In December of 2000, I wrote this article for the Journal of the American Chiropractic Association. I can’t remember if it got published or not. It’s interesting to reflect on the observations in the piece. Not sure much has changed for the chiropractic profession.
Navigating the Issues of Integrated Health Care
By Stephen Bolles, DC
In the last decade and a half, doctors of chiropractic have borne witness to a changing health care market that has moved at a dizzying pace. Pressured by a variety of forces, health care delivery has fundamentally changed for virtually every person in the United States. Whether on the cutting edge or the bleeding edge, chiropractic physicians have had a front row seat to the rapidly changing landscape before them. The process has already placed tremendous pressure on our profession, and we are well advised to watch the forces of change at work.
These confusing forces are not in alignment, and are often conflicting; some are expansive, and some are contractile. Efforts at managing health care expenses have found legitimate excess in a number of areas within the system, while at the same time imposing a level of medical decision-making that is burdensome, self-reinforcing, often inappropriate, and in many cases downright dangerous. For most people who participate in today’s health care delivery, the overarching order of things seem to be dictated by the recurring corporate mantra “less is more, and more is less.” Patients, inured to the loss of the protection long-standing relationships with care-givers offer in times of confusion and concern, find themselves shuttling from one new face to another. At the same time, providers, numbed and leveraged into submission by critical tools of access and simple survival, find ourselves trapped in losing arguments as patient advocates time and time again. In too many cases, we have stopped being advocates for health and become forced apologists for the shortcomings of our own system.
In healthier contrast to this bleak picture, consumers have been flexing their muscles. David Eisenberg’s first insight into this unfocused force1 caused dramatic reactions in all segments of health care delivery. Traditional medicine’s public response tended toward muted panic; “What’s going on here that we aren’t being told about?” was the recurring question. For those of us for whom medicine is “complementary” and not the other way around, this and following studies have been a source of both vindication and concern. Sixty-five thousand American practitioners of a healing art that has helped millions of patients cannot be wrong, we say. “It works!” is an unapologetic celebration. At the same time, the sobering light of scientific evaluation has forced us to realize that we badly need a substantial effort in research and investigation to assure our continuance as a distinct and vital profession. As has been pointed out on a number of occasions, we should be mindful of the reality that this distinctiveness and vitality are by no means assured. Without care, dialogue, frank self-analysis and planning, our healing arts may be entirely subsumed within another, eager profession—even one we may now regard with suspicion—or worse.
As the proportion of Americans who are reporting more accurately their utilization of non-traditional modalities increases2, two things are happening. One is certainly that relationships between medical and chiropractic physicians are at their most opportune and positive moment ever. But another trend is a source of serious concern: mainstream health care systems and providers are incorporating, adopting, and in some cases, co-opting providers and therapeutic approaches that until now have been distinct arts and providers.
The pressures for revising the traditional system of medical delivery, and erasing some of the boundaries that have existed between medicine and non-traditional healers, are substantial. In no certain order, economic and relational pressures, together with a generational shift in medical personnel, have helped create a speed of institutional change that seemed unimaginable a few short years ago.
All three sources spring from different influences. The economic pressures alone are seductive. Against a backdrop of downward compensation pressures under managed health care, a glimpse of Americans’ $21 billion annual budget2 for elective health care providers looks rather attractive. The relational pressures are more complex; as one among many studies3 has identified, consumer/patient satisfaction with non-traditional care is often higher than for traditional medicine, or at least dependent in part on the availability of non-traditional options under a given health plan. As chiropractors, the importance of our relationships with patients as a component in successful health outcomes is old news. Since medical education is as much a cultural molding process as anything else, the expectations generated by medicine’s position of primacy in the public mind are often unmet when consumer/patients are unsatisfied—and demonstrate their displeasure by seeking alternative treatments and explanations. The impact of this “institutional disappointment” on the part of traditional medicine is hard for us to imagine. It is easy to see the implicit, plaintive cry in every study and editorial that is critical of “alternative care” and its proponents; after all, how can patients turn away from such good, traditional, scientific health care and run to the arms of alternative providers?
The generational shift of medical providers is of no small significance, either. Those trained in medicine after the landmark antitrust lawsuit against the AMA have had the benefit of notably less prejudice in their own cultural training. The benefits for us in forging cooperative patient care relationships are dramatic.
