that if they do not have the right to control the size of the provider population, that they will not be able to control the costs of health care. In one respect they may be correct. If part of their financial strategy has been to contain cost by controlling access, any willing provider laws would hurt them badly.

Using this strategy, managed care companies deliberately select providers that are inconveniently located relative to their population of subscribers. In most cases, this involves locating the providers a considerable distance from the homes or work places of the subscribers. By making access more difficult, the managed care company hopes that the patient will choose to live with the discomfort of their problems for a longer period of time, rather than be inconvenienced by the long trip to the chiropractor's office.

This is particularly true for a chiropractic patient. A patient suffering from a back or neck problem may find it very difficult to drive long distances. If they are forced to do so in order to reach the provider selected for them by the managed care company, they may actually exacerbate their injury because of the length of the trip. If they choose to delay their visit because of their discomfort, the very patients who need care the most have been effectively denied access to that care by the managed care company.

This same lack of sensitivity is displayed in major cities when a provider has too many patients assigned to them. The increase in patient volume means that they can no longer provide the quality of care previously experienced by the patients. If the patient does not have access to their provider on a timely basis; or, if the provider does not spend sufficient time examining or treating the patient, the patient loses.

Long term, patients may not be the only losers. Patients who are given inadequate treatment for small problems have the propensity to develop larger ones. Ultimately, this cost will be borne either by the providers or the insurance companies, depending on the compensation arrangement when the patient comes back for the more serious problem.

Current managed care relationships

Would any willing provider language solve this type of problem? Perhaps. But it is equally possible that any willing provider language is a Trojan horse designed by the insurance industry as its ultimate weapon. To comprehend its secrets you must first understand the business relationships of chiropractors and insurance companies as they stand today.

Managed care companies have been successful because while they have limited participation and compensation, they have not had difficulty in filling their panel of chiropractors. Chiropractors have been all too willing to give up some of their rights in order to protect, or expand, their base of patients. When, in rare instances, managed care companies are not able to find sufficient chiropractors to meet their needs, they take the same action as any business in a competitive situation--they increase their financial offer to make the contract more attractive.

Negotiating in an any willing provider environment

Because the insurance industry would have won the right to be competitive in the marketplace, they will have the right to modify the contract in any way they choose. This means that not every chiropractor will necessarily receive the same contract. While the insurance industry would not want to exclude chiropractic altogether; they would merely seek to do what they are doing today--to manipulate the contract terms in a manner that allows them to control the number of chiropractors in the group.

An individual chiropractor could, of course, accept any contract. The terms might be terrible, but anyone would be free to accept them. Complaining to the public or the legislature would not be of much help. The public and government officials would remember how the chiropractic community claimed this language was vital to their interests. The insurance industry would respond with an avalanche of financial data supporting their contention that the system was functioning properly. As a result, chiropractors would have to live with the situation for years before anyone would give credence to their concerns.

Potential safeguards

There are safeguards that would help alleviate many of the problems associated with any willing provider language. They include:

s Minimum care standards. In a managed care environment that has financial disincentives for providing needed patient care, the chiropractic community should develop the standards for the minimum amount of care a patient should receive.

These standards might include:

1. A patient history, which details all pertinent aspects of the patient' s current condition and past health status. The Mercy Guidelines could be used to define this responsibility.

2. A competent physical examination commensurate with the patient's condition or complaint. The Mercy Guidelines could be used to define this responsibility.

3. A diagnostic impression. Again, the Mercy Guidelines could be used to define this responsibility.

4. A course of treatment, which is intended to cure, relieve, or ameliorate the patient' s symptoms, or to improve or maintain function. This treatment would be provided until a defined therapeutic benefit is reached, unless interrupted by patient non-compliance or self dismissal; or, proper referral of the patient by the chiropractor to another licensed health care provider.

5. Written records of the findings and procedures performed. The Mercy Guidelines could be used to define this responsibility.

These standards would insure that a patient is not discharged for financial reasons.

1. Accurate information. State and national chiropractic associations must provide their members with the type of business education that allows them to completely understand the risks of each contract they are presented.

Because the practice structure of chiropractors is small compared to the larger hospitals and clinics of the medical profession, chiropractors do not have the financial management resources of other health care providers. The state and national associations must provide this resource to their members or they will be at a considerable disadvantage.

You cannot afford policy made by anecdote. Information must be given on a timely basis, and in a manner that states facts clearly, so an individual chiropractor can make an informed decision as to what is in their best interest.

2. Frequent communication. Again, the chiropractic profession is at a disadvantage to other provider groups in this area. Whether it is through grand rounds in a hospital, or over the lunch table in a large clinic, other providers have more opportunities to discuss business issues.

Chiropractors must be willing to meet with each other, on a regular basis, to share information. State associations must guide this process so that chiropractors format their discussions in ways that do not violate anti-trust laws.

These discussions are so important because chiropractors are not trained as business men and women. In addition, they do not generally have business managers to assist them with these decisions. The complexity of these issues demands informed discussion among chiropractors in their communities.

The medical community also suffers to a lesser degree from managed care companies who restrict access to medical care. For this reason they are strong supporters of any willing provider language. The difference is that they already have many of the above safeguards in place. Without the safeguards, the chiropractic community could be insisting on a solution that would guarantee even bigger problems than it now has with the managed care industry.s

Russell A. Leonard, of Madison Wisconsin, has served as the Executive Director of the Wisconsin Chiropractic Association since April of 1990. He is responsible for all facets of trade association management including financial administration, health care policy development and members services. Please contact Mr. Leonard at 608-256-7023.