The profession of chiropractic is under profound stresses and pressures. There are a number of doctors who are successful, passionate about their work, magnets for prospective chiropractic students and engaged with their peers as leaders. There are also a number of doctors who are failing in business, getting poor clinical results, driven to add questionable therapies and side business lines, overwhelmed with crushing debt and exiting the profession.
This column is intended to serve as a basis for discussion and to present elements that may help craft a strategic plan and tactics for improving the circumstances of the profession. I’m offering it as a starting point, not asserting it’s the optimal ending point without quite a bit more input. I’m including a number of observations, perceptions and conclusions I’ve come to over my career in chiropractic and the business world from direct experience and discussions with others who do and do not share my views.
Some of this will be polarizing to some in the profession. It is my hope that it provokes discussion and engagement. It’s also my hope that the effect of these discussions lead to concrete action plans, and that these action plans serve to refocus enough of the profession that a collective effort on a new appropriate set of targets can help reestablish the profession of chiropractic as not simply relevant in the emerging retail healthcare marketplace, but actually essential for its success. It’s my opinion and the opinion of a number of people I’ve talked to over the last few years that it’s perhaps more valuable to start with a proposed plan and revise it through discussion and consensus than to attempt to produce one through a committee or more democratic effort. This, then, is a start of what I hope becomes a blueprint for establishing the relevance I believe is available to the profession. It is also presented with a sense of urgency; I am not sure how much time we have to achieve it.
The content follows the links below:
How do we know something is wrong?
In addition to the observations in the first paragraph, there are any number of visible aspects of the set of problems that are dogging the chiropractic profession. Among them:
Problems on the outside: public confusion
The general public knows of chiropractors as ‘back and neck doctors,’ but in many respects do not see DCs as legitimate doctors due to the differences in training and approach. We can point defensively to the comparison in hours and subjects, but the cultural authority here belongs solely to medicine. Chiropractic education is not visible in the mainstream as medical education is, and the chiropractic university system is not connected to the medical university system (not pointing fingers; that’s just the reality). Enhancing the perception that the profession is ‘outside the fence,’ chiropractors are also frequently quoted and visible in making charges regarding medical orthodoxy. These charges may in fact have truthful elements, but are often seen as careless and irresponsible. When we make statements about vaccinations and other aspects of public health that run counter to mainstream (accepted) public health assertions–whether public health policy is fully supported by evidence or not–we face an uphill battle in public perception. Chiropractors are also disaggregated and frequently competitive, operating in very few group practices and even fewer clinics and systems integrated with medical staff. The net effect is one of a public perception of a profession that has immense variability (perceived meaning: unreliable) and unorthodox practices (perceived meaning: unsafe and unpredictable). This confusion is a barrier to adoption, utilization, acceptance and trust.
Problems on the inside: paradigm confusion
Within the profession and its patients, the context for chiropractic care has dramatically changed over the last several decades. Prior to the 1960s and 1970s, when efforts to gain insurance coverage and inclusion in Medicare produced early participation (note: not integration) with the medical system and its paradigm of disease management, chiropractic care and treatment was offered very much in its own, self-supporting context. It didn’t try to be medicine. There was a uniqueness to the types of diagnoses, case management plans and payment structure. In addition, there was a social order in the profession that supported, encouraged–even demanded–participation, citizenship and service. At its heart, chiropractic began as a way of addressing a conceptual model of neurologic dysfunction and the resultant effects on structural form and end-organ function. This clinical and philosophical paradigm, rooted in vitalism, was distinct from the allopathic paradigm (rooted in controlling and managing disease). Its separateness and distinction offered the public a clear choice.
