A roundtable report from the Chiropractic Summit’s Integrated Practice Workgroup.
The Chiropractic Summit was founded in September 2007 for the purpose of addressing the key issues facing the chiropractic profession now and going into the future. The members of the Summit represent key constituencies and leaders in chiropractic, and they meet several times a year to coordinate their activities and gain consensus on Summit initiatives.
To work as efficiently as possible, in addition to meeting together, Summit members form working groups that focus closely on areas of critical interest. One of these is the Summit Integrated Practice/Professional Satisfaction Workgroup, which seeks to explore how DCs can better work in tandem with other healthcare professionals.
On August 31, 2015, the Integrated Practice Workgroup met in the form of a roundtable moderated by Chiropractic Economics to discuss pressing concerns and identify best practices. Below are highlights from that meeting.
CE: What is an “integrated practice”?
John Nab: Many in the chiropractic speaking network say integrated practice is anybody doing two or more services, meaning maybe the chiropractic adjustment and nutrition. I’ve also heard the other end of the spectrum where it is a multidisciplinary team working within the same location.
I would like to think that an integrated practice is a patient-centered health support team that focuses on the mind, body, and spirit that is cost effective, value-driven, outcomes-based, high-quality care with the patient at the center.
Mark Sanna: Oftentimes, we think of the multidisciplinary or integrated practice as being one that combines both allopathic and holistic therapies with both a corrective and a wellness type of an approach and combining them both to have, as you said, a patient-centered practice focused on producing the very best outcomes.
Jim Powell: An integrated practice, I think, would be more natural healthcare providers, depending on the scope and licensing in the states to practice in like massage therapists and acupuncturists and physical therapists and non-drug related therapies, where the multidiscipline is defined where chiropractors are working with other disciplines, medical or otherwise.
Mark Ford: I think there are two definitions. One would be a non-drug integrated practice where you have different practitioners who are non-allopathic. I would consider that integrated, as well. So that would be an example of an integrated practice that’s not multidisciplinary but I think all multidisciplinary practices are integrated because you are having a holistic and allopathic approach.
Jim Powell: In the integrated practice, you need to be able to communicate with other disciplines and that’s where I think the students today are much more aware of the need to do that because we have patients that both disciplines may be taking care of but the doctors have not communicated well enough.
Ray Foxworth: One of the first steps for us is to truly make the distinction between what we’re calling an integrated practice and a multidisciplinary practice because I think those terms, to a lot of people, are interchangeable. In my practice model, we have an integrated campus. So they have neuro and orthopedic surgery, physical medicine and rehab, PT, pain management and pain psychology.
Brendan McCann: At its most basic, integrated practice is healthcare delivery which creates continuity between providers as patients find complete care for the issues and illnesses that limit them. It acknowledges that no single provider can fully address every patient, and seeks to maximize efficiency as providers work in a team.
Mark Sanna: Yes and they don’t necessarily have to be within the same entity. In other words, they could be referral sources and an integration with the community versus a single practice or corporate structure, as well.
John Nab: So the integrated practice must have high degree of collaboration and communications with other healthcare professionals.
Ray Foxworth: Well, there’s just often one other modality so if we take historically the “chiro only” versus someone who’s using rehab and therapy and nutrition, are we considering that an integrated practice as well, or is it only when we are working with someone, another professional or paraprofessional inside our walls or outside of our walls?
Jim Powell: I think the reality is that most all chiropractors do work with medical providers. So I think our profession is integrated in that respect without having to be in the same building together in a multidisciplinary definition.
David Odiorne: I’m not sure that simply making a referral rises to the level of being integrated. We’ve all made referrals for a long time but I’m not sure that brings the level of collaboration that’s required to truly be an integrated practice.
Mark Sanna: I agree. There has to be a level of co-management, cooperation and collaboration between the various disciplines.
Mark Ford: To me, having two young chiropractors in my office, is the concept of actually having other professionals within your own group and having that collaboration under one roof, that’s what’s different than what’s been in the past.
Winston Carhee: Yes. I would agree with that analysis. My thought of integrated practice is having another professional, another discipline, working within your entity and then collaborating using that to treat the patient.
Ray Foxworth: This is one of those things where there’s no right or wrong. This is a relatively new concept term in healthcare, historically, so I don’t think there is a Funk and Wagnalls definition that we can refer to that would satisfy everyone.
CE: Does the integrated practice model work well in chiropractic?
Mark Sanna: I think it can work extraordinarily well and I’ve also seen it sink practices. So if it’s done correctly, properly and with the right intent with the focus on the patient in delivering cost effective care, it can be a wonderful adjunct. If it’s used as some sort of scheme or a scam to defraud insurance companies and fool patients into receiving unnecessary tests and treatments, it’s a fiasco.
