The tribes continue to form on the Great Plains of managed care. Who would have thought years ago that medical and chiropractic physicians would end up on the same page of a preferred provider listing book? Gradually, this historically antagonistic professional relationship has taken on soap-opera proportions, chiefly because of the shot-gun marriage presided over by managed care organizations. We are both doing the best we can as provider commodities in a system that has changed referral relationships forever. In classic HMO’s, the primary care “gatekeeper” now has the power and obligation to control all referrals to specialists, even to contracted chiropractic providers.
I signed my first contract with an HMO in 1987. Now, some nine years later, I have noticed that referrals from family practitioners and internists have become easier to obtain for my patients, notwithstanding the treatment limits imposed by the system. Primary care providers (PCPs) have even referred patients to me for chiropractic care instead of physical therapy. Is it possible that managed care has actually given some chiropractors a source of referrals never before fully realized? Referrals from primary care practitioners can be a significant source of new patients in the future of chiropractic.
PATIENT SATISFACTION AND DEMAND
However, there should be no illusions. PCPs still refer to chiropractors mostly because the patient asks them to do so, and they still often resent the request. With capitation as the common method of reimbursement, every referral can potentially cost a PCP real money if the HMO has cost over-runs at the end of the year. So why would they refer?
In my experience, managed care organizations (MCO’s) have done for chiropractic what we have partially been unable to do for ourselves. They have established our credibility as valuable members of the health care community. Those chiropractors that have been credentialed by MCOs, report that medical doctors have expressed more confidence, justified or not, in a referral to a DC that has been “inspected” by such an organization. Before becoming gatekeepers, primary care doctors could ignore the entire prospect of a chiropractic referral since that was the patient’s business. Now, it is quite clear to the PCP and the patient that the only way the traditional chiropractic patient is going to be able to access such care in an HMO is through a referral. Even the most reluctant MD cannot say no all the time. The very fact that the patient finds his DC on the “list,” and communicates to the PCP satisfaction with previous care, increases the chances of a referral.
REFERRAL ETIQUETTE
The fact that the PCP knows his patients are satisfied with the care they have received from a particular chiropractor is important, but it is just as important that the PCP is satisfied. A crucial response to any referral from a primary care physician is to send a written report of findings back to that physician, even if the referral was on the demand of the patient. After having a few patients in common, an unfriendly or ambivalent PCP might at least comment, “I don’t know about chiropractic, but at least that guy down the street sends me his notes.” Hopefully, this attitude can grow into a statement like, “If you’re going to try chiropractic, try the guy I know.” It does not seem to be necessary to call or court every PCP in order to attract referrals. In fact, too much effort in communication that requires additional phone time for the PCP can be annoying.
FRIENDLY REFERRALS
Recently, spinal manipulation has been treated fairly by government agencies, the media, and favorably in the medical literature. This has helped our referral position with doctors who have always been inclined to refer to chiropractors. Those PCPs who sincerely want to help their patients are not as hesitant to refer, especially when they are more familiar with guidelines of care and the criteria of who may be the better candidates for manipulation or adjustments. They understand that physical therapy usually requires an assessment and a treatment plan of 1-12 visits. Most cases average around six visits in a typical HMO atmosphere. If chiropractic was promoted as taking longer or achieving poorer results, PCPs would not refer. A few doctors have confided to me that they are often disappointed with the results of physical therapy and have welcomed the option of referring to chiropractors for many of the same conditions.
Some HMO’s have even been rumored to have encouraged referrals to DCs among their primary care doctors, with the hope that money can be saved and that patient satisfaction will remain high. Since most of the PCPs are capitated, an effective and efficient referral is prized. If physical therapy is not succeeding in being cost effective with many common musculoskeletal problems, is it any wonder that PCPs will try something else in the battle to save their yearly withheld bonus funds? It is always interesting to me to have a new patient come in that was referred by an MD, but has never been a chiropractic patient before and never would have, if it hadn’t been at the insistence of their PCP.
WHAT ABOUT OTHER REFERRALS?
Since the entire country is not yet under managed care, the possibility of a family doctor or internist referring a patient with other coverage is greater when that doctor already knows you. If the PCP has had a good working relationship with you in a gatekeeper protocol, he or she may also think of you when the patient has indemnity insurance, is in a PPO, or is simply a cash patient. The doctor, of course, would appreciate referral of these same fee-for-service types in return, since managed care has limited everyone’s income.
DIRECT ACCESS CAN INTERRUPT PCP REFERRALS
Most of the chiropractic Independent Physician’s Associations (IPAs) seek to market a “carve-out” option for a health plan, thus giving the patient direct access to chiropractic. This takes the gatekeeper PCP out of the picture, but also takes away the opportunity of a forced professional relationship for the DC. This trade-off should be handled by the attempt to join as many different types of MCOs as possible. Obviously, the entire discussion of PCP-DC referrals is moot in cases of PPO design rather than HMO. Historically, MDs appreciated the “carve-out” approach, since they resented the demands from patients for chiropractic referrals, but, as presented here, this may be changing.
Relations with specialists such as orthopedists are a different story. We cannot refer directly to them in a gatekeeper model. Since most of our referrals are to specialists, this situation disrupts referral patterns that have taken years to develop.
NOT FOR EVERYONE
Many DCs still feel we are in competition with medical doctors, or they may feel the constraints of managed care are too great and have opted out of the system altogether. HMOs offer “adequate” care, not optimal care. In any case, developing greater referral circumstances with PCPs may not be for every chiropractor. But the trend among providers of all types, including hospitals, is to vertically integrate into a system that can manage the complete health needs of an entire community or contracted group. Improving our professional dialogue skills may have already become a necessity, rather than a luxury.s
John W. Hanks, DC, FACO is a 1974 graduate of National College of Chiropractic and practices in Denver, Colorado. He received his diplomate in the American Board of Chiropractic Orthopedists and is a Certified Chiropractic Sports Physician (CCSP). Dr. Hanks serves as the Western Regional Chiropractic Consultant for MetLife Insurance Company and has been a member of the board of the Colorado Chiropractic Health Providers. Dr. Hanks is currently enrolled as a graduate student in health care systems at the University of Denver.
