Why a diversified treatment portfolio will counteract the effects of managed care: A comprehensive model for spinal care.
Unfortunately, there is not much we can personally do to alter some factors that are shrinking the health care dollar allocated to providers from the insurance industry or government. The population of the baby boomers, the balanced budget considerations, and the new wave of massive shareholder profits from health premiums are just a few of the complex issues of managed care of which we have little control.
However, beyond these issues there is something that we can do professionally. I continue to observe too many of my colleagues and clients believing they have exhausted all measures to counteract the managed care system. Contrary to these beliefs, there is still one major area that many chiropractors have not trieddiversifying their own treatments.
As a result of the managed care onslaught, most doctors have been proactive towards the changing environment, and have reacted appropriately in an organized downsizing program. They have reduced overhead expenses, retrained remaining staff, streamlined office procedures and policies, transitioned patients to more or all cash, and even drastically reduced all personal expenses. At the same time, others have overreacted and signed every contract that came before them, cut productive staff, and altered effective procedures and policies. Some chiropractors, and even doctors within the medical community, have become so desperate that they are selling vitamins from multiple-level marketing programs just to get more dollars from the patient.
However, there are three profitability areas that are generally over looked by the average doctor, and are not directly related to managed care:
- Multi-doctor practices.
- Effective time management.
- Treatment diversification.
Chiropractors seem to have the greatest resistance to changing in these three areas. The idea of a multi-doctor practice or sharing office space is slowly becoming a reality. I am not just talking about associates, but equal partners. Sadly this step is seen by some independent seasoned practitioners as a professional and personal defeat. How many chiropractors are within walking distance of each other who could simply increase their profits by sharing space? Chiropractic students, on the other hand, see this as a logical step in efficiency.
The second area of resistance is time management. This is usually considered after all the other areas have been exhausted. Now due to the new procedure codes, we must face our inefficiency in this area. We tend to be comfortable with our practice rhythms and would rather keep the status quo, even if it is not productive.
The third area that would bring the most profitability has been the one most overlooked. It is the diversification of treatment recommendations, with corresponding treatment techniquesa comprehensive approach.
Doctors see only one problem managed care. If we can change that we will become profitable again. However, that is not the real issue.
I have found in my teaching and consulting experience that this third area has the greatest amount of resistance. Some practitioners became quite angry when I tried to bring to their attention the lack of diversification of treatment they actually offer. Others just passively resist by saying their clinical results speak for themselves, although it is only short term care patients improve. Yet others are frustrated and wonder why their recommendation of wellness care is not accepted by the patient. Most patients do not want the same endless care without goals.
By defining diversification of treatment I am not referring to offering massage therapy, nutritional counseling, or monthly membership to your new exercise equipment. These are areas that can bring in more patients and increase profits; however, we already have within our profession the tools and the ability to grasp all that is necessary to achieve high profits in spinal treatment alone. This is a comprehensive model of spinal care in a multi-dimensional, paralleling treatment approach, with sequential recommendations of ongoing care that have corresponding payments options.
Diversification is not how we approach care by who pays or what techniques we specialize in, but from the total presentation of the condition of the patient’s spine. The spine is evaluated multi-dimensionally; meaning in its entirety, sectionally, and segmentally within the various levels of care required to bring the spine to optimal function. Treatment is then given either parallel or sequentially to each area of the spine as needed with acute, chronic, corrective, preventative, supportive, or well care. Each area of the spine has its own goals and end cycles, or transition periods into the next level of care.
Many chiropractors are trying to reach a multi-dimensional approach with limited treatment evaluations or techniques. Do you have the tools of clinical assessment and techniques to service the entire spine? Have you looked beyond the initial complaint that satisfies the insurance criteria? What specific treatment techniques do you have corresponding to your ongoing care payment options?
Professional consultants are not addressing the issue
What is typically offered by consultants within the Report of Findings are three important areas:
- Transitioning the patient to cash.
- Offering patient choices in care.
- Communications in a scripted format.
These how-to, step-by-step approaches for the Report of Findings do not address or correlate the doctor’s mono-focus in clinical assessments. When doctors use these canned reports and offer the flexible financial approach, it just does not work.
Simply offering the same treatment repackaged in another way changes little for the patient and for your end-of-the-month stats.
The second variation is a cafeteria-style approach to offering patients choices for care. All too often many wonder why when they tried to apply this style, it did not work either. What we are actually saying is, “Do you want acute care, acute care, or acute care?” The scripted formats line up with what we are actually giving. However, the flexible financial plans or cafeteria care choices can only be effective if the treatment recommended is comprehensive and based upon a comprehensive evaluation. Insurance or cash are not clinical options for the patient. Nor is acute or well care options unless the treatment evaluation, techniques, and goals vary and are applicable to what the patient actually has, with or without symptoms.
