Where Will You Fit In?

Speaking to a group of chiropractors and support staff recently about the chaotic world of health care reform, I was left wondering how to answer a basic question: where will they fit in? This isn’t an off-hand question, and it’s not about a social fit. In many ways, it’s the critical question to ask, because perhaps more than at any time in the short life of the amazing profession of chiropractic, answering ‘where we fit in’ is going to be a much more complex set of considerations. If you’re not thinking about this, you need to be.

Reasonable people will disagree about the importance or reality of different trends in health care, but from where I sit, the following trends are likely to change how health care is practiced more than at any point in its long history. That’s a bold statement. But consider:

  • For an average family of four with employer-sponsored health care, employee contributions and out of pocket expenses in 2014 topped $1K/month.
  • A bronze-level plan for an individual BCBS insurance plan in Indiana on HealthCare.gov has a premium of only $263/month, but a deductible of $6,300. That’s more than a quarter of after-tax income.
  • Value-based purchasing (contracted care for outcomes in a population, instead of paying for individual services) is predicted to be used by 80% of employer-sponsored purchasing efforts by 2020. If values = outcomes over costs, and people’s decisions are based on how they feel about the services they’ve bought, understanding that calculation is critical.
  • Those using online exchanges to purchase health care plans increased by half from 2013-2014, and can only continue to grow. Most predict 90% of workers will use them by 2020.
  • Half of employers offered high-deductible plans in 2014; that will grow. In 2014 23% of employees bought high-deductible plans, up from 18% in 2013.
  • In 2014 40% of those with high deductibles whose deductibles exceeded 5% of their income skipped needed health services.
  • In 2014, 63% of workers had traditional job-based coverage. That’s predicted to shrink to 20% or less by 2025.
  • The current minor trend of ‘skinny’ networks to control costs is likely to be replaced by open networks, because health plans won’t be able to justify the expense of managing networks when providers are directly competing on price with each other in online exchanges.
  • More employers are moving to defined contribution benefits models, which means they’ll give employees an ‘allowance’ to buy whatever health plans they choose to.
  • The health care ‘wearable’ technology industry is taking off, and predicted to be a $5 billion industry by 2020.
  • Consumers’ PHI will be collected from a dizzying number of wearable, external and even internal monitors, relayed and collected by new applications (Apple’s HealthKit app, for example) and imported to various health records, other ‘Big Data’ repositories and mined for economic and predictive value by businesses most of us will never know about.
  • Decision-support tools will be available everywhere for health care consumers, and providers will be making fewer and fewer independent clinical decisions.

If your head hasn’t exploded yet, take a look at your practice and ask yourself if you’re prepared to operate in this new world–a world coming at us very, very quickly. If you’re in school, ask yourself if you are being taught the business practices that will be required to survive.

If you can answer ‘yes’ to those questions, good for you, but you may feel very alone. Most providers are not ready, nor have they been prepared by the business education they have received.

Before you jump off a bridge, there are three very basic, practical things you can do–and, I would suggest, must do. Now. Those who do will be prepared and are much more likely to survive and thrive. They aren’t necessarily easy, because they require you re-thinking a good part of how you practice. But I submit that these three tactics are very important.

  1. Cut the cord on insurance reimbursement dependency. All you’re getting paid for is a minor portion of the value you’re delivering, and chances are good you’re providing your services below cost. Decide if you want to ‘take what you can get’ and have that determine your case management, take what you can get and convert people to cash plans, or forswear insurance compensation altogether. Pro: independence from the mechanistic value proposition of ‘insurance.’ Con: bumpy ride to get there. Dependency: Adequate presence on the Internet with patients as your co-promoters.
  2. Ensure you are capturing ‘lifestyle context’ data from your patients and clients. What does this mean? It means capturing a more holistic picture of how people live their lives, so that your biometric data can’t be used alone to define your value. Work with your patients to create a narrative about how your practice, your services and your staff enhance peoples’ lives. Pro: Acquisition of data that permits a broader understanding of the benefits of chiropractic care. Con: Revised effort managing your time and relationship with patients. Dependency: coordinating how you document this with your other health record information.
  3. Align yourself with your patients’ changing relationship with the health system. What this means is that health care consumers need more help, not less, in managing their health finances, options, decisions, and relationships with other providers and plans. How can you help them? How can you help them see you as outside the system–just like they are? Pro: Helping health care consumers see you as a valued and necessary resource. Con: New efforts in working to understand what problems your patients are trying to solve outside of your office. Dependency: Being able to provide them with necessary guidance, help and resources.

Do these, and you will begin to answer the question, ‘where do I fit in?’ You will fit into a new relationship with health care consumers who are going to be more discriminating about where and from whom they purchase health care services; you will fit into what is going to be more of a ‘health care ecosystem’ rather than the current disease care system, and you will fit in with your current and prospective patients–when consumers decide to become patients–by positioning yourself differently. Beyond being a competent and important source of optimal neurologic health through chiropractic, you can be a source of necessary guidance and support. I’m afraid there isn’t a lot of time to get ready for this.

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