“The New Millennium Chiropractor” is an important new trend forecast commissioned by the Foundation for Chiropractic Education and Research (FCER) and funded by the National Chiropractic Mutual Insurance Company (NCMIC). Mr. Gerald Celente and his team of experts at The Trends Research Institute completed this report to determine which trends were emerging that would point the way to viable practice opportunities that could fit into the chiropractic paradigm. I am certain that you will find this report to be fascinating reading. But more importantly, I hope you will learn something of value from it that will help you in your practice of chiropractic.
Excerpted from the Forward
by Stephen R. Seater, MA, CAE
Former Executive Director, FCER
Chiropractic Economics is pleased to provide “The New Millennium Chiropractor” for you, our readers, to keep abreast of the latest trends affecting chiropractic as we rapidly approach the 21st Century. We have obtained exclusive permission to share this edited version of this highly important report. The complete version, which was underwritten by NCMIC, is available from the FCER (ordering information is available on page 56) and we respectfully request that duplicate copies of this report not be distributed unless purchased directly from the FCER.
I. Statement of Purpose
The purpose of this trend forecast is to provide the chiropractic profession with proactive strategies to adapt in order to survive and prosper in the new and rapidly changing health care environment of today and tomorrow.
Our aim is to present a practical agenda which, if followed, will:
- Enable chiropractors to overcome their over-specialized public image and become recognized by the general public as primary health care providers providing a spectrum of valuable services capable of effectively treating a variety of common health problems.
- Position chiropractic as a ‘complementary’ rather than as an ‘alternative’ therapy. We will identify specific health care opportunities and provide strategies and programs for turning these opportunities into immediate and long term revenue.
II. Program Design
- Methodology: Using the Trend Research Institute’s Globalnomic® trend tracking methodology, we will identify and define issues on a global or macro level. We will then isolate relevant interlocking elements of the trends we identify and provide precise strategies and recommendations targeted toward the chiropractic profession.
- Analysis: We will assess the health implications of current and emerging socioeconomic, political, environmental, life-style, medical, consumer and retail trends. We will demonstrate how these trends affect the health care industry and the position of chiropractic within the industry.
- Solutions: We will demonstrate how and why these trends will create demand for a range of new products and services and why they should be integrated into the daily practice of chiropractic physicians.
The trend opportunities we have identified if properly implemented will enhance the scope of chiropractic practice without undermining its core principles. These recommendations will help chiropractors reverse the trends of decreasing gross income and decreasing patient visits (down dramatically from 129.4 visits per doctor per week in 1993 to 109.2 in 1994).
III. The Crisis for Chiropractic
Three chief problems face chiropractic, all well recognized within the profession itself: managed care (present and future), political positioning and public image.
A. Managed Care
Over the past five years, the growing dominance of managed care has seriously eroded the income of most chiropractors throughout the country. Chiropractors were not the only health professionals to feel the negative effects of HMOs. After years of steady increase, medical doctors saw their earnings drop 4% between 1993-1994 because of managed carethe first drop in physician’s incomes since statistics were first compiled in 1982.
Unfortunately, neither chiropractic nor any other profession can influence the overriding economic environment that has brought about the managed care phenomenon. For chiropractic to survive and prosper in these conditions it must employ the chiropractic equivalent of evasive action. It must find a way around the conditions since the conditions cannot be directly countered within the foreseeable future.
Following is a summary of the conditions:
While 46% of HMOs cover chiropractic to some extent, access to chiropractic is generally controlled by recommendations made by MD PCUs, who are in turn, generally unqualified and ill-trained to refer or recommend chiropractic care. In effect, that 46% coverage, impressive in principle, is less meaningful in practice.
Unrealistic limits (caps) set by HMOs on fees, services and office visits severely curtail the incomes of participating chiropractors.
Because few HMOs allow subscribers to “opt-out” (choose the health professional of their choice), and because 70% of U.S. workers with employer sponsored health benefits are currently enrolled in HMOs, in effect it means that the individual chiropractor (or other health professional) who is not enrolled in an HMO program has his or her patient base severely diminished. While most chiropractors, given the choice, would not join an HMO, the difficulty, often impossibility, of sustaining a reasonable income independently makes joining seem like the only viable option for many.