This separateness and distinction did not last, however; education about and commitment to this vitalistic paradigm softened and became very diffuse over the last several decades. The early ‘straight/mixer’ divide widened as a portion of the profession sought to stay connected to its conception of the purest form of chiropractic, another portion sought to enhance its principal therapeutic tool with additional therapies, polarizing the profession into two overlapping but distinctive camps. After the Wilks v AMA decision was rendered, it was in the portion of the professional spectrum that embraced therapies that medical providers more generally found familiarity, and through that familiarity a basis for referrals and collaboration. But it is also true that this interface with the medical paradigm had the effect of softening the boundaries of both medicine and chiropractic, resulting in less and less distinction in everything but the adjustment. But what really hastened the problems of the profession, paradoxically, was insurance reimbursement. As chiropractors came to receive insurance health plan reimbursement for services the trend towards alignment with medicine was reinforced and codified, but it came at a cost. For insurance reimbursement, the context for coverage of chiropractic services has almost exclusively been in the medical model (Medicare’s exclusive coverage of subluxation treatment is a notable exception). From this, an unsurprising effect has been that it has become generally accepted to evaluate chiropractic based on medical paradigm criteria–a reductionistic approach that is very difficult to support unless non-mechanistic, multivariate research models are utilized. This is a fundamental mismatch, and the blurring of the figurative edges of these two different paradigms has contributed to intraprofessional identity confusion as well as external marketplace confusion, uncertainty and a clearly diminishing percentage of market share.
Problems with compensation: economic confusion
The evolution of the economic ecosystem of health care benefits moved in the early twentieth century from a fee for service model that often employed barter to one of employer-supplied overall health coverage. Employers used benefits as a means of inducing post-World War II veterans in an undersized workforce to choose and remain with firms. As people used the benefits the coverage models moved to being one of essentially proprietary discounted service purchasing networks. This model lasted until escalating costs forced a reconsideration of the model in the 1970’s and 1980’s. The result is that true ‘insurance’ generally now only covers a portion of catastrophic health events. For chiropractors, at the apex of the employer-sponsored health insurance benefits phenomenon it was not uncommon to receive compensation from insurers that was higher than what had been submitted. With easy payment and little oversight as insurance coverage began to be more widely provided for chiropractic services, elements of the profession did not handle the opportunity responsibly, and perception and evidence of over-utilization and fraud became too common. In the 1980s, the economic model of managing care came into vogue as a way of addressing overt and presumed waste across the whole system. Because the medical paradigm was used to evaluate the appropriateness of chiropractic services, the economic imperative to reduce healthcare spending drove down utilization and compensation. This pushed many doctors of chiropractic into areas of practice that were not subject to the same economic controls, such as workers compensation injuries and personal injury treatment. Setting aside issues of ethics, misuse and questionable business practices in these areas by some, non-insurance compensation for worker and personal injuries has for many doctors of chiropractic been the only source of external compensation that has been generally regarded as commensurate, fair and reasonable compensation for professional services.
Problems in regulation: legislative confusion
Chiropractic scope of practice laws vary–often wildly–state by state. This variability has contributed to a high degree of difference in how the profession is practiced. It has also fostered intraprofessional conflict where efforts to expand or update scope laws have often produced chiropractors testifying and lobbying in direct opposition to each other.
Tribal warfare: circling the wagons and shooting inward
The problems cited above as well as others have created a significant problem for the profession. While utilization of ‘complementary and alternative medicine’ has increased proportionately across the American public, utilization of chiropractic has decreased. It stands at this point somewhere around 5-10%, and little data exist to suggest it’s expanding. In response, the profession has not effectively organized to address the areas of visible problems listed above. A number among the current leaders have found that it is simply more effective to stop trying to unite the profession and pursue their own strategic vision and tactics. Perhaps more telling is that some see opportunities in the confusion, and are moving to exploit it. National organizations are facing shrinking membership numbers and challenges getting and keeping younger providers engaged. Because of the increasing competitiveness of the marketplace, decreasing compensation and increasing numbers of graduating DCs, internecine battles and destructive intraprofessional relationships are resulting with malignant implications for chiropractic. Domestic competition is moving outside the US, with new legislative battlegrounds being established in countries where chiropractic is new and growing. In many cases, the polarized and toxic domestic relationships are being replicated overseas.
