We recently spoke with Louis Sportelli, DC, on why NCMIC recently acquired a chiropractic managed care network. As the president of the leading malpractice carrier, Dr. Sportelli offers an insider’s opinion of how managed care may affect your bottom line.
I believe within the next three to five years you will see a total reversal in the mind-set of the insurance industry… that they will, in fact, remove gatekeepers. Not because they suddenly come to any great revelation, but they will recognize that it is not cost effective. And cost is what motivates them to do anything.
I think the second motivator will be the incredible dissatisfaction. You see, there hasn’t been a long enough time for the HMO’s to get the negative feedback from the patient, but now you’re starting to see people’s dissatisfaction particularly in America where we have had this freedom to choose our own practitioner. Now that that freedom has been removed, people are recognizing that, ‘Hey, I don’t want to go to an assigned doctor. I want to go to the one that I like.’ Patients are rebelling against their loss of freedom of choice.
The expense of the primary care provider is not cost-effective. Malpractice will increase as well. They’re finding there are a lot more malpractice suits for failure of the primary care provider to refer directly to the specialist in areas such as cardiology. And the care given by the specialist is obviously better than the care given by the primary care provider. There are a lot of things coming together at the same time to encourage the insurance industry to finally remove what constitutes an unnecessary barrier.
Will that essentially eliminate the middle-man?
Exactly. They thought it would work, but it doesn’t. Do you remember the old business of toll-gates, where they had a tollgate going into a toll road and one coming out of a toll road? Well, now they let you go in one way without paying and pay on the way out. They’ve eliminated half of the barriers and traffic flows smoothly. When somebody first proposed that idea, they thought, ‘Well you’re crazy!’ But if you go in someplace, you’ve got to come out.
We’re seeing some reasonably simple, innovative ways to correct problems. The finest solutions are always simple. We’ve erected a complex system and the complexity of it in itself will cause it to break down.
What are your thoughts on a patient’s ability to self-select care?
People are a lot smarter, than the insurance companies give them credit for; I believe the entire process of self-selection is going to be enhanced. I have great confidence that the more information people have, the better their ability to self-select.
I don’t believe there’s anybody who goes to their primary physician with a toothache, primarily because they have been educated over the years if you have a toothache, you should go to the dentist. For example, you’re starting to see advertisements on television from oncology centers who are suggesting to women that radical mastectomy is not the treatment of choice, but lumpectomy and radiation are just as good. And years ago radical mastectomies were the treatment of choice.
What are your recommendations for the practicing chiropractor?
There’s an old saying that, ‘The only problem with change is what do you do in the meantime?’ To the Doctors of Chiropractic who have felt the immediate impact and whose practice’s have downturned 30 – 60%my suggestion is hang onhelp is on the way.
Number one is the fact that there is an entire attitude changing about chiropractic. Secondly, I believe that managed care companies are recognizing that the demand, cost-effectiveness, patient satisfaction, and outcomes indicate that chiropractors are the best-suited practitioners to treat. In other words, it is to their benefit to include Doctors of Chiropractic.
Has that attitude affected NCMIC’s decision to purchase Managed Chiropractics?
Yes, that’s one of the reasons that National Chiropractic Mutual Insurance Company decided to get into the managed care business, because we recognized that there is no national player. We are attempting to meet these people at the boardroom level.
The battles of the chiropractic profession are still waging, but the method of warfare is different. In the old days, prior to licensure, chiropractic’s real battles were fought in the halls of the legislature; thus, chiropractic did an excellent job of getting licensed. They did an excellent job of passing insurance equality legislation and so forth. However, in one fell swoop, all of those efforts essentially were almost nullified by the Erisa self-insured plans. The battle is still on, except the battles are now being fought in the boardrooms of corporate America.
How can chiropractors help?
By developing and being willing to participate in gathering data for outcomes. And, yes, it’s going to mean a shift in practice patterns. Yes, it’s perhaps going to mean a little more attention to outcomes and measures that are not generally used in chiropractors’ offices. But chiropractors need to be willing to participate so that a national player, such as our new network, the National Quality Health Care Network, can build the kind of solid evidence so you can go to any player in the marketplace and say, ‘Look, this is no longer supposition, this is no longer a theory. Here are the facts-patients come in with these conditions. They’re satisfied. Here are the outcomes. Here are the costs.’
What would it take to get that data?
We’re going into a paperless world and the requirements are going to be rather simple to meet. With the new technology and the new software they’ve developed, every time a doctor transmits claims, data will be able to be extracted. It’s going to be a relatively easy thing. Thank God for the sophistication of computers.
How directly will the merger benefit the policyholders of NCMIC?
Immediately. We’re a mutual company, so we don’t have stock. Our stockholders virtually are our mutual policyholders. Everybody knows that their practice’s incomes are down between 30 and 40%. Now look at the health insurance bill you’re paying. Did it go down 30 or 40%? Where did the 30 or 40% go? Into the pockets of corporate America.
The profits of NCMIC’s new subsidiary, Managed Chiropractics, will go directly back into NCMIC, which will then ultimately go to each policyholder. In essence, every policyholder of NCMIC will virtually be a stockholder as if they purchased stock in a company that was in the health care business. How many of you would like to have Aetna stock or US Healthcare stock or Oxford stock? In fact, Doctors of Chiropractic who participate currently in managed care organizations or participate in any health care plans do not receive one dime of the profits of those companies.
Can a non-policyholder join the Managed Chiropractics network?
Essentially any Doctor of Chiropractic in the U.S. who meets the credentialling criteria can be a candidate for participation in the network. Participation in the network wholly depends upon number one, geography, and, number two, the number of insurance policies (or covered lives) that NCMIC is able to contract with. There will be a direct ratio between the number of covered lives we have under contract and the number of chiropractors in the geographic area.