Brendan McCann: Conservative care and primary care should be the first options. Ensuring communication between providers and minimizing the time and expense to patients should benefit both patients and practitioners.
CE: Do you think that integrating a practice compromises chiropractic principles?
Jim Powell: I agree, that it is a compromise on one side or the other. You’re going to have to find a holistic MD that believes in what we believe in or you’re going to have to have a chiropractor that’s going to compromise their principles of natural healthcare to work comfortably with the MD.
Mark Sanna: I think that there is a very clear scope of what chiropractors do and excel at and a very clear scope of when allopathic medicine is a necessity. I think with a clearly defined scope of what each of us does, having the two disciplines work together can be a synergistic and successful combination.
Brendan McCann: To me, chiropractic has never been about opposing other forms of care, but rather about providing an appropriate spectrum of care, with conservative options addressed first. I see integrated practice as an opportunity to ethically provide more specialized chiropractic care, while ensuring that patients will have access to other providers if their needs are beyond the scope of services I provide.
John Nab: If chiropractors are providing quality care, effective care, value-driven care, getting the right outcomes doing what they do within their scope, I don’t think there’s any compromise at all. I think we all probably agree the best healing modality is the power of touch and there’s nobody better than a chiropractor in a health support team that does that.
Ray Foxworth: This is interesting. In the practice model that I have, even from some of my old colleagues, I’ve been lambasted for “selling out to the MDs and working with the MDs” and my perspective is a bit different.
I do consider myself a portal-of-entry healthcare provider and I think it’s my obligation to try to take a patient and do the most conservative, least invasive, least expensive things first in a conservative mode.
However, when it’s clear that what they have is outside of my scope, I would much rather be in charge and be able to direct and guide that patient where they should go to providers that I think will provide the level of care they need rather than doing surgery on a first date like some surgeons are known for.
So from that perspective I don’t see that that compromises my ethics or my principles as a chiropractor. I am still doing my best to serve the best interest of the patient, even if that means outside of my office.
Mark Ford: In my practice that’s what I have found. If I’m thinking about what’s best for the patient, I realize I can’t take care of everything and what better way, if they have to have some other choices, than have that practitioner within my practice? I’d rather have them under my wing and knowing what’s going to be happening rather than sending them out where they may disappear or be led down a path that’s not the best thing for them.
So to me, as long as I’m staying within my scope and realize what the other scope is and we can collaborate together, it is great having an allopathic provider who has the same mindset as you.
CE: Are there any examples of outstanding success with an integrated practice?
Mark Ford: We actually had brought in a pain management doctor who I’d worked with for a number of years and I had referred to him for over 20 years in an outlying town because we didn’t have any pain management people in our small rural area.
I’m sure all of you have sent patients out; maybe they needed an epidural, etc., and you never saw the patient again or you weren’t sure of the outcome and when we brought this pain management doctor into our office and we had those patients we had run through our chiropractor protocol and we didn’t want them to have surgery and the MRI indicated they might be a good candidate, it was remarkable after that medical doctor had worked here for a year he goes, “You know, the patients I see he have better outcomes and get better faster and you have less surgeries than the patients I just see in my practice alone.”
This was a guy who had been in practice 20-plus years and, to me, that was a great success and in that one year that I had him here, I never sent anybody for surgery and that may have been the first time in my 33-plus-year career I’d never sent somebody to a surgeon. So to me that was an outstanding success.
Ray Foxworth: That’s the experience we have. Our model is distinctly different. My practice isn’t under the umbrella of NewSouth NeuroSpine, but we’re on the campus, all in the same building and we’re all partners in this development. I can think in years past when I would refer a patient out and, like you said, sometimes they disappear or it could be two or three weeks before you can get a consult with a neurosurgeon and there’s nothing like being able to call an extension upstairs, have a pain management doctor or neurologist literally come down and see the patient in your suite.
That truly is collaborative. It’s trying to do what’s in the best interest of the patient and what has really been interesting is there have been a number of cases that I truly thought were surgical and it’s nice to have the surgeon say, “Nope, they’re not surgical. You guys need to keep doing what you’re doing.”
Having that collaborative mindset among the physicians that we have in the building and, trust me, it’s not with every neurologist in the building or every doctor in the building, but those that get what we do and appreciate what we do, they are sometimes great proponents for patients continuing with chiropractic care because they do see that we have great outcomes.