If we stay this course, it can’t end well. Without some effort to align the interests of the broadest segments of the profession, and without some commitment to the health of the entire profession, this current direction will fragment the profession into a set of warring tribes and produce winners and losers. The inevitable tiering of the profession will not end the confusion the public feels; it’s much more likely to enhance it, leaving other professions (read: physical therapists) more room to position themselves more favorably and more prominently in the public’s imagination and awareness.
As dark a take on our current affairs as the content above may be, there is reason for hope.
Healthcare reform is transforming the marketplace chiropractic operates in, and there are changes taking place that are so profound we have a chance to reinvent ourselves and establish a place of prominence and relevance that can support a healthy chiropractic profession. It is actually possible to realistically imagine a near future where chiropractic is a highly visible and significant contributor to public health. We won’t achieve this, however, unless we come to grips with some realities of this volatile and dynamic marketplace that is taking shape under our feet.
Marketplace realities: wake up and smell the coffee
Any service provider operates in a marketplace; health care, and chiropractors specifically, are no exceptions. Until recently, a fundamental marketplace dynamic characterized American healthcare: the retail supply/demand dynamic so familiar to consumers was, in fact, inverted. The demand side–patients–have historically never had the influence and de facto control they enjoy as consumers in the retail market. The supply side controlled what was available, and that was that.
In recent years that has begun to change, and the implications are profound.
The historic roles of stakeholders have been pressured into a set of transitions that are having a significant impact and effectively remodeling the health care marketplace.
- Insurance plans have gone from providing ‘insurance’ against catastrophe to managing discounted service networks and transactions. While each plan competes with each other for the attention and dollars of potential members/subscribers, the health plan ‘products’ that characterize the market now are at their heart different ‘skins’ on service discounts. The amount of discounts, and the proportion of shared economic responsibility on the part of members, varies somewhat across plans and products and is used for competitive differentiation. But the net effect is that health plans are largely transaction managers, and their infrastructure is designed to facilitate that–and in reality, only that.
- Employers have gone from disinterested sponsors to active (albeit unhappy) purchasers. As employer-sponsored health benefits have gotten more and more expensive, most employers have found themselves in the uncomfortable position of having to make decisions about what plan products to purchase to offer to their employees. The net effect is that they are occupying a middle-person role in the market that is rarely popular with their employees.
- Providers have gone from positions of clinical autonomy to required compliance. Independent of considerations for determining appropriate content, amount and duration of care, providers now have less autonomy in making clinical decisions and more pressure (incentives and disincentives) to adhere to the sparest of case management models.
- Patients have gone from the role of being sheltered and protected to one that requires skills in case management, comparative shopping, critical evaluation of care and claims, and fiscal management of complicated economic requirements. This is perhaps the most profound change of any stakeholder because of the power it is exerting on the function and components of the health care marketplace. The trend of requiring patients to occupy these roles, becoming more autonomous and empowered has had what for many is the unintended consequence of revising the identity of being a patient to one of being a consumer. Formerly, patients’ experience of a paternalistic system produced a more universal sense of protection and shelter. In many instances that is still true, but for now that experience is being replaced by a sense of isolation, disengagement and confusion as the new ‘consumer/patients’ struggle to navigate the new requirements and demands of a system that is collapsing under its own weight, inefficiencies, and unproductive paradigm.
- New stakeholders are emerging. Technical innovation is creating an entirely new segment of the marketplace that only existed before as a medical device industry largely managed by the supply side of providers and academia. An explosion of offerings in personal monitoring, remote interaction capabilities, individualized care management and diversification of trusted resources is fundamentally reshaping the ability of consumer/patients to more effectively function as their own case managers–and in some cases, caregivers. And because these devices are coming from ‘non-legacy’ device startups and manufacturers, their genesis, availability and competitive product sets are underscoring the development of the retail healthcare marketplace.
The emerging retail healthcare marketplace
Taken together, the direction these trends and transitions point to us a new health care marketplace characterized more and more by retail supply/demand dynamics, aimed more explicitly at consumers who choose on their own (often new) terms how they function as patients.