With a substantial number of former patients obliged to seek help from their HMO providers, the patient bases of independents are severely diminished. Moreover, approximately 50% of chiropractors practice in communities with under 50,000 populations, giving them a limited potential patient base. Independents in these small communities are effectively cut out of the loop, with few possibilities of attracting new patients to replace those lost to managed care providers.
B. The Managed Care Future.
Mainly because of economic trends, managed care will continue to gain a greater share of the American health care market. According to Trends Institute Research, economic conditions in America will not improve significantly for the overwhelming majority of Americans in the foreseeable future, and in fact conditions will deteriorate for the majority of American households.
This overriding socioeconomic trenddeclining real wages for 80% of U.S. householdsalong with double-digit increases in health care costs and massive corporate downsizing, has created the climate for the managed care phenomenon and with it, the crisis for chiropractic.
Perceived and embraced by the public and private sectors as a means of reducing costs, managed care will continue to gain enrollment throughout the next decade of the 21st Century. (70% of U.S. workers with employer-sponsored health benefits are currently enrolled in managed-care plans up from 48% in 1992).
In addition, health care reform will remain a primary political issue throughout the remainder of this decade and the next:
1. As the nation’s population ages there will be strong public pressure on the government to provide affordable health care. (By 2000, 75 million Americans will be over 50 over 75%, of all health care is consumed by people over 50).
2. As the standard of living continues to decline for the majority of U.S. households, health care coverage will be unaffordable for yet a greater segment of society. (In 1996, 40 million people are without health care coverage).
The Trends Research Institute forecasts that the government will eventually succeed in initiating a national health care system that will heavily favor managed care.
TRENDPOST: The combination of existing and emerging trend forces will further erode the profitability of the chiropractic profession (already undervalued by the public for the services it provides) unless a concerted, totally integrated campaign is launched by the various recognized professional associations with the full support of their memberships.
C. Political Positioning.
The professional associations are already engaged in efforts to get chiropractic recognized on an equal footing to other health care professions. The political initiative can be furthered and accelerated by successful campaigns on two other separate, but complementary fronts: increasing marketing programs and acquiring new therapeutic weaponry.
The net result of these initiatives will be to increase public acceptance of chiropractic. Increased acceptance can then be transformed into public pressure. And it is increased public pressure combined with lobbying efforts that will ultimately compel the political/medical establishment and the insurance industry to recognize the importance of chiropractic and to put it on an equal footing with other doctors.
D. Public Image.
On this front, there is more room to operate. In order to successfully promote itself, chiropractic must improve its ‘image’ through marketing/publicity/advertising.
While steadily gaining public credibility since World War II, chiropractic is still not recognized by the general public as a mainstream practice; the average chiropractor to this day still does not enjoy the prestige of the average medical doctor ‘Prestige’ = Image. But ‘image’ itself varies according to demographic categories and ethnic groups. Effective marketing/publicity/advertising strategies must reflect the needs, perceptions and idiosyncrasies of demographic target groups.
1. Depression Era Elders and World War II generation.
These two groups share a similar viewpoint one that impacts negatively upon chiropractic. While 75% of all health care is consumed by people over 50, Only 40% of the average chiropractor’s patients fall in this age group. In other words, chiropractors should be seeing roughly twice as many people in this age group as they are at present.
This age group grew up through a time in which chiropractors were denounced and derided by orthodox doctors and systematically hounded by the police (often at the urging of the medical establishment.) However, the message has been imperfectly conveyed to the huge key 50 plus population sector (65 million) spending 75% of the nation’s health care dollars.
TRENDPOST: The chiropractic profession should launch a carefully crafted marketing/publicity/ advertising campaign aimed at the 50 plus age group. It should focus attention upon those chronic ailments that tend to surface with age, that respond favorably to chiropractic, and that do not respond to orthodox procedures and/or are usually improperly treated. The proven benefits of chiropractic must be emphasized.
Those of the 50 plus generation who do accept and visit chiropractors mainly think of them as musculo-skeletal specialists. However they are generally unaware that most chiropractors have the knowledge and training to address a host of other age-related disorders including cardio-vascular conditions, arthritis and metabolic problems.