John Nab: Look at the rousing success the Cancer Treatment Centers of America put into their integration. I know there are other entities with chiropractors. One would be the Alliance Institute for Integrative Care in Cincinnati, Ohio. If I remember right there’s four medical doctors, there’s three chiropractors, and then there’s a whole gaggle of other healthcare professionals and they’re holistic and I believe they get that rousing success, very similar to the story we just heard where the patients had better outcomes than they do if they were to go to any one of those people individually.
Mark Sanna: Some chiropractors have adopted a formal medical-home model and reimbursement model that accompanies it. The concept of the chiropractor working in conjunction with providers to deliver a higher-quality level of care is certainly something that’s driving the medical home model.
John Nab: A chiropractor does not have the ability to start a patient-centered medical home or an ACO, is that correct?
Mark Sanna: They can’t start an ACO, but the chiropractor can actually direct a medical home. So there are two. The ACO is hospital-based, a little bit larger, with the same concept of managing cost and outcomes for a population of patients. But a chiropractor can actually be in the driver’s seat in a patient-centered medical home and there’s a great white paper on the Foundation for Chiropractic Progress website that’s available for download for chiropractors who want more information about the chiropractor’s role in the medical home.
CE: Have you seen any clear barriers or failures to integrate a practice?
Ray Foxworth: This question brought a smile to my face. Short story, but it actually happened: My practice was in South Jackson. I was also practicing at the VA Medical Center and I was invited in to practice at a rehab center and, literally, we were down to picking out the carpet and the X-ray equipment and we got a call that said sorry, but the CEO of the practice found out we were bringing a chiropractor in and his medical colleagues said there’s no way they would send patients if they had a chiropractor on staff.
The bottom line is, attitudes change one funeral at a time, and I will never forget when I got the phone call that said, “He’s passed, come on over.”
I see less of it today than I did 20, 30 years ago, but there are absolutely still some of those hardcore attitudes out there that are anti-chiropractic, but the good news is I have seen a tremendous change in that and that’s significant being in a state that was the second to last to license the profession, second to Louisiana.
Mark Sanna: I’d add an additional component is that when becoming an integrated or a formal corporate multidisciplinary practice, the Medical Practice of Corporate Medicine Act changes in each and every state. So you may have to jump through various hoops to legally create an integrated entity; it’s very much state-dependent.
Then once you do develop that entity and follow all of the rules and regulations, we’re seeing some challenges with credentialing providers. There are some carriers where this is still very much cutting-edge and groundbreaking, where credentialing the group becomes a difficulty.
As Dr. Foxworth said, it is also very much based upon you getting involved, who you know, who you can meet, getting them to know you, and I see that’s how those barriers are broken down one at a time, person to person.
David Odiorne: Off topic but just a side note because my daily mail just landed on my desk, and just for interest the issue of Acupuncture Today, which just came out, the lead story is entitled “The Integrated Medicine Puzzle: Putting the Pieces Together.”
Winston Carhee: I think the climate is just right for the term “integrated practice.” The whole healthcare field is looking for ways to improve outcomes and I think for years chiropractic has been to the side, its own subset of healthcare, and now we’re moving into the mainstream, so to speak. That’s important if we want to increase the number of people who are exposed to chiropractic, that we do integrate and allow the medical doctors to easier access chiropractic care to make it easy for them to refer back and forth such that the majority of the population will get to experience chiropractic in that phase of care where we are most effective.
Mark Sanna: I agree. It is about patient access and that the practice that adopts the integrated model, whether it’s as Dr. Powell recommends, interacting with the physicians in the community, or the other model that we’re discussing is having them under one entity, that it’s all about patient access. The greater you integrate with the medical establishment, the greater will be the access of patients to the care you deliver.
Jim Powell: I think the integrated practice as it’s being defined here is a great option for those interested in that method of practice, but it’s not necessarily where the chiropractic profession should go. There’s all sorts of options, and if a chiropractor wants to focus on working with the VA then that’s a great track to follow; or corporate wellness or primarily nutrition or combining with other practitioners like massage practitioners and acupuncturists. But then those chiropractors who would like to work in an orthopedic office, there’s nothing wrong with that either. I don’t think it’s where chiropractic belongs. I think it’s a great option for students to consider what track they want to be on rather than when I went to school you either got out on your own or opened an office or you didn’t make it. Today, there are all sorts of options.
Ray Foxworth: I agree 100 percent and I don’t recall in the discussions at the Summit or along the way that this was to try to steer the profession in any given direction, but I think our challenge has been to get students coming out and coming into the profession. What you and I did 30 years ago, now are distinctly different and they do have some significant, some wonderful options that we didn’t have. So hopefully our discussion and what comes out of this workgroup gives them a perspective of the range of options they have, rather than you’re either solo or you’re an indentured servant, as has happened in the past.