How might this new marketplace be characterized? It’s likely to have a number of new elements. The following should be visible as these trends continue:
- The marketplace will support the ability to independently determine needs. As more and more self-assessment, self-diagnosis and consultative tools become available, consumer/patients will present to providers with fewer questions about ‘what’s wrong with me?’ and more questions about ‘give me feedback on this plan I’ve developed and help me choose how to go about it.’ News sources on January 18th 2014 reported that Google has developed a contact lens that monitors the glucose level in tears, giving millions of diabetics the hope that they can monitor their serum glucose levels without having to draw their own blood every day. If no one thinks an app for back and neck pain will ever appear on the market that for some takes the place of chiropractic, they are likely to be very sadly mistaken.
- The marketplace will help establish and benchmark expectations of a retail customer service experience. Retail customers expect warranties, returns or exchanges as a condition of their importance as a source of revenue. Further, there’s the presumption that the ‘buyer is always right.’ Almost all retailers have to operate with an acknowledgement that if consumers aren’t treated well (on terms they themselves establish) they will vote with their feet and take their business elsewhere. A corollary set of expectations in health care has been almost inconceivable…but it’s coming. ‘Customer service’ for health care isn’t all about juice bars in waiting rooms and smiles at the desk; it’s going to become more and more an explicit dynamic of an exchange of value between partners in an experience. What will that dynamic be? As a consumer/patient, I will give you, the provider, something of value (money). In return, you will give me something of value (services). Because that quid pro quo (“something for something”) is becoming more and more explicit as consumers have to pay more for care and make more choices about that care, health care will become more like the retail relationship dynamic that is expected in every other marketplace where there’s competition. Price and demographic tiering of services and resources is already here (The Joint vs. Cleveland Clinic, for example). It will only grow more complex and nuanced over time.
- The marketplace will offer support for making informed choices about providers and resources. While many providers scream about HealthGrades and other provider rating sites, they are here to stay. And they are going to get more robust in the things they evaluate about providers. If you think Yelp reviews and ratings can make or sink a restaurant, wait until you’re a solo provider with $250K in student loans, $125K in equipment and office obligations, and a single discontented patient goes on an ‘Internet rage’ campaign against you. That’s obviously an extreme example, but the truth is that retail market health care consumer/patients are going to have instant access to intermediate services and guidance/ratings sites position themselves in their view as a way of helping guide and inform choices about whom to see for what problems and conditions.
- The marketplace will offer support for the ability to coordinate care. Consumer/patients are already operating as their own case managers in many (if not most) cases. Because it’s unusual for chiropractors to be on the same information platform (EMRs and the like) as allopaths, and because it’s unusual for allopaths, chiropractors and other non-medical professionals to be in active communication, care is commonly (normally) fragmented. Fragmentation adds costs to the system, opacity to siloed providers and confusion all around. Health homes and accountable care organizations contain structural components that hold the prospect of the ability to change this, but until chiropractors are routinely included in these, existing problems of duplication and waste are likely to remain. As more decision-support tools and resources come on line, consumer/patients will evolve into more sophisticated case managers.
- The marketplace will foster broad awareness of the ability to independently organize. Consumer groups are now frequently targeting aspects of the retail world they want to see change. Whether it’s on issues of genetically modified foods, calling out corporations for ethical breaches, or boycotting products over source workers’ wages or working conditions, consumers are realizing they are more and more empowered by social media tools on the Internet to effect social change. When this same force takes shape in the retail healthcare marketplace, the present dominant forces driving health reform (Federal, state and corporate efforts) will very likely take a back seat to consumers’ interests and needs. This isn’t to say that organized consumer/patient efforts will result in bad, ineffective or misplaced products and services, but it is to say that the locus of control in health reform is moving inexorably away from the system (supply) side to the consumer (demand) side.
- The marketplace will support younger generations’ expectations regarding the ability and requirement to define relationships in new ways. Not every consumer/patient coming into providers’ offices will be seeking care; some will simply be seeking consultation and information. Not everyone will want to be called a ‘patient;’ some will want to be accorded a term based more on a sense of peerness and collaboration. Not everyone will be interested in being taken care of; some will be more interested in training and empowerment. What is likely to more and more characterize consumer/patients’ expectations is that they will want to define what their needs are, and will expect providers to respond on their terms and conditions–or they will find one who will.