With 75 million 50-plus Americans consuming 75% of all health care, particular attention should be paid to attracting this huge group of potential patients. The main point to get across to these potential patients is that chiropractic is already recognized as valid therapy by insurance carriers. Therefore fear or distrust of the profession is utterly unwarranted. Bluntly, millions of people who could be helped by chiropractic still do not go to chiropractors because they are still afraid and/or suspicious.
2. Baby Boomers.
Beginning in the late 1960’s and continuing through the 1980’s, alternative medicine began to find its way into mainstream America. This new awareness took root in the massive baby boom generation. The 76 million boomers, accounting for the largest single segment of the American population, was the first generation to question authority of established institutions. Many baby boomers, unlike their parents and older siblings, declined to view medical doctors as demigods. The boomers looked with open minds into a variety of alternatives: acupuncture, homeopathy, yoga, special diets, vitamins and supplements, shiatsu and other massage techniques, naturopathy and, of course, chiropractic.
This interest spawned an alternative health industry that in 1995 grossed $12 billion and growing by an estimated 7 to 12 percent annually. Unlike the two previous generations, many baby boomers view chiropractic as mainstream health care. A small, but growing segment of boomers would and do consider chiropractors as their primary health care physician.
However, the dominant attitude among boomers (as it is among their elders) is to view chiropractors as specialists in treating musculoskeletal ailments. They are unaware that (formally or informally) many chiropractors are highly knowledgeable in a number of other related specific health fields and therapies (e.g., nutrition, kinesiology, homeopathy, physical therapy, x-ray analysis).
TRENDPOST: Without suggesting that chiropractic is a substitute for orthodox medicine, the task facing the chiropractic profession is to raise the level of awareness regarding these other areas of common chiropractic expertise. Baby boomers should be consulting chiropractors for a much wider range of ailments than they are.
Many baby boomers still have an ‘image’ problem with chiropractors. These millions of boomers who still don’t go to chiropractors, don’t go because they have some of the same fears and suspicions (but not as deeply rooted) as their elders.
3. Generation X.
The Trends Research Institute’s previous studies reveal that Generation X-ers’ attitudes and perceptions generally mirror those of their baby boomer parents. Unlike the boomers, in open revolt against their own parents, today’s 20-29 year olds (25% of the population) tend to agree with their elders on many fundamental socioeconomic and political issues and generally on health issues as well. Unlike the ‘generation gap’ of the 60’s that prevailed between boomers and their parents, today there is a ‘generations blending’. Boomers plus X-ers create a 123 million strong population super-segment.
TRENDPOST: Marketing/publicity/advertising programs designed to promote chiropractic directed to the baby boom generation will attract Generation X-ers as well. No special strategies are required.
4. Ethnic minorities.
While fully 93% of chiropractic patients were white (ACA Study 1991), in 1995 over 25% of the U.S. population was made up of ethnic minorities. This represents a massive under-representation, in effect a lost chiropractic market.
Still more ominous from the chiropractic marketing viewpoint, the birth rate among whites will decline throughout the rest of this decade and will begin to rise slowly in the next century. In contrast, births to Hispanics and Asians are projected to more than triple by the year 2050. Projecting current ACA figures forward, with only 7% of chiropractic patients coming from ethnic minorities, it means that a huge and growing potential market for chiropractic will go untapped and the profession could stagnate unless the situation is addressed.
Put another way, by the year 2050, if chiropractic is to prosper, roughly half its patients, not just 7% should be coming from the descendants of today’s ethnic minorities.
TRENDPOST: Marketing/publicity/advertising campaigns intelligently pursued, make this goal realistic and attainable, in part because of the demographics of chiropractic. While there is always a handful of upscale chiropractors with a high income clientele, the majority of DCs cater to middle, lower middle and blue collar classes, who make up the bulk of the ethnic minorities. The ethnic markets must be targeted and addressed.
Because of their cultural heritage, many of the most populous and fastest-growing ethnic groups should prove easy to access. They have been brought up with natural therapies that do not depend so much upon drugs and surgery. Moreover, their culture accustoms them to hands-on and more personal forms of treatment.