John Nab: Regarding access for the patients, consumerism is happening and I think with all the advances in sciences and research that’s out there, not just focused on the body but focused on the mind and the spirit and, quite frankly, politically, even philosophically as a culture, the patient is willing to embrace and even value a holistic approach. So we have to skate where the puck is going. I think patients have more data than they’ve ever had before to make decisions and we need to make sure that when they’re looking at that data, that chiropractic is something that they can find.
Daniel Sosnoski: As this point was raised I think we can all agree that the purpose of this group is to not attempt to steer the profession towards integrated practice as the future of chiropractic but I think we can agree that it does have the opportunity to strengthen chiropractic as a modality within the umbrella of all healthcare options by helping it become more mainstream and more widely recognized by the public.
Jim Powell: The public is looking for a doctor or practitioner, a licensed professional to go to for non-drug care. With all you hear about the addiction problems and the cost and side effects of medicine, if you are in an integrated setting are they going to feel safe that this is going to be more holistic or is it going to be watered-down holistic?
So the chiropractor who represents natural healthcare will become even more needed in the future as more people recognize that natural healthcare is effective and affordable. But I’d rather go to a non-medical doctor before I’d consider going to a medical doctor. I think that moving in with them is a good idea but to change or water down our philosophy would be a big mistake.
Mark Sanna: Jim, I want to piggyback on that. As you mentioned, patients are coming into chiropractic practices with a whole laundry list of drugs. It’s not unusual for patients to be on six-, eight-plus drugs when they come into a chiropractic practice. And in a properly structured multidisciplinary integrated practice, it would be the allopath’s job to take patients off of those drugs and that’s a great way that the two professions work together. It’s not so much the allopath ends up writing prescriptions but actually gets the patients off of the prescriptions with the right mindset.
Jim Powell: I agree and the harmony that can be best in an integrated practice like that needs to be more of a holistic-focused medical doctor and that’s who you’re defining, someone who looks forward to taking people off drugs. That’s not necessarily the mainstream medical practitioner. Because of their training they feel that people need that as their solution to their problem, but the integrated practice with a holistic MD would be an ideal situation.
Brendan McCann: I see practical barriers to integration that are consistent throughout the healthcare industry. One is recordkeeping and communication between providers. There is great redundancy in healthcare records, and so far the EHR systems have not done an impressive job of reducing this inefficiency.
Mark Ford: I’m in a rural area. We are the place to go for chiropractic care and the big awakening to me when we brought on a medical primary care person was that I didn’t realize how many people went to the primary care medical provider for back problems. I thought I was the guy. It was remarkable how many people were going to them first and with them having the mindset of understanding what we do, of course, they’d say, “You need to go see the chiropractor.”
The other thing was when we first brought on medical people some of my 30-some-year wellness patients were like, “Well, Dr. Ford, are we going to be in the same reception room with these sick people?” I had to tell them you’ve been coming in for 30 years with sick people and they had no idea. It was a real eye-awakening thing to me and my patients, too. It helped my patients who were coming for back problems that we treat more than that. I thought I was a good educator. But then all these back, musculoskeletal, neuro-musculoskeletal problems that were going to the allopathic guy, they didn’t realize they could come to us. That’s a win-win for the patient.
Mark Sanna: In 2016, the Affordable Care Act employer mandate kicks in, and we now have so many more people out there with these high-deductible, $10,000, $20,000 deductible policies and a shortage of primary care medical doctors. To go to a medical doctor it’s a three-, four-, five-month waiting list for low back pain, which is the worst thing that could happen to that patient. So having us be effective and affordable is going to be a major driver in seeing chiropractic rise in its use in the future.
CE: What advice would you give to the DC who wants to move into integrated practice?
Ray Foxworth: I think the most important thing is don’t go it alone. We go through school and we’re taught to do everything, our own exam, our own X-rays, our own labs, everything. So we tend to operate as islands and think we can do everything on our own and the ones that I’ve seen have problems are the guys who go out and say, “Oh, I can figure this out. I’ll set it up.”
You really need to surround yourself with true healthcare attorneys. Look for a coach or a business entity who’s done this before. In other words, don’t be the Lone Ranger. Don’t be the renegade but truly follow a proven path or track that others have followed to do this right.
Then the other thing is everybody hears about is compliance. You better have everything together in this type of practice because, just by default, as Dr. Sanna said, when they are looking for audits and things of that nature, the multidisciplinary truly integrated under one roof practice goes to the front of the line. So it’s very possible to be good for the patients and providers, but you’ve got to make sure you do it right.
