A cheery letter on 12/1/14 by UnitedHealthcare’s Optum business unit noted that the company was ‘pleased to announce’ that its new Charter product group would impose a ‘new’ requirement on its members. In this new product, members will be required to choose a primary care physician and seek their approval for a referral to a doctor of chiropractic.
Not only did it seem like a cold blast from the unfortunate past, but it also seemed to signify that the profession has turned a corner in its relationship with the health care system–and turning that corner has led us into a blind alley with no way out. As a profession we should be very, very concerned about the implications of this action. And only look as far as the bathroom mirror for whom to blame.
Let’s imagine that an argument can be made that this business strategy (because that’s all it is, an effort to limit exposure to a source of expense) will result in the potential of more people seeking chiropractic care by making it seem ‘safe and accepted.’ As dubious as the concept may be, some may argue that some people who would not normally feel comfortable seeking chiropractic care would feel a bit more so with a physician’s referral in hand. Perhaps. Unfortunately, it’s much more likely to function as a barrier to care, with some real consequences–intended and otherwise.
But what stands out more to me is how this signifies what we have lost. Let’s review some of those implications–understanding that this is (for now, at least) unique to UnitedHealthcare:
- In this model, we’ve lost the ability to function as portal of entry providers, thereby weakening any attempt as a profession to improve the performance and accountability of doctors of chiropractic to function responsibly in that role. We’ve abdicated the responsibility for our own cultural maturation and development, and it’s now in the hands of political medicine. As they say, good luck with that.
- By accepting a gatekeeper’s approval we’ve lost the ability to define any deeper understanding of any broader context for care. As a licensed profession we need to have the freedom to develop a fuller understanding of the need for and the effects of chiropractic care. But with medical doctors defining the context for care as a basis for referral that’s acceptable within their own clinical paradigm, we should have no illusions about what will be approved. Or that it will result in more and more narrow parameters for approved care.
- And the bigger picture shows that in this approach we’ve lost the ability as a profession to establish a distinct model of health and wellness that corresponds to our clinical paradigm of optimal neurologic function. We have accepted the parameters of data gathering, management and interpretation as defined by political medicine and the business metrics of UnitedHealthcare. Our acceptance of this mode of subjugation means that we’ve lost control of defining our own profession on our terms.
- In addition, this action will support those who want to add medical responsibilities to chiropractic scopes of practice law, further fracturing and tiering the profession into two distinct groups. If this concept spreads, chiropractic schools will be in even more trouble than they are already. How will they sell an education that costs over $100K to prepare someone to function as a physician’s chiropractic assistant?
Taken together, the practical impact of this ‘product’ is that we’re back to an even worse position than we were with medical gatekeepers in the late 1980s. It didn’t work then, and the fate of these ‘new’ products is yet to be seen, but because of the intense cost management pressures in health care no one should bet against the concept spreading.
Consumers are less bound by benefits restrictions than they were in the 1980s. There are more choices now and more options for making them in the health care marketplace. So it will be interesting to see what consumers do with this. It’s at least likely to drive them further ‘underground’ in what they feel comfortable telling their medical doctors about. And with the shrinking economic value of a chiropractic ‘benefit’ in most insurance plans, it’s also likely to drive those expenses off the books for insurance companies and fully to the checkbooks of plan members. That likelihood could not have escaped the planning efforts of those behind this type of misguided product. So everybody wins–except for chiropractors and their patients.
We have no power to make an argument against this practice because we have accepted the terms of engagement with insurance companies. At a time when the phrase ‘evidence-based’ is everywhere, the reality of the limitations of that approach are rarely discussed. Dr. Larry Dossey’s recent article about this in the Huffington Post is a sober review of what some understand but many miss: that most of what passes for normal medical care simply has no evidence to support its effectiveness. Worse, billions of dollars are spent on things that are simply ineffective or even harmful. And because political medicine’s fox is in charge of the insurance company hen-house there’s no one in a position of cultural authority to point out the problems this creates.
A pessimistic read on all this is that, for a profession with weak evidence based on the wrong questions we’ve now accepted a subordinate role to a profession whose own practices for the same kinds of problems and conditions have even less support. What could possibly be wrong with that?
Because as a profession we spend more time avoiding collaboration, cleaning up our own act and working to strengthen our position, we’re allowing ourselves to be neatly boxed up and controlled. Political medicine has only had to be patient and watch as our internecine warfare weakened us to the point where we, faced with this new affront dredged up from the past, can only meekly accept it.
The Emperor has no clothes, and yet we’ve accepted the role of his valet.