Collectively, these forces coupled with continually expanding consumer utilization of non-traditional providers, might tempt us to smugly wait for the institution of medicine to implode in dysfunctional glory. There’s just one problem with that type of self-vindication: it isn’t happening. The mantle is not being passed. Allopaths, their support structure, and their educational resources are all moving with dramatic rapidity to not simply coexist with non-traditional providers and therapies, but in many cases they are embracing and advancing their usage. Integrated health care is all the rage, and we need only turn to any business-related chiropractic publication to find advertisements, strategies and testimonials regarding the value of integrated health care as a means of helping to assure individual success.
This is the context we find ourselves in. Our profession is at a major inflection point in its existence. It is arguable that, perhaps more so than at any other point in our history, the decisions and actions we take in the next two to five years will determine the health and continuance of our profession. Integration is happening around us, and we need to decide how we want to participate in, mold, and define the process—or be carried along by it.
We should remember how little protection we have. Our art is the pinnacle of the application of specific analysis, diagnosis and treatment of neuromusculoskeletal disorders, along with the host of their systemic, behavioral and global effects in the context of whole-person health considerations. Our excellent training reflects the state of this art. Our science is being explored; although with resources that, while increasing and encouraging, can only be described as meager in contrast with every other area of health care. And if we look in the rear view mirror, pretenders and imitators are numerous. Our “title protection” is tenuous. Our professional tendency to circle the wagons and shoot inward does not create much confidence.
With this awareness as a background, it is interesting to listen to the awkward harmony generated by the two most distinct voices in our profession. Many of us who value the fullest diagnostic process as a basis for care maintain that this “philosophic” orientation provides the broadest middle ground for developing relationships and co-management strategies with traditional medical providers as a means of increasing public and professional acceptance. By these assertions, we believe our profession can maintain the distinction of its art by finding common ground for discourse, with the assurances that the quality and credibility of our efforts will offer immunity from assault. At the same time, many of us who value the “alternate philosophy” of subluxation-based care place their substantial stake on a future that is based on a “separate but equal” status. “We are different from them, and we should be,” is the message carried by the standard-bearers of the self-declared purists.
In many ways it does not matter what we “believe,” or how we practice. It matters more that we agree on a goal, and that we collectively and individually aggressively define a place for ourselves in the rapidly changing health care market. As the American health care delivery system pursues integration—for it will fully integrate not only chiropractic, but also naturopathy, oriental medicine, therapeutic massage, wholistic touch, therapeutic touch, aromatherapy, homeopathy, remote intercessory prayer, and a host of other approaches—if we do not define our role, it will be defined for us. The elements of our art that are judged to be most effective will be studied, refined, and ultimately incorporated by other professions, if we do not continually claim them as our own. The most effective defense of this claim may be to integrate our profession—its art, science, and education—into mainstream health care delivery, based on a plan of our own devise.
Fortunately, this strategy already has a contextual home. The “transformational model” of chiropractic practice5, delineated so well by the Institute for Alternative Futures, describes a set of professional skills and areas of expertise that, if accepted, followed and advanced by the profession, probably offers more assurances of our profession’s continuance than any other means. This model essentially affirms both positions of our fractured professional stance: we are different, we should maintain that difference, but that the consumer—and by influence, the system—will gravitate toward us when we offer the fullest spectrum of health care analysis, diagnosis, case management emphasizing structural and neural health, and lifestyle counseling. To not do this will leave both philosophic positions weakened and vulnerable. We all are, and will become more so, vulnerable to being reduced to spinal technicians as distinctions between us and others who evaluate patients’ health become more and more blurred.
For many of us, and certainly for the rapidly expanding numbers of chiropractic program graduates, simple survival is dictating that we look at new strategies for becoming more embedded in mainstream health care delivery. We rightly believe that integrated health care should include our profession, and there are signs across the country that individual allopaths, clinics, hospitals and whole systems are agreeing. Chiropractic is on the verge of one aspect of success, and it is a dizzying prospect.
We should be careful what we ask for, however. Integration as a concept should rightly cause us concern. The object lesson of osteopathy, with its professional and philosophic gains and losses, can be an enormous help to us as a guide. Turning for a moment to our friend Webster’s New Collegiate Dictionary, we are given some insight to the complexity of the problem by the variety of definitions of the word “integrate.” One definition states that to integrate is to “form, coordinate, or blend into a functioning or unified whole.” Another is “to unite with something else.” Yet another is to “incorporate into a larger unit.” And finally, it can mean “to end the segregation of and bring into common and equal membership in society or an organization.” 6
These three different definitions provide insight into some of the choices—and perils—facing us. Different strategies will either protect our distinction or diminish it. Integration can either result in a loss of identity, subrogated to the larger whole, or a reinforcement of our identity by a clear niche being described—and protected. Do we want to be reduced to roles that others define for us? Or would we rather define our own place in the health care system in a way that broadly incorporates the spectrum of capabilities of all expressions of chiropractic practice? We should be valued as a new breed of natural care generalists with a special focus and capability that others cannot match.