IV. New Services
The Trends Research Institute forecasts a major health/ fitness/nutrition revolution as we move into the new millennium, health issues will loom ever larger in the nation’s (and the world’s) consciousness. This revolution will be driven by two interlocking forces:
A significant percentage of the baby boom generation is coming to the vivid realization of the importance of health. The vanguard of the boomers, approaching fifty, is finding it emotionally, financially and physically draining to deal with their parents’ aging. They are witnessing the suffering and complications of their parents’ old age, much of it unnecessary. Old age is an unavoidable fact of life, but sick old age is not. According to the National Institute on Aging, fully 80% of older people’s health problems are not due to aging at all. They are due to improper care of the body over a lifetime. The enormous baby boom generation, seeing the terrible health problems faced by their parents and elders from lives lived in a state of health unconsciousness, is beginning to ‘preview’ their own lives in the illness and death of their parents.
Baby boomers are intensely youth-oriented and have always been. A recent survey discloses that 76% of boomers think they look younger than their age. In addition to controlling the reins of business and government for the next twenty-five years, boomers will control the vast majority of the nation’s wealth and discretionary income.
TRENDPOST: The youth conscious baby boom generation will spend a lot of money doing what they can to hold on to their youthful vigor, while maintaining and improving their health. They will be seeking treatment and direction, both of which fall within chiropractic’s present and potential province.
This determination to stay healthy will be strengthened by the ravages wrought in the physical world by unwise industrialization and development. Increasing air, water and land pollution (in all likelihood) increasing world radiation levels, the cumulative effects of additives, depleted soils, pesticides and toxic chemicals in the food chain… all will contribute both to undermining the nation’s health and to making the majority of the population intensely and increasingly health conscious.
Chiropractic finds itself in a unique position within this big picture. As the most accepted of the ‘alternative’ or complementary therapies, chiropractic does not have to fight the same uphill battle for recognition that less well known therapies still must wage. On the other hand, chiropractic’s very success has its own down side. Its public ‘image’ tends to restrict it in the public mind to strictly musculo-skeletal problems. In plain talk: you go to the chiropractor when you’ve thrown your back out or twisted your neck. You usually don’t go for anything else.
V. THE HIDDEN MARKET
The Trends Research Institute has identified and isolated two primary professional opportunities for new millennium chiropractors to implement in the scope of their practice. These will be two of the more profitable areas of growth in the health care industry for generations to come; they will affect the largest segments of society for the foreseeable future. Combined, they already represent a $30 billion market. They are:
A. Weight Management
B. Vitamin Counseling
These two major health care opportunities are at present neglected or approached piecemeal by both orthodox and alternative medical practitioners including chiropractors.
If chiropractors integrate weight management and vitamin counseling into their practice, it will significantly enhance the scope of their practicewithout undermining the core principals of chiropractic.
In fact, weight management and vitamin counseling already fall within the average chiropractor’s normal interests. But they are unclearly defined and unsystematically approached by chiropractic schools and therefore unformulated as training.
Note: Though many chiropractors enroll in additional weekend seminars on nutrition and even acquire diplomate level status, that additional expertise is inconsistently practiced by individual chiropractors. The extent of their knowledge in these potentially lucrative areas is unrecognized by the public and unexploited by the chiropractic profession as a whole.
Meanwhile, a confused and undirected public does not know where to go for trustworthy professional advice for weight management and vitamin counselling.
A. Weight Management
Among the issues ineffectively addressed by post World War II establishment medicine is the rapid increase in overweight Americans (Exhibit Two). The failure to address these specific health problems has contributed to the steep rise in health care costs. According to government studies, obesity-related conditions are costing over $100 billion a year and causing 300,000 premature deaths in America per year.
Moreover, there are serious emotional costs associated with being overweight that can not be quantified. Obesity affects one’s self image, family, relationships, creativity and job performance.
In their attempts to lose weight, Americans spend an estimated $24 billion a year. About 50 million people (over 20% of our adult population) is “dieting” at any given time about 1 in 4 women and 1 in 5 men.
People wanting to lose weight turn mainly to:
- Primary care doctors
- The media (magazines and newspapers, television and radio)
- Self-help books
- Commercial weight management programs
- Hospital-based weight loss programs
Examining these major weight-related information sources reveals the reason for the confusion and the lack of structured advice.
1. Primary care doctors.
Only a small percentage of medical schools include a few hours (2.5 on average) of basic nutrition in the four-year standard curriculum.
However competent, well-trained and knowledgeable he or she may be in other areas, the average physician knows very little about nutrition, and little or nothing specifically related to weight management. The medical profession lacks the expertise to significantly ease this massive national problem.