- The marketplace will reward diversification of options and support for the health care market. Every marketplace needs markets, and healthcare is no exception. Right now, the markets are comprised largely of those buying large amounts of health care–employers and the government. More and more, though, consumers will be freed up to make purchasing decisions independent of their employers and direct to consumer (D2C) ‘n of 1′ plans. Subsidies, allowances, sponsorships, and other means of offering employees support for making their own decisions will become more and more popular. Employers want to step back, anyway; they’re overextended in the artificial roles they’ve been forced into when they have to shop for health care benefits. So the appeal of offering employees money and telling them, ‘Okay, now go buy your own stuff’ will be overpowering. As rough and tumble a start for the new state- and federally-based health exchanges has been, they will get better and better, and products for sale on them will get more and more compelling and varied.
To sum up, then, there are a number of basic characteristics of the emerging retail health care marketplace that are relevant for the future of chiropractic. We should all be prepared for the very near future where consumer/patients will:
- Be better informed about their own needs;
- Expect to be treated as a customer;
- Be prepared to make informed choices about providers;
- Be prepared to be their own case managers and coordinate their own care;
- Be prepared to organize to help achieve their goals and needs;
- Expect to define the parameters of their relationship with providers; and
- Be prepared to function as a ‘market of one’
If these are accurate, then many of the problems the profession has might be explained by understanding that it’s fundamentally misaligned with the interests and needs of the marketplace (and not alone in that, certainly). If that’s true, then these same characteristics potentially offer a template for rethinking what chiropractors should be prepared to do when they graduate from school and/or have been shaped by business support services, advice and guidance. What might happen if we go through a process to “reverse engineer” a doctor of chiropractic so that they are effectively prepared to function and thrive in this marketplace?
What do we do with this? New competencies are required
There is no doubt that a DC has to be technically proficient in adjusting, needs to have all the background educational requirements, etc., that form the foundation for being a scientifically grounded health care practitioner. But chiropractors are already getting that education, and it’s clearly not enough. What else should they be prepared to do?
The emerging marketplace characteristics above can be used to define a new set of competencies that can more effectively inform how clinical services are provided, the business environment where they take place, and the parameters of how those businesses function in the marketplace.
Defined, tested, implemented and measured, these can offer chiropractors a significant advantage in the marketplace by positioning them as being effectively aligned with marketplace interests and needs. No provider group is yet organizing around this the way they need to.
Getting there: reverse engineering the relevance we need
Over and above revising the education and preparation of chiropractors for the new healthcare marketplace, there are some ‘mission critical’ steps the profession must take to reestablish itself as a relevant (or critical) solution to the needs of the market. This ‘reverse engineering‘ exercise is not intended to forsake any aspect of chiropractic, nor intended to malign its history or those working very hard today to improve the lot of the profession. Rather, it is an approach that assumes that iterative changes over time cannot solve the problems and needs of the profession, and that bold and dramatic steps must be taken to make chiropractic relevant in the healthcare marketplace. This can and should be an inclusive, positive and constructive process. So what do we do?
I believe there are some fundamental steps that need to be taken to improve conditions for the profession. They essentially build on each other. I am sure brighter minds can enhance and improve this set of recommendations. But to get started, here are the basics, described here as a basis for further discussion, development, and planning:
1. Understand that we need a common and consistent identity. There is a core foundation in common with nearly all expressions of chiropractic. The profession needs a broad-based commitment to explore that, define it, and settle on how to describe and contextualize the things some (and not all) doctors will do as they build on that foundation. Fail this, and the public will stay away.
2. Use that identity as a basis for defining a distinctive and unique chiropractic paradigm. This isn’t just a matter of language or taxonomy. This is a matter of rejecting the inappropriate imposition of the allopathic paradigm of disease control and management and the primary use of medication and surgery. While those interventions have their appropriate and important roles, they are not part of the chiropractic paradigm. (Side note: this is not to say that chiropractors can not seek prescription privileges. It is to say that they should not offer these services as chiropractors.) Fail this, and chiropractic will be co-opted by medicine, just as osteopathy was.