By the same token, even if there are some policyholders who are not part of the network, because of the financial way it is structured, they will still be able to reap the profitability with a dividend.
How many chiropractors are currently in the network?
Approximately 2600 Doctors of Chiropractic. We are also in the process of acquiring several other managed care organizations.
What are your goals for the managed care subsidiaries?
Number one, to remove as many barriers as we possibly can and number two, to not make this punitive. We want to make sure that the Doctors of Chiropractic feel a sense of liberation. Every one of us practices under incredible paperwork and absurd information overload. We’re trying to make this streamlined and simple for the provider.
How many chiropractors do you think are currently in a managed care network?
I believe that most practitioners have participated in some network in some form. I have talked to doctors who are in no less than 30 managed care networks.
Is that in some of the larger managed care states?
Yes, and some of the more aggressive practitioners who have been sensitized to the fact that this is tomorrow.
Does this mean greater success for them?
These are probably the survivors. They’re likely working harder than they did in the 80s to meet the same kind of economic status in the 90s, and they’re probably seeing more patients to do it.
Do you see the value of a national campaign to promote chiropractic? Is that the next step beyond the research?
That’s the next step, but we need to caution that we must be able to deliver what we promise. We’re not going to survive with style over substance. The worst possible thing is to promote something for which you have no substantiation. We need to get our research house in order, and we need to focus on the type of message we want to portray. Then the true public will be responsive to it. We have to find out what the various publics’ wants and desires are. I always say ‘various publics’ because we tend to broad brush the publics, and that’s not the case at all. We are at an absolute multitude of publics and each are tuned to a different kind of messagewe need to be sensitive to that. Chiropractic has a tendency towards ‘one size fits all,’ and that’s not the case. We need to tailor our message to the various publics in ways that it will be acceptable.
Can you give a couple of examples?
I believe it is ludicrous for chiropractic doctors to spend much time getting into hospitals. Think about it. Hospitals are closing down. Hospitals are down-sizing, they are being bought and acquired by larger hospitals, and they’re being transformed into some other kind of facility. The ability to get into the hospital today has been so diminished because of the ambulatory outpatient surgery and the things that doctors are able to do in their offices that hospitals are becoming finalized trauma centers. There is almost no value for chiropractors, yet we have many chiropractors trying to get into hospitals. Do I think that’s a worthy use of your expenditure of effort? The answer is no. Was it correct fifteen years ago? Yes, because it was symbolic. We were essentially denied hospital privileges at a time when hospitals were a viable function of society. Today hospitals are really, in fact, almost obsolete. So why are we wasting our efforts trying to get into hospitals?
Then we have Doctors of Chiropractic who believe that the savior of the profession will be for chiropractors to get drug licenses. Now you have chiropractors trying to use the drugs when the value and benefit of the profession is that it is a non-drug, non-surgical alternativethe evidence suggests that people are flocking to alternative health care by the millions. There are already too many doctors who are qualified to prescribe drugs. So why are chiropractors going into a marketplace where (a) we won’t be the best, (b) there’s already an abundance, and (c) it diminishes the entire value of the appeal of the chiropractic profession, which is non-drug and non-surgical.
Where should we be concentrating?
How many chiropractors are in a policy-making employment in the government? How many chiropractors do we have in the legislature? How many do we have in Congress? How many are in the House and Senate in the states around America? If there’s an area we need to have our voice, it is in those areas that chiropractic can shine.
What about multi-disciplinary clinics?
I think that is going to be the wave of tomorrow, although I don’t think it will be the immediate model. I see it as a long-term specialty modelnot a viable model for at least a decade. And then it will be a model that is housed in central facilities that practitioners refer to when the situation is more complicated than the framework of their own group practices. Did you notice I said ‘group practices,’ and not ‘single practices?’
I believe the single practitioner is a dinosaur. Not only does it not make sense economically, but it does not make sense from a clinical standpoint. That’s one of the problems chiropractic has had as a professionthe individual practitioner remains isolated in his or her own offices. When they got out of the professional and academic arena where their peers would mandate they keep and continue their skills at the highest levels, their notes got sloppy, their vocabulary got sloppy, and their reading materials got sloppy because they were not challenged by their peers. Group practices keep people sharper than a single practice ever will. The second reason obviously is economics. The third reason is going to be the change in demand from the public.
What do you see for the future?
I see group practices forming, I see services being offered 24 hours per day, seven days a week to meet the needs of the marketplace…. I see the target being focused on low income and bringing an awareness on spinal screening, on going into areas that are under served such as, senior citizens who are unable to drive so you bring a well-equipped van to a senior citizen community. Care however, must be exercised, in order that the innovations always reflect a high level of professionalism. There is such a line between marketing genius and schlock.
NCMIC Acquires Denver-based MCO
Dr. Louis Sportelli, who is President of National Chiropractic Mutual Insurance Company (NCMIC) recently announced the acquisition of Managed Chiropractics, a Denver-based national chiropractic managed care organization. This is the first wholly owned managed care subsidiary to be acquired by the leading malpractice insurance carrier in the chiropractic profession. NCMIC, based in West Des Moines, Iowa has approximately 25,000 policyholders and sizeable financial reserves.
Thomas H. Dillingham will remain with the newly formed network. Managed Chiropractics is the largest specialty care network serving nearly 20 million covered lives. The network of approximately 2,600 licensed Doctors of Chiropractic provides chiropractic services to several of the nation’s PPOs (preferred provider organizations), including USA Health Network, Admar Corporation, Private Health Care Systems, Aetna Health Plan and One Health Plan of Colorado, Inc.