Dietitians are trained professionals and represent a subset of establishment medicine. The American Dietetic Association, the country’s largest professional organization of dietitians has 65,000 members. Their large national network of publications and spokespeople are widely quoted on nutritional matters. They sponsor educational programs from grades K to 12. Most American children receive their first dietary information from such programs. In addition, in order to be accredited, any school’s dietetic curriculum must be submitted for review to the American Dietetic Association.
However, the objectivity of the ADA is suspect. It has come under increasing criticism for soliciting cash from trade groups, and processed and fast food companies.
In 1995, The American Dietetic Association received $3.2 million from corporations and trade groups including Coca-Cola, M&M Mars, McDonald’s, Sara Lee, The Sugar Association and the National Livestock and Meat Board.
Defending the ADA position, Dr. Doris Derelian the President of the American Dietetic Association says, “Actually, we could put our name on any McDonald’s meal… I honestly believe there are no good and bad foods, only good and bad diets.”
An organization that cannot officially distinguish between good foods and bad foods is a questionable authority. The public at large has been generally misinformed about nutrition since early childhood.
3. The mediamagazines and newspapers, television and radio.
The main problem with diet-related information derived from the media is that it is next to impossible for the layperson to judge what is valid and what is invalid, with confidence. The primary problem is to distinguish between valid and invalid; the secondary problem is to try to determine ‘what’s good for me?’ These important decisions should be determined by factors such as genetics, personal medical history, emotional/psychological profile and occupation. Putting these factors together and arriving at the clinically correct decision calls for a trained professional.
4. Self-help books.
The book audience comes mostly from a higher socioeconomic/education stratum. But the validity/invalidity problem inherent in media-broadcast information applies to the information provided by self-help books as well. And the reader is in no position to judge the reliability and effectiveness of the recommended programs as they apply to his or her personal needs. The immense ongoing popularity of diet books reflects public concern for weight loss and contributes to the confusion. The current best selling diet books are:
Labeled a protein adequate diet, it advises eating small meals throughout the day, with a low fat protein at every meal, plus lots of fruits and vegetables and monosaturated fats such as olive oil.
Dr. Atkins New Diet Revolution:
Severely restricts carbohydrates to promote the burning of stored fat.
The Five Day Miracle Diet:
Recommends hardchew vegetables like carrots and green beans and soft-chew fruits like peaches and plums. Different foods are eaten only at designated times.
Suggests eating plenty of protein and limiting foods like breads, pasta, potatoes and dessert.
Apart from best-selling books, the diet fad now sweeping the country is the “old cabbage soup diet.” It allows only soup and a few other items a day.
An analysis of these recommended diets and programs reveals there is nothing new about most of them beyond a few added gimmicks. Though radically different in approach and in substance, what they share in common is they severely restrict calorie intake. If followed conscientiously, all will result in lost pounds.
However, studies show that 95% of the people who lose weight by “dieting” gain most or all of it back.
5. Commercial weight management.
There are five major commercial weight management programs in the U.S.: Weight Watchers, Jenny Craig, Physicians’ Weight Loss, Diet Center and Nutri/Systems. These programs generally attract women with moderate weight problems and men who are moderately to seriously overweight. The remainder of the weight control business is divided among vitamin and herbal supplement companies that are heavily skewed toward network marketing and product sales: Herbalife, Heritage-Lite, Shaklee, Ultrafast, Life Extension and Nutrition for Life, to name a few.
Weight management programs fall into two principal categories: those based mainly upon counseling and support groups (with a more or less high-pressured sales pitch to buy company associated or company produced products) and those mainly offering weight loss products.
Despite the vast amounts of money and emotional energy spent on weight loss, the field has received relatively little concerted scientific and medical attention. There is at present no overall consensus or authoritative professional body able to pronounce specifically upon weight loss.
As a general rule, most people who are serious about losing weight are able to lose it by following any one of the above programs. As an almost invariable rule, most people (95%) gain back all or most of the weight they lose. In a Consumer Report study, respondents showed that overall dissatisfaction with weight-loss programs was higher than that for all other consumer services they had ever evaluated in reader surveys.
Among the reasons for their failure: blatant commercialism; lack of skilled health professionals on staff; lack of individualized treatment; faulty, unbalanced programs often relying upon weight loss drugs.