Northwestern College of Chiropractic, now the flagship program of Northwestern Health Sciences University in a Minneapolis, Minnesota suburb, committed itself several years ago to supporting the transformational model of chiropractic health care. This model is elegant in its completeness and inclusiveness: that we offer the fullest spectrum of health care analysis, diagnosis, case management emphasizing structural and neural health, and lifestyle counseling to the public and other professions.
In the process of weighing the value of different collaborative partnerships with mainstream health care systems in the Twin Cities, Northwestern received an invitation to open a clinic in a new health campus that was being built which would include a hospital, medical office building and a rehabilitation center. At the same time, institutional strategic plans were being developed that identified integrated health care as a specific area of interest and long-range planning. The new health campus identified “complementary and alternative” care as a specific area of clinical services that it would provide for its patients and customers, and has aggressively advertised and promoted that fact. This synergy has created a potentially unique setting for exploring new models for health care delivery.
The Northwestern Natural Care Center is scheduled to be open in May of 2000. Chiropractic will be the sentinel service of the Center. Other services will include oriental medicine, therapeutic massage, naturopathy, and some aspects of traditional medical care. Support services will include radiography, physiotherapy, a clinical laboratory, and a retail health and wellness products store staffed by a master herbalist. The Center will be part of Northwestern’s clinic system, and the director of the Center will be a doctor of chiropractic.
The Natural Care Center will develop and test models of integration and clinical training. Collaborative care algorithms will be developed and tested with the medical staff in the other primary care clinics on the medical campus. These efforts will take place in a context of a general understanding that “integrated health care” is not a cookie-cutter approach, but a highly individualized, customized process that is site-specific and dependent on a large number of factors.
This experiment will be only one of many our profession needs to undertake as we explore how best to create the future that preserves and enhances chiropractic for ourselves, our present and future patients, and for future doctors of chiropractic. Among the many questions that need to be answered are:
- Who forms a core team of essential providers, skills, and interventions in health care delivery?
- Who is the most effective director of patient care and tracking, under what circumstances and for what conditions?
- Who provides the most cost-effective care?
- What kinds of research will be most cost-effective in helping us expand our understanding of our science and application of our art?
- What concessions of “therapeutic territory” must be considered when a health care team is caring for a patient? How are overlapping areas of expertise handled?
- What happens when different providers have different degrees of acceptance by third party payers—and different management requirements need to be agreed to as conditions for coverage?
These and other efforts are essential to our profession and our patients. It is extremely important that our profession lead these efforts; too many other experiments are simply revised medical models in both thinking and practice. They are also important as a basis for exploring the common ground we must establish between the political and philosophic constituencies within chiropractic. If we are not aggressive in defining our direction, if we are not successful in learning to speak as a more cohesive profession, our skills will be learned by others, our art will be co-opted, and our science will be for sale. We are at risk of becoming a footnote in health care history textbooks.
With apologies to Shakespeare, the decision facing all of us is not, “To integrate or not integrate, that is the question.” We will become integrated. The issue at hand is more specifically how we define our role as architects in designing the most effective version of integration in our own practices, education, and lives.
Dr. Bolles is the Director of Interdisciplinary Services at Northwestern Health Sciences University
1 Eisenberg, DM et al Unconventional Medicine in the United States: Prevalence, Costs, and Patterns of Use New England Journal of Medicine 1993 Jan, 328(4), pp 246-52
2 Eisenberg, DM et al. Trends in Alternative Medicine Use in the United States, 1990-1997: Results of a Follow-up National Survey Journal of the American Medical Association. 1998, 280, pp 1569-75
3 Schmittdiel J et al Choice of a Personal Physician and Patient Satisfaction in a Health Maintenance Organization Journal of the American Medical Association 1997, 278, pp 1596-9
4 Institute for Alternative Futures The Future of Chiropractic: Optimizing Health Gains 1998 National Chiropractic Mutual Insurance Company
5 Mish, Frederick C., et all Webster’s Ninth New Collegiate Dictionary Merriam-Webster, 1983, p. 628