Chiropractic: Dualism and Integrative Health Care

The term integrative healthcare has been around for more than twenty years, and means something different to nearly everyone who uses it. More than 40% of Americans use methods, providers and therapies that are ‘alternative’ or ‘complementary’ to Western medicine, and the constellation of those relationships are extremely personal and individual. Many have tried to come up with institutional, organizational and economic models that support integrative healthcare, but there are very few examples of viable business models that are not substantially funded by philanthropy.

As seemingly popular as integrative healthcare is, why isn’t it more widespread and successful?There are several reasons success has been elusive. Primarily, political medicine has been resistant to adapt its culture to share power and clinical leadership, and it has held others to standards of evidence and research that it itself cannot meet. Secondarily, compensation models for non-medical providers have been wrongly based on the medical disease/pathology identification and management paradigm, and the accepted business approach of managing services numerically does not appropriately align with the contributions of chiropractic and other non-medical professions. Thirdly, the often-defiant, independent behavior of chiropractors in particular has made it difficult for healthcare consumers to enjoy a ‘standardized product’ of professional services, and competing chiropractic programs’ efforts to differentiate themselves has exacerbated the problem.

Although provider interest has driven most experimentation in the field, integrative healthcare is supposed to serve consumer/patients. Because healthcare reform is increasingly making the consumer truly the center of all exchanges of information and commerce, it’s worth looking at their position in all this. Healthcare consumers are being forced to deal with more and more dimensions of a very complicated role. Some aspects of their new roles include:

  • Comparative benefits shopping. Consumers are now in the position of needing to make increasingly nuanced choices regarding insurance plans and healthcare costs as employers provide less leadership and online insurance shopping becomes more and more common.
  • Critical thinking. The range of information on the Internet is overwhelming, and so many competing claims of therapeutic expertise are made that consumers have to make many decisions without a common index of truth.
  • Case management. Because different healthcare professions (even in the same system or clinic) don’t normally work together or coordinate information, consumers are, more and more, becoming their own case managers.
  • PHI stewards. Patients’ PHI has been turned into a commodity without consumers really understanding or benefiting in proportionate amount to those making money off their data. As the healthcare system fragments into more transparent pieces consumers are going to need to make more and more decisions about where their information is stored, who has access to it, and what can be done with the data.

Given all this, integrative healthcare offers many opportunities for providers to align themselves in new ways to meet the needs of consumers–both as they are understood now, and as they will come to be. So for chiropractors, what’s the best path to take, and what are the conditions we should insist on?

Dualism: the critical difference
One of the greatest challenges in many past integrative efforts has been efforts to combine medicine and chiropractic. In reality medicine and chiropractic (and other non-medical professions) operate under different paradigms. The philosophic and clinical paradigm of allopathic medicine is based on the identification, prevention and treatment of disease. In practice, applying this paradigm means that patients are essentially viewed as potentially sick until sickness is ruled out. This can be critically important when disease is suspected or present, but when disease is not present medicine literally doesn’t have much to do.

In contrast, chiropractic and other non-medical professions have a philosophic and clinical paradigm that is more congruent with vitalism: the philosophic orientation, acknowledgement and appreciation of the intrinsic capacities of the body to grow, develop, recover from injury and maintain health. Where medicine seeks to manage disease, chiropractic and others seek to optimize the body’s own abilities to respond to disease and other environmental insults. Where medicine seeks to intervene to control, chiropractic seeks to support and withdraw. Surgical intervention is a godsend in time of critical need; optimizing neurologic function is a godsend when environmental insults and subluxation diminish its capacities.

Put together, these two paradigms offer a comprehensive continuum of ways to address the health and illness needs of people over their lifetimes. For providers who operate within their own paradigm, there really is little in the way of competition between the two. Both look at health and healing very differently. But if they are combined in settings where both have to operate under the same paradigm, things don’t work as well. Asking doctors of chiropractic to fulfill the range of primary care responsibilities–including writing prescriptions–puts them in the medical paradigm. And asking medical doctors to identify and remove sources of interference so that bodies’ innate wisdom and healing capacities can function optimally puts them in a similarly inappropriate position.

So the first requirement for integrative healthcare is that it needs to be dualistic. There needs to be an explicit acknowledgement of the fact that there are two clinical and philosophic paradigms at work and available to healthcare consumers who decide to become patients. In practice, this means that those managing these services (and paradigms) are peer collaborators and not placed in a hierarchical relationship where one dictates the work of the other.

The second requirement is that both professions need to incorporate the same information sources. If to ‘integrate’ as derived from the word integer means ‘to make one,’ then all professions involved must share and use the same information about diagnoses, treatment options, outcomes options and active care. Unless this happens, alternate options become competing claims, and consumers trying to make sense of it all will have to turn elsewhere.

The third requirement is that consumers’ role as case managers needs to be honored and facilitated. All professions involved in integrative healthcare efforts need to treat the consumer as the true center of decision-making, and align their relationships, communications and care to that fact.

The fourth requirement is that patients need to assume an active role in managing their own PHI. This does not mean housing or hosting it, but it does mean that they understand and participate in how their PHI is distributed, who has access to it, how it is monetized, and become business partners in its potential commoditization.

Most of the efforts in integrative healthcare in the last two decades have focused on the structures of the effort: what kind of services were available, how the offices were laid out, who was in charge, and how the providers interacted. Rarely has an integrative healthcare experiment explicitly acknowledged the duality of paradigms that is required for integration to achieve its potential.

I write this fully aware that orthodox delivery and compensation models are not prepared to easily adapt to these conditions. As healthcare costs have skyrocketed (largely due to technology and end of life care), the economics of healthcare for most of the rest of our needs have been placed under excruciating pressure, and the management paradigm in place looks at care through the wrong end of the telescope. But as healthcare becomes more ‘retailized’ and as consumers’ retail preferences are adopted more and more in healthcare delivery and products, population health compensation models will change.

Using these four requirements means that all of the structural elements required for delivering care will dictate themselves organically, based on and responsive to the unique circumstances of each effort. They can and should be applied to any version of integration: a virtual ‘clinic without walls,’ where providers are not co-located but collaborate; a profession-specific clinic (exclusively chiropractic or medicine), where referrals are made to a range of providers; or a multidisciplinary, shared location with a range of services available all under one roof. These requirements do not preclude establishing successful delivery models such as medical/health homes, nor population health management businesses such as accountable care organizations. In fact, they are likely to enhance their success and viability.

Potentially successful versions of this approach will require that professions participating in integration have honest and direct discussions about their own philosophic and clinical paradigms, and how potential challenges are handled in practice when consumer-patients are presented with stark choices about care options. Those conversations can produce clear strategies about what the focused clinical contributions of each profession can be and turn interprofessional relationships into the sources of egalitarian collaboration they should be. The new clinical algorithms that appropriately incorporate these considerations will not be ‘if/then,’ but based more on ‘both/and.’

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