What consumers learn, who they learn from, and how they learn it is inadequate in relationship to their real health needs. The information provided is often false and misleading; the teaching relies upon conditioning, and programming rather than educating; and staffs are often product-and-commission rather than health-oriented.
6. Hospital-based weight loss programs.
Hospitals have only about five percent of the weight management market sector. While currently an insignificant competitive force in the weight management field, hospitals may decide to enter the market more forcibly in their attempts toward developing programs to increase revenue.
While hospital-based programs registered fewer complaints from participants than from the commercial weight loss companies, the results are generally the same: people regain the weight they lose shortly after completing the program.
TRENDPOST: Weight management is a field of tremendous potential. Of all health professions, the chiropractic profession is in the ideal situation to formalize weight management as a professional specialty to help people lose weight and gain weight.
Most chiropractors tend to take a holistic view of health. The average chiropractor knows far more about fitness and nutrition than the average medical doctor does and tends to integrate these elements into his or her practice.
Many people treated by chiropractors are overweight, and suffer from musculoskeletal and other problems caused or exacerbated by excess weight. However, in many instances, chiropractic schools do not train students to aggressively address such weight-related problems.
To capitalize upon this situation, the profession as a whole should formalize the natural relationship between chiropractic and weight managements helping people lose and gain weight.
TRENDPOST: By integrating ongoing personalized weight management programs into their practices, chiropractors will substantially increase their incomes while measurably improving the effectiveness of their treatment.
B. VITAMIN COUNSELING
On an individual and on a mass scale, Americans feel they do not get the nutrition they need out of the food they eat. Many others believe that vitamins, supplements, minerals and herbs can be used for therapeutic purposes. These two perceptions have fueled a $5 billion dollar market, growing at approximately 7% a year. Half the country was taking some type of vitamin supplement in 1995.
1. Knowledge Gap.
While many people have the general sense that vitamins and supplements are beneficial, even crucial, for health, consumers lack specific knowledge on what to take, how much to take and when to take it.
According to Trends Research Institute findings, fully 90% of consumers in the United States have little or no idea about what ‘proper vitamin usage’ means to them. Indeed, their knowledge of vitamins is less than their knowledge of nutrition in general and Americans are ‘nutrition ignorant’ according to Dr. David Kessler, Commissioner of the Food and Drug Administration.
2. The Open Market.
As a potentially lucrative field, vitamin counseling provides an even wider scope for implementation than weight management where, however inadequate, there are already structured weight management programs.
Vitamin counseling is virgin territory:
- There is no formidable competition.
- There are no formalized programs.
- There is no specific training.
- There is no single profession associated with providing expertise.
Indeed, the Trends Research Institute identified the need for vitamin counseling and coined the term.
The reason why we are calling this vitamin counseling and distinguishing it from nutritional counseling is in part a marketing/public relations strategy. Many chiropractors already practice nutritional counseling, a growing sub-field in chiropractic. We have singled out vitamin counseling as a distinct field or discipline within nutritional counseling in order to take advantage of the potentially huge and confused field occupied by vitamin, supplements, minerals and herbs.
When it comes to vitamins and supplements, the consumer (half America) is confronted by product chaos and no single trusted source of advice. As with weight management, information comes from the media, self-help books, nutritionists, network marketers, company advertising and promotion and to a very limited extent, the medical profession. But unlike weight management, much of the information dispensed on what to take for specific conditions comes from minimum wage clerks in mall-based vitamin outlets or, at a higher, but hit-or-miss level, health food store personnel.
Practically speaking, who does the consumer go to to find out what benefits will accrue through acidopholous laced with blue-green algae, anti-oxidant enzyme nutrition, liquid chlorophyll, citricidal, basic synergistic multiple vitamins, FructoOligo-Saccharides… and a vast array of competing products?
It is only the knowledgeable vitamin counselor who will be able to lead clients through the bewildering thickets of available products and the forests of product claims.
4. Non-Professional Advice.
Based on the understanding that no two people are alike, effective vitamin counseling must be individualized, just like effective medical advice. Age, sex, lifestyle, profession, eating, working and sleeping habits must all be taken into consideration. Store clerks and network marketers are not in positions to provide authoritative advice on suc