A Modest Proposal…Okay, Three of Them

As the Minnesota Chiropractic Association takes a deep breath and reenters discussions with Blue Cross about how BCBSM treats chiropractors and chiropractic care, I recently had an extended chat with one of the people who has knowledge of these discussions. Our conversation, as they often do, turned to, “What can we do?” It’s a painful question, because it’s leavened with the helplessness that characterizes much of the malaise afflicting our profession. In my view there are basically four choices, but probably only three of them are worth seriously considering. One of the three is highly disruptive. Do any of them make sense in dealing with Blue Cross–or any other insurer?

One of the challenges in dealing with any insurer is that they really don’t care about chiropractic. There is little to no real appreciation of what chiropractic treatment does, nor what doctors of chiropractic do, because the medical paradigm has so dominated the context of insurance coverage for chiropractic. And the medical paradigm is completely inappropriate.

This is not a small issue. A paradigm defines, really, the kind of figurative lens you use when you look at something. The same situation can look very different from different paradigms. Medicine’s paradigm is wonderful where drugs and surgery are the best (or only real) answer to problems. Chiropractic’s paradigm is wonderful where it’s possible to determine that adjustments and conservative case management hold the promise of improving neurologic function through improving structure and the power of our own natural healing capacities. While these are not necessarily mutually exclusive, they are really two very different options, and not just in terms of clinical decisions. They are fundamentally different in how they view the body, its capacities, and clinicians’ roles. Our legal scope of practice laws reflect this: doctors of medicine cannot practice chiropractic, and doctors of chiropractic cannot practice medicine. Are we each staying within our scope laws?

I would argue that we are not, that in point of fact we are crossing these boundaries regularly, and that it has not been to our benefit. ‘Medical necessity’ is a case in point. The concept of ‘medical necessity’ sounds reasonable; it is used as a contractual basis for providing all health care services by insurance companies (the state approves all health insurance ‘products’ for Minnesotans, and the term ‘medical necessity’ is cited as a basis for all health services–even chiropractic). What should exist as a parallel concept of ‘chiropractic necessity’ is not employed. As a profession, we have never established it. It’s my view that we’ve weakened ourselves by not having the concept in use. We struggle when we try to argue for our own paradigm because we’ve tacitly accepted the medical paradigm as a way of evaluating our own effectiveness. How are we doing with that?

One of my teenage sons was involved a few months ago in a car accident. He got a mild cervical sprain, and I took him to a local DC friend of mine for care. The concept of MMI came up, in terms of documenting ‘maximum medical improvement’ as a way of addressing reasonable parameters for case management–on the insurance company’s terms. I was struck by the consideration, though (not for the first time), as it seems so inappropriate for a condition that is so much more effectively dealt with by chiropractic than by medicine. Yet we’re so used to this defective paradigm that we have become acculturated to using the term, and have lost touch with how inappropriate and offensive it is.

I believe we have as much business determining ‘maximum medical improvement’ as medical doctors have in determining ‘maximum chiropractic improvement.’

And I submit that it’s because of this disconnect that we are at a fundamental and permanent disadvantage in dealing with insurers, because the context for chiropractic care is based on our acceptance (however reluctantly, or at this point, habitually) of the medical paradigm. We’ve essentially begged, lobbied, whined and stomped our feet over the years to be incorporated into the medical paradigm. Should we be surprised that we have been given so little? We don’t belong there in the first place!

So when we go to any insurer seeking fairness, justice, equality, or reasonable treatment, we are able to make ethical arguments, but no arguments with any real teeth. The possibility of legal action always is worth considering; at times it’s certainly been an effective solution. And legally seeking equal pay for equal services may seem appealing from a conceptual standpoint, but are we really arguing our services are equal? We chafe and seethe that physical therapists perform manipulations and are paid more for inferior treatments that require less training than ours. Then we argue we should be paid the same as them. Despite the fact that our services are viewed as the same by the ICD system, we should be paid more than PTs for superior services requiring superior training. That’s certainly the case in medical specialty vs. generalist care. But because we’ve acceded to the medical paradigm, we get nowhere. Over, and over again. God bless those who are still trying. But I know how the story turns out.

The situation is painful to consider, because many chiropractors have become unfortunately dependent on the crumbs insurers drop from the table for us to have. Not to add to the pain, but simply to register some ideas that I believe are actually relevant to potentially change this, here are four options I believe we have as a profession. I’m sure smarter people can think of more. No option is a short-term solution. Any of the three relevant options would require an unbelievable amount of work. But let’s consider them:

Option 1: Continue to live in the medical paradigm. So Blue Cross is proposing…how many tiers of providers now? It’s not hard to imagine the qualifications for those providers given access to the top tiers: live within the medical paradigm, more and more strictly the higher in the pyramid you go. At a time when all care that’s being provided and paid for should be open to challenge as to its effectiveness and relevancy, chiropractors should not be afraid of this type of examination. But the examination is being done on medical terms; BCBSM years ago denied our attempts to evaluate the care on outcome models we considered professionally more relevant. As a consequence, we will never be viewed fairly, and any argument that we should be is wasted effort. But…it’s an option. Sort of.

Option 2: Turn the MCA into a provider network. In my opinion, the only way that doctors of chiropractic will ever have any leverage that forces purchasers to reconsider and more fairly provide compensation, the context for care and how chiropractic outcomes should be viewed is if the MCA becomes or creates a provider network and is able to exert bargaining leverage with insurers who want to offer chiropractic services to their members.

I say this knowing how complex and daunting a job this is. But in terms of actions that change the marketplace, this is one relevant option.

Option 3: Develop an MCA chiropractic service product. As the retail consumer healthcare marketplace continues to evolve and develop, it’s very possible to imagine a chiropractic-specific insurance/care coverage product that emulates the best of what many DCs are finding to be an effective business strategy: a core of services (numerical, time-based, episode-based, etc.) that, when exhausted, lead to a cash-based extension strategy. This is less real insurance than a discounted services model, but it’s where the retail healthcare marketplace is headed, and that’s really all what passes for ‘insurance’ is these days anyway. Placing this product on MNSure and promoting it effectively could be a game changer for many DCs.

Again, this is a complex business undertaking, but probably offers the profession better chances of business viability–and clinical effectiveness with centralized data management–than most others.

Option 4: Blow everything up. I’ve written and discussed this before, but the fact that insurance contracts on file with the state offer chiropractic services on a basis of medical necessity is not only a fundamental paradigm flaw, but I would submit is potentially illegal. I’m not an attorney, so I may unintentionally misuse terms of professional art, but I believe strongly that by providing chiropractic services on a basis of medical necessity we’ve tolerated an ethically inappropriate and potentially legally inappropriate application of our professional scope of practice. Medical doctors cannot direct chiropractic care; chiropractic doctors cannot direct medical care. Contracts the state has approved have essentially been used to give insurance subscribers health care services that have no credible or demonstrable basis from the medical paradigm perspective. Do we think there might be an issue there?

There are some interesting stakeholders in this. The Board of Chiropractic Examiners are charged with protecting the health and safety of the public. Do they have any responsibility when patients are being given chiropractic care under medical standards? Insurance subscribers are contracting with plans to have coverage based on inappropriate standards. Do subscribers have a potential issue with their plans? Doctors of chiropractic are providing services based on medical necessity (standards). Are we operating within the bounds of our legal scope of practice statutes?

I’m laying these considerations out as part of what I hope becomes a larger discussion. Let your opinions be heard.

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