With apologies to Nicholas Meyer, this post isn’t about Sherlock Holmes upping his dosage, but about chiropractic and the American health care marketplace. Research recently released by the National Institutes of Health looked at data from surveys combining data from almost 89,000 adults through the National Health Interview Survey. It found that chiropractic and osteopathic manipulation was the fourth-most commonly used ‘complementary and alternative’ approach to clinical care, used by 7.5% in 2002, 8.6% in 2007 and 8.4% in 2012. In terms of actual population, in 2002 DCs treated 21.57 Million individuals; in 2007 25.9M individuals, and in 2012 25.3M individuals. So despite what we want to think of as advances in terms of acceptance by political and organizational medicine, insurance companies, other payers and the consuming public, it’s possible to say we peaked in 2007. What’s the solution for greater market share?A starting point for numbers is the US Department of Labor’s Bureau of Labor Statistics for Chiropractors. These data illustrate the range of employment numbers, compensation rates, and so on. Figures for 2013 illustrate the range of annual mean national wages to be from $78,260-$125,260. If a student graduates with $150,000 in student loan debt (an arbitrary number, but low for many), it can take ten years to pay back loans at 6% at monthly payments of $1,665. Based on very general numbers of after-tax take-home salaries from the range above of $4,239-$6,785, the remainder of income for other living expenses is in the range of $2,574-$5,120. Not living fat, by any means. In fact, arguably not even a survival wage on the low end. Now these are very rough numbers, but are used to make a point: the current compensation picture for the statistically average doctor of chiropractic is not encouraging. Market penetration mapped against education costs shows that there’s a corrosive asymmetry between the expense of becoming educated and the economics of practicing.
Is ‘spinal physician’ the answer?
This discouraging dive into numbers is prompted by another article on the concept of DCs as ‘primary spinal care physicians/doctors/whatever’ in the February issue of The American Chiropractor (online). The authors, Drs. Studin and Owens argue that among other compelling reasons to broaden and revise chiropractic scope laws to practice limited medicine, in their personal experience workers compensation judges predominantly support prescription drug use and find it more challenging to support chiropractic treatments. They argue that DCs should incorporate the ability to write limited scrip and make it more convenient for their patients who need pain mediation and anti-inflammatory drugs.
It’s a compelling argument for some, and an increasing number of doctors are supporting it. It might be an organizing principle that ‘saves’ the profession–if, in fact, it would change anything. But the truth is that we as a profession have no idea whether the marketplace would actually reward this approach. We have tons of anecdotal stories of patients for whom we’re sure it’d have been a convenience if we could have just whipped out our little pad and give them some pills. A good portion of them would certainly feel better while Nature is doing her work, facilitated by chiropractic adjustments. So do we think things will change if we add more education (more costs) and partial regulation under medical practice boards? Based on my legislative experience, I’m not sure I can imagine chiropractic boards being given the opportunity to regulate prescription activities. Will writing prescriptions and the expected influx of patients grow revenues so greatly that the economics of education and delivery make sense? Are we going to become so much more popular and trusted that we will become the primary resource for treating medical spinal conditions or ‘enhanced’ chiropractic treatment?
Well, maybe. I don’t think so. But I don’t really know, and neither does anyone else. The research on this just hasn’t been done.
Market research doesn’t sound like it’s a natural solution for answering questions about the future of chiropractic practice, and prediction efforts such as those undertaken by the Institute for Alternative Futures normally look at trends, potential convergence points and make educated guesses about what those convergences create. But prospective modeling depends on a history of data and information, and there’s just one problem with doing that for this question: the American consumer is an entirely new stakeholder in the health care marketplace, and there is literally no history to draw on. Consumer/patients have entirely new pressures, factors and opportunities in front of them that didn’t even exist just several years ago. Greater financial autonomy, responsibility, independence, and less requirement that they rely on discounted access to captive provider networks are just some of the dynamics at work.
Setting aside all other (significant) questions regarding identity, philosophy, practicality and so on, to really answer the question of whether American health care consumers will use doctors of chiropractic more with a scrip pad on the counter requires that we ask them. Unless we have any real data on this, no one really knows, and everyone believes they’re right. How do we go about this?
Large-scale surveys by big vendors aside, there are some simple ways to gather information. Survey smaller populations and aggregate the data. Here’s a sample of how a set of questions might be laid out to get at this important information:
- Do you now, or have you in the past, seen a doctor of chiropractic?
- Were you generally satisfied with the care you received?
- Did you have significant pain and/or inflammation while you were recovering from your complaints, injury or problem?
- Did you receive pain or anti-inflammatory medication from a medical doctor while you were being treated by the chiropractor?
- If you did not receive such medication, do you wish you had been able to have it available to you?
- If your doctor of chiropractic had been able to prescribe one or more of these, would you be more or less likely in the future to use that doctor instead of a chiropractor who does not prescribe medications?
- Would you be more or less likely to recommend a chiropractor to a friend or loved one if they prescribe medication as opposed to recommending someone who does not?
These basic questions, or some like it, could give us actual market intelligence to use as a way of knowing whether or not the legislative strategies some in our profession are considering actually make sense.
Survey your patients! Create your own survey, or use this one on SurveyMonkey. I’ll share any results the survey produces if people use it. Send in your own consumer survey results to your state association.
Until we ask these questions of our patients–the public, health care consumers–we don’t know whether our opinions are right or not. And while there are many other strategies that are likely to be needed to improve on our current eight per cent market penetration, the prominence of this proposal in our profession right now demands we have some actual information to work with.