Chiropractic’s history of limited payment options cash, cash or cash
Before chiropractic was ever involved in reimbursements from insurance [the good old days, some would say], we only had a cash system. Because of this history many financial consultants are calling for a return to the past, however, this nostalgic view will not survive long. Yes, we must transfer much of the health care cost back to the patient, and it is becoming easier today because patients are slowly being weaned off the insurance dollar by the entire industry. In reality, this still leaves most chiropractors just as unprofitable in volume and services because by changing to cash we falsely believe we do not have to process forty new patients a month at the 4.5 office visit average to meet our overhead. All we are left with is the patient paying more for the same acute model care instead of the insurance carrier.
The average patient and even the chiropractor, de-mands more than philosophy to sustain paying for on-going care. It may have worked in the past for a small percentage of patients, but today we live in a technological show-me society, not to mention an increasing number of chiropractors per population ratio. Offering all the care that is needed will provide the clinical basis for ongoing care.
The Chiropractic Model and The Dental Model of Care
We need to start at the beginning what care are we offering? Limited care. If we look to the clinical dental model, not the dental model of payment plans we hear so much about, we will see certain parallels of care. The dental evaluation accounts for each tooth’s current and future condition, in addition to the entire orthodontic structure and gums. The dental treatment usually begins with the most acute condition, and may proceed to the level of next priority or it may discontinue when each cycle is completed. Patients are comfortable with this approach.
Chiropractic spinal care clinically correlates quite well with the dental model procedures. Spinal corrective care is similar to orthodontic care. Acute spinal care is similar to acute dental care, such as a root canal or an infected tooth. An endless list of parallels can be drawn for the patient if we provide the type of comprehensive care as I have discussed. For example, handling patients’ acute pain while offering care to repair areas for prevention.
The physician-patient relationship and patient autonomy
Using a diversification evaluation approach now offers the patient a variety of end cycles. This supports the idea of autonomy in selecting on-going care. This treatment plan selection is now much more cooperative because the doctor and the patient know what is expected. Moreover, this develops a collegial model of the physician-patient relationship to which we as chiropractors especially aspire.
Comprehensive Model of Spinal Care checklist
Most chiropractic techniques address at least one of the following areas: spinal analysis, application of treatment, and indications for a level of treatment. Use the following steps to take your own inventory of how much diversity your current treatment provides.
1. Diversification in chiropractic spinal analysis
Our history of chiropractic spinal analysis has richness that is not being utilized. We have specific techniques that view the entire spine as a functioning unit, while other techniques concentrate on the sections of the spine having normative approaches for abnormal curves. This is not to imply that each has to cancel the other out. Almost every technique has an approach to specific segmental problems. Do you use all of them as indicated? What about using all static and motion analysis, with or without x-rays?
Further, many techniques bring us into the extremities and all the paraspinal tissues related to spinal function, while some bring us to only a few choice areas. Others give us specialties in the area of rehabilitation in occupational or sports injuries. What techniques do you use? How complete is your analysis compared to what could be done? Have you drifted, specialized, or not ventured out into other areas?
2. Diversification in the application of chiropractic manual therapy
Our collective clinical experiences have proven we can apply a variety of spinal adjusting applications and forces comfortable to the patient’s tolerance. For example, we have levels ranging from non-force instruments to specific osseous thrusts, with or without audible releases, to diversified forceful movements. Have you only concentrated on one technique or pressure? Do you really know what the patient would prefer and stay for longer care if asked?
Diversification in types of care
When was the last time you presented a patient choices ranging from full spectrum of care and all the available options? Do you have average treatment schedules for acute, chronic, corrective, preventative, and supportive care? Or well care for each section of the spine and pathological condition of the spine and its relationship? Do your current techniques address these time frames?
If we consider looking at the full spectrum of recommendations needed in each spine presented to us, instead of the sectional or acute models of evaluation, we will have so much more work to do than we can ever imagine. Patients then would have a variety of options in this comprehensive, multi-dimensional model of care. This allows patient autonomy at a maximum, which will bring increased patient satisfaction. They can then select care for the future.
The Report of Findings on each segment, spinal section, and full spine will include specific treatment. The treatment goals are to bring the spine into a state of optimum function and of course, over-all health, which coordinates with all philosophies and clinical judgments. In addition, most of this focus would satisfy an ethical issue we must faceomission. Why do we feel we have done a complete job by just looking at the symptomatic spinal section? Why not tell the patient what is going on with the entire spine? Let them decide what care they desire.
How have you justified a mono-dimensional approach? Have you merely drifted away from a holistic spinal view? Have you been lulled into following an acute medical model of treatment? What about the parallel treatments for the different spinal areas that need acute, chronic, corrective, preventative, supportive, or even well care attention? Is it because the insurance company will not pay for it? These are questions that require serious consideration and critical self-reflection for growth in income, but most of all growth as a professional.s
Dr. Karen Shields is a practice counselor and educator. She has taught Practice Management and Clinical Communications, as an adjunct professor at the University of Bridgeport College of Chiropractic since 1994. Dr. Shields practiced successfully for 15 years in Greenwich, Connecticut prior to her retirement, due to an injury. She has won the ACA’s Office Design Award for her work and is a 1980 graduate of New York Chiropractic College. In addition to her business success and honors at NYCC, she has achieved academic success at NYIT and Fordham University