3. Demand ethical practices. Based on a commonly held professional identity, the ethics of practicing within–or outside–that identity need to be more clearly determined, promulgated, adopted and subscribed to. Fail this, and the climate of suspicion (“Can you help me find a good chiropractor?”) will never go away.
4. Hold those accountable who will not work within that identity or within an appropriate ethical framework. As a profession we have become reluctant to call out those who are making decisions and adopting practices that are harmful to the profession as a whole. One provider can contaminate the public perception of a large number of providers around them. Those doing this damage need to be called out and held accountable. Fail this, and increasing marketplace pressures will continue to force vulnerable individuals into questionable practices.
5. Use a commonly-held set of values based on our identity, ethics and accountability practices to define a model for professional citizenship. As with any social model, citizenship involves a conscious acceptance of roles, rights and responsibilities. This needs to be an explicit model, opportunity and expectation within chiropractic. Fail this, and the profession will never establish the social order it needs to be healthy and thrive.
6. Collectively define our value proposition. If we understand and hew to a common identity, we have the basis for defining our fundamental value proposition. Within the context of a vitalistically-grounded unique professional paradigm, for instance, one version of that value proposition might read something like this:
“Doctors of chiropractic are trained and prepared to help people under their care and management achieve optimal form and function by addressing neurological system integrity and all that it influences.”
There are many ways to shade that, of course, but what in business is a ‘value proposition’ is also a way of describing a role and responsibility for public health. 7. Determine the parameters of appropriate compensation. We do not have our own version of the RBRVS (Resource-Based Relative Value Scale); we need one. Because this is a formula that includes variables that are specific to chiropractic, the profession needs to establish its own version and promote its reference and use within the profession. As others attempt to hold us to the current version defined and controlled by political medicine, we need an alternative we can use to define the gap between what appropriate compensation should be and what is being offered. What we tend to do now is to point to the ‘same or similar services’ model, but in fact this pushes us back into the medical paradigm. Fail this, and the cultural authority of the medical paradigm will strengthen and we will never establish cultural authority of any measure.
8. Aggregate into legal, appropriate, ethical and efficient self-managed networks or other service structures oriented toward consumer-driven markets. Chiropractic managed care delivered networks to insurance purchasers; it’s time to develop open-market networks of chiropractic doctors who can individually benefit from effective business representation and guidance. Fail this, and there will be no way to arrest the ability of payers to continue to suppress utilization and payments.
9. Establish patient registries. There aren’t enough research dollars in the world to do justice to the backlog of need regarding chiropractic. It’s also true that non-mechanistic research models are quite a bit trickier to confidently create. If we truly believe in the ability of chiropractic care to foster and support neurologic system integrity, structure and function, we had better begin to gather that data on our own if we ever want to have the real ability to make defensible claims about the profession’s potential contribution. Patient registries would be a significant way to create the opportunity to collect, own, and manage our own data in this regard, and give us control over the conceptual models used to evaluate what the data mean. Fail this, and we will never be able to effectively justify a broader context of chiropractic’s contribution to overall health, and we’ll be stuck with compensation that only covers the ability to treat symptoms.
10. Dramatically remodel provider education. A much more dynamic, market-facing model of education that lowers the costs, diversifies learning channel options, and establishes new ways of measurement and accountability must be crafted, or the economics of the legacy institutional structures will become insurmountable barriers for most people. Fail this, and chiropractic education will price itself out of the marketplace.
What should happen next
Everything here should be discussed and reviewed. If there is enough evidence or information to revise any of the assertions made pertaining to the scope or source of the profession’s problems, let them be revised. Post comments and discussion points. If there are more appropriate goals to establish, let them be substituted. A grass-roots change agency effort must get going. Let’s see where this leads.
Stephen Bolles, DC
POB 46263, Eden Prairie MN 55344