Chiropractic Economics recently caught up with Louis Sportelli, DC, to discuss how health care delivery of the future will be “managed” to insure value, clinical necessity, adequate outcomes, cost-effectiveness and patient satisfaction and how the profession’s largest specialty care network is poised to provide equitable chiropractic services.
Dr. Sportelli, two years ago you accurately predicted HMO gatekeepers would be obsolete ["Goodbye Gatekeepers,” March/April, 1997]
Where do you feel managed care is headed now?
When managed care first started, every newly developed model was going to be the model that worked. As time went on and the problems began to unfold with each particular model, almost every one has fallen by the wayside, and a new one has emerged to take its place. The entire issue of managed care and the various models can be summed up by stating that every single entity is essentially a “work in progress” as opposed to a proven “health care model.”
The whole process of health care delivery is changing every day, and my hope it that it is being driven by a better-informed consumer. The managed care fiasco has been in place for about nine years. When it was first introduced, consumers were terribly confused by the terminology, the selection process, the change from doctor-driven to corporate-driven and the lack of any control over their health care. Today consumers are not as confused. They know exactly what they want, exactly what to look for and have the ability to differentiate hype from substance. This issue of managed care is going to be driven and changed by old-fashioned consumer demand that will be emphatically conveyed to employers, payors and the government.
What is the next model going to be?
Complementary and alternative health care is everywhere and it’s become almost a “craze.” When the Journal of the American Medical Association (JAMA) devoted the entire November, 1998 edition to complementary and alternative medicine, you know something is happening. Not to mention every popular magazine, newspaper and television health show is featuring entire segments on everything from acupuncture to Zen. Ironically, they are not disparaging these therapies; rather, they are doing serious informative programs to point out the benefits of “why” the therapy may work, while not yet understanding the process of “how” it works.
How will this impact the future delivery of health care?
You may ask, “Where does this all fit?” Chiropractic and the other disciplines that have been labeled “alternative” must be incorporated into the basic benefit package of all health insurance coverage. There also needs to be specific provisions to ensure “direct access” by the public to these services.
Having said that, there will be a corresponding accountability on the part of every provider. The days of providing unlimited care without validation or clinical necessity and evidence of benefits regarding functional outcomes will never again be permitted. In other words, the health care delivery of the future will be care that is “managed.” Managed to insure value, clinical necessity, adequate outcomes, cost-effectiveness and patient satisfaction. All health care providers will be asked to demonstrate the same criteria. If they can provide the documentation, they will be permitted to participate; if not, they will be excluded.
Why do you feel this will happen?
Simply because the previous health care system was a total economic disaster. The new health care designers simply took the old system of fee-for-service and transposed it into a managed care model. The system did not work previously and will not work now simply because it has been given a new name. The underlying issue is “health care” and “wellness” rather than “acute heroic disease care.” Many employers and health care organizations are now starting to understand the inherent value of keeping employees healthier. They are seeing it is less expensive than attempting to treat them when they become ill. A new wellness model is emerging from the ashes of the old system. A model that is driven by long-term and ongoing health promotionnot immediate and costly acute sickness intervention and crisis care.
How does the movement toward wellness fit with the medical model?
The entire health care system is being turned upside down. The positive aspects of medicine cannot be denied. For example, these superb aspects of medicine and crisis care will be needed crisis intervention, innovative surgical techniques, trauma care, genotype and phenotype research and even “smart drugs.” Yet, as these areas expand, they still do not address chronic illness.
In terms of general health care and progress with chronic diseases, medicine has been a dismal failure. We are looking at a model in transition. People are recognizing that the bio-medical model, which has dominated for a hundred years and has had billions of dollars allocated for research has not produced a “healthier” society. This recognition, driven by economics, has now forced everyone to take a fresh new look at how we deliver health care and what health care truly means.
What is the force behind the movement toward wellness care?
The new model is partially driven by economics and partially driven by the recognition that the old model is not working and has significant long-term impact. For example, consider the issue of antibiotic resistant organisms, the iatrogenic complications of many new pharmaceuticals and the adverse and complicating effect of long-term treatment with medication. These issues are understood today not only by the medical and pharmaceutical industry, but also by government and the general public. The evidence can be seen in the avalanche of interest in complementary and alternative health care. Consumers are willing to spend billions of dollars out of their own pocket for care they believe to be effective. People are looking for something to help with their chronic illnesses. They are no longer mesmerized by the proclamations of the American Medical Association, which may try to denounce the methods as fraudulent.
The public is now seeing the AMA and other prestigious institutions instituting courses to teach medical doctors about alternative and complementary health care and how to use it. People are willing to experiment with St. John’s Wort for depression and Saw Palmetto for prostate hypertrophy, Glucosamine and Chrondroitin for arthritic pains and botanicals and homeopathic remedies are increasingly being used by the public.
Additionally, the public recognizes that chiropractic has been around for 100 years and it has not only survived the onslaught of negative press and an organized effort to contain and eliminate the profession, but it has flourished. The public knows and recognizes that chiropractic is the best intervention for neuromusculoskeletal problems, back pain, neck pain, headaches and a host of ailments related to the spine and muscular system. They are willing to visit a Doctor of Chiropractic because they know that “pain” is disabling and “pain” can alter their life. The public has determined what and where the value of health care is, and they are willing to utilize the particular providers they trust and have confidence in, regardless of what others may say. People are now exercising their ability to make independent decisions about their health.
Who is going to pay for chiropractic care and other alternatives?