Mark Ford: I’ll second what Dr. Foxworth said: You have to have someone who’s been there, done that, and bought the T-shirt. For instance, in Texas there are a lot of legal factors you have to get through, and if you don’t have a coach or someone who’s done that before, you’re going to run into a lot of trouble.
I would tell them, too, that if it’s truly that they want to create a niche where they can help the patient from every perspective, they have to have that mindset. If they’re thinking it’s going to be a quick get-rich scheme, they are not the right person for having integrated practice,
Ray Foxworth: I’d second that.
John Nab: I have a question for Dr. Odiorne: What are the chiropractic colleges doing to prepare the student for integrated practice?
David Odiorne: Well, I can’t speak for all the colleges, but certainly in our curriculum we emphasize ways to work with other professions and other modalities. We prepare students to communicate with those folks and we also have opportunities for them, within their internships or clerkships, to practice in integrated settings, VA hospitals, and others, so that they begin to get a taste of that. Some of the other colleges are doing some of the same things. And at NYCC, working in integrated settings is really woven into much of our curriculum and certainly our clinical experiences.
Mark Sanna: I was very impressed, Dave, the last time I was on NYCC campus to visit the clinic to see they actually had a whole Chinese medicine pharmacy. They had a whole nutritional pharmacy, and they actually did have coordination of care with MDs and chiropractors right there on campus.
David Odiorne: Thanks. You’ve got to get students to experience as much as you can of this while they’re still in school so that they are ready for it when they get out there.
CE: What combinations of providers and services are most effective in integrated practice?
Mark Sanna: I’ve seen the physician extender, in particular the nurse practitioner versus a physician’s assistant, be successful. When a nurse practitioner comes in to a chiropractic practice, they often have a much more holistic family practice orientation, much less of a drug approach, and I find that nurse practitioners work extremely well. Some of the most successful multidisciplinary practices that I’m aware of have a combination of chiropractor and nurse practitioner on board.
Mark Ford: I was a standalone doc for 20-plus years, and then we brought on a massage therapist and that led to a physical therapist and that led to a nurse practitioner and that led to occupational medicine, drug testing, alcohol testing, post-employment physicals, and DOT exams. That led to pain management services, which led to offering immunotherapy and allergy services. Just kind of one thing built on another and they’ve all worked successfully under the umbrella of our chiropractic organization.
Jim Powell: Dr. Ford, that’s a good point: As you brought additional providers into your practice, you were able to offer new modalities to patients in a natural way.
Mark Ford: That’s correct and the thing I like about it is that the chiropractic side is the driving force in our house, and the patients are being handled the way we would want them by these other providers.
Jim Powell: So the DC has an oversight role, a management role for the patient?
Mark Ford: Right. Using the model that we were taught through our coaching service, we have a meeting every morning and review the cases and what’s going to be the best management, the best outcome. How can this person be benefitted the most? Patients really appreciate that and not having to run all over town to get the services.
CE: What are the costs of building out this type of practice model?
Mark Sanna: To undertake a multidisciplinary practice structure, a chiropractor must first have a mastery over a practice that delivers chiropractic services before they consider adding on additional practitioners with different specialties and different licenses. So I want to know that the chiropractor can be successful at running their practice at the level that they’re at and then, as Dr. Ford said, you can seek to add different services and grow the practice. But if the chiropractor is looking at the multidisciplinary or integrated model as a way to help generate revenue before they have a well-run organization, it can sink the ship.
Mark Ford: What we found was that it was very difficult getting the medical providers credentialed within our office as far as reimbursement purposes and into the various networks. Even Medicare took longer than we expected. So you do have to have those operating expenses there to pay these providers because it’s going to be a while before you’re being reimbursed for their services.
The Summit Integrated Practice/Professional Satisfaction Workgroup
John Nab, DC, director of professional development for Standard Process.
Mark Sanna, DC, ACRB Level II, FICC, CEO of Breakthrough Coaching.
James P. Powell, DC, DIBAK, FICC, Owner of Powell Chiropractic, consultant for special projects with Standard Process.
Mark W. Ford, Jr., DC, vice president of the Christian Chiropractors Association.
Ray Foxworth, DC, president of ChiroHealthUSA.
Brendan McCann, Student ACA immediate past chair.
David Odiorne, vice president of institutional advancement and special assistant to the president, New York Chiropractic College.
Winston Carhee, American Black Chiropractic Association, founder and director of Pain 2 Wellness Center.