As the November issue of JAMA revealed in the study by David Eisenberg, MD, “Trends in Alternative Medicine Use In the United States (1990-1997)” people are spending a lot of money out of their own pockets. They made 629 million visits to alternative health care providers and many of these visits were to Doctors of Chiropractic. They spent approximately 29 billion dollars on alternative care and are now beginning to make demands on the government and their employers that they want chiropractic and other alternatives included in their health care coverage.
The debate coming in the year 2000 and beyond will be centered on policy issues of what should and what should not be included in the basic health care benefit package. This is one of the most critical components of the health care debate that will change the health care landscape for everyone provider, patient and payor.
What is the position of the HMOs and PPOs?
When we look at this issue from the standpoint of the HMO and PPO communities, they are locked into the old medical model every service has a cost. If they want to reduce costs, they need to reduce services.
This concept is now being challenged by economists who recognize that lowering costs by utilizing safe and effective conservative care can and will save significant money than more costly interventions. While this is a theoretical model, it will soon emerge with data to support the premise of utilizing and incorporating chiropractic and other cost-effective care. It will prove, in fact, that overall costs will decrease and overall health care gains will significantly improve.
How has the change to managed care affected the way doctors practice?
Although this issue is not discussed very much, the managed care model has destroyed one critical fundamental component of healing the doctor-patient relationship. If people do not have a choice in selecting their doctor, do not have confidence in the provider who is assigned to them and cannot develop the necessary rapport with their doctor and vice versa, then a significant component of healing is missing. This basic fundamental element of the healing process must be re-established if “health care” and “wellness” are to be a part of the process.
What do you feel has affected and impacted Doctors of Chiropractic in the managed care setting?
Those who control the health care system are not senseless. They realize that the movement toward chiropractic and alternative health care has reached critical mass and that the desire for and utilization of these services will continue to increase. Recognizing this fact, many HMOs, PPOs and other payor arrangements have marketed these services in a very disingenuous fashion. They have advertised that “chiropractic” services are included in their plan, recognizing that the public would consider this as a value-added benefit. Only when the consumer actually tried to access the service would they find out that chiropractic care is not being provided by a Doctor of Chiropractic or that chiropractic care was limited. Care may be limited because of a gatekeeper, a high deductible, a limited number of chiropractors or an access barrier making it inconvenient or impossible to utilize the services. Thus, slick advertising created the hype, but the practical reality demonstrated there was in effect, no such service. This type of “Madison Avenue health care fraud” will be stopped when the public recognizes they can exert control in a variety of ways.
How can chiropractic patients impact the major insurers and major employers?
There is no magic formula. The power is going back to a simple fundamental principle that has worked for decades-“old-time, grass-roots, people power.” There is nothing terribly sophisticated about it. Patients who want chiropractic services and do not have these services included in their benefit package must complain, protest, advocate, support and demand that their employer include chiropractic services in their health plan and provide unrestricted access to chiropractic care.
Every one of the HMOs, PPOs, employers and insurers have a constituency to whom they are accountable. If they continue to get complaints that chiropractic services are not included, they will soon change the model to include chiropractic services. This is how chiropractic has won every battle it has fought for the past 100 years. It is how the profession became licensed, gained legislative initiatives, gained reimbursement and other consumer benefits. That is how it will be in the future, with the next Congress and the debate over health care reform. People will have to make their voices heard and Doctors of Chiropractic will have to become advocates for the process and influence their patients one at a time.
How many Doctors of Chiropractic do you believe are currently involved in a managed care plan?
That’s a good question because it is a very deceptive number. Many will tell you that more than 75-85% of the plans cover chiropractic services. However, from my previous statement you will see that the practical application of the chiropractic benefit is virtually non-existent. HMOs, PPOs and other managed care plans have driven down chiropractic utilization in one way or another so the actual utilization is probably less than 1%.
The old model of fee-for-service indemnity plans essentially had a 10-15% utilization rate of chiropractic services. While the vast majority (75-85%) of DC’s will tell you they are involved in a managed care plan, the better question is, “How many patients do you see from your plan?” The vast majority will tell you the number is negligible. In essence, they are a “provider on paper,” but the reality is that a significant decrease in chiropractic utilization has resulted because of artificial barriers that have been designed to prevent chiropractic utilization.
Do you feel the practicing DC’s are ready to evolve with the grass roots movement?
Let me preface my remarks by stating that the new health care reform measures, whatever they may be, will have a management component to the care. In other words we may not call it managed care, but it will be carethat is managedin some fashion. There will be no more unbridled care delivered by any provider who seeks reimbursement for his or her services.
The health care delivery of tomorrow will be a “partnership of accountability.” The provider will be accountable for his or her services with valid clinical indicators for the service rendered and not some arbitrary number or economic target. The payor will be accountable to insure the fact that every provider is not micro-managed or harassed by artificial constraints on care with arbitrary caps or unreasonable denial of services.
The partnership will also extend to the patient who in the past has exploited the system with demands that were forced upon the provider because the service was reimbursed and desired by the patient without sound clinical indicators. For example, the issue of unnecessary antibiotics will always involve a strong parental demand for antibiotics for a child with Otitis Media or URI’s, despite the pediatrician’s knowledge that antibiotics in many instances would be useless at best and harmful at worst. Parental demand created the situation and greater accountability on the part of the parent will be imperative in order for the system to work.
There is a general awareness of how each component impacts upon the overall health care system in terms of utilization, costs, outcomes and satisfaction. As time goes on, the system will iron out these issues and what will remain should be a system that will improve general overall health and increase patient satisfaction at lower costs.