DCs as Primary Care Providers
Dynamic Chiropractic; September 1, 2004, Volume 22, Issue 18
New Managed Care Study Finds Improved Patient Outcomes and
Significant Cost Savings With DC Gatekeepers
See DC’s interview with the study authors at the conclusion of
this article.
A new research paper published in the Journal of Manipulative
and Physiological Therapeutics (JMPT) has found that a managed care network
consisting of doctors of chiropractic as primary care providers (PCPs) provided
equivalent care and saved substantial costs compared to patient management
utilizing medical doctors and osteopaths.
The analysis found that chiropractors were not only able to diagnose and
treat patients at a level nearly equal to medical doctors, but also that
patients enrolled in the chiropractic network were admitted to the hospital
less frequently, spent less time in the hospital for care, underwent far fewer
surgeries and used far fewer pharmaceuticals than other HMO patients, resulting
in tremendous cost savings and extremely high patient satisfaction scores.
“Reliance on the conventional medical model, in which
pharmaceuticals and surgical interventions represent first-line treatment, may
not provide the best therapeutic index to our patients,” noted the study’s
authors. They added that a chiropractic gatekeeper model of managed care “seems
to demonstrate the potential superiority of an integrated health system in
which chiropractic and
Foundations of the Chiropractic Gatekeeper Model
In 1996, a large health maintenance organization serving the
needs of over 600,000 people in the
The following year, an independent provider association (IPA)
known as Alternative Medicine, Inc. (AMI) was created to serve as the new
integrative health care system. It functioned within the classical gatekeeper
HMO model, and adhered to the same rules and regulations as any other
contracted conventional allopathic IPA.
Medical doctors, osteopaths and chiropractors in the area were all
invited to join the new IPA network. Curiously, only doctors of chiropractic
were willing to participate in the project; according to the authors, the MDs
and DOs interviewed declined to take part in the project “for a variety of
professional, personal, political and economic reasons.” To ensure that
chiropractors could successfully function as primary care providers, a unique
credentialing process was created, consisting of personal interviews; reviews
of the DC’s treatment modalities and scope-of-practice patterns; and educational
seminars given by medical directors to review conventional medicine diagnostic
and referral decision patterns. All of the chiropractors had to be credentialed
before they could be included in the network and begin seeing patients. AMI’s credentialed chiropractor network
began treating patients on Jan. 1, 1999, with an enrollment of just 37 members.
By Dec. 31, 2002, enrollment had grown to 649, largely through “word of mouth”
advertising from patients.
In the chiropractic network, the DCs performed all patient
examinations, treatments and procedures at their own discretion. Recommended
follow-up visits, choice of appropriate treatment, and ancillary therapies
utilized did not require approval from a medical director; however, ancillary
testing and treatment performed outside of a chiropractor’s office was subject
to MD approval, so that patients could benefit from a medical doctor’s
experience in dealing with more complex types and states of disease. If a
life-threatening disease was diagnosed, or if the patient required
hospitalization or allopathic care as a result of an advanced stage of disease,
the chiropractor would delegate his or her authority over the patient to an
attending medical physician who had been consulted on the case.
The chiropractors participating in the IPA had a higher number
of initial patient visits, which were designed purposely to correct structural
abnormalities in patients, and provide information on lifestyle and diet
modifications to prevent more serious diseases from occurring in the future. In
many instances, AMI enrollees saw their chiropractors an average of twice per
month, sometimes more. “This is in contrast to conventional medical IPAs,
wherein the majority of members have PCP encounters on a ‘crisis-only’ basis,” the
authors noted. On several occasions,
the chiropractors also utilized “nonphysician
AMI Model Leads to Better Patient Outcomes, Lower Costs, High
Satisfaction Rates Analysis of coding data by the chiropractic primary care
physicians, combined with data on referrals to specialists and pharmaceutical
usage, revealed that when making a patient diagnosis, “agreement was found
between the conventional medical specialist and the chiropractic PCP 93.1% of
the time.” This analysis showed that properly credentialed chiropractors could
diagnose conditions almost as well as medical doctors, including a mange of
conditions they might not normally see in the conventional chiropractic
setting.
|
Comparison
of ICD-9 diagnostic profile by percentage of member enrollment, AMI
vs. comparison group I |
||
|
Diagnosis |
AMI % |
Comparison Group I% |
|
Wellness |
28.5% |
34.7% |
A comparison of those cases seen by chiropractic PCPs and a
comparison group of medical/osteopathic providers revealed some interesting
similarities, particularly with respect to asthma and neoplastic conditions.
The wellness category included those patients who had no visits, patients who
came in for nonsymptomatic screening tests only, and encounters that did not
receive an ICD-9 code, but may have included chiropractic codes for
subluxation/dysfunction.
|
AMI
clinical outcomes comparison with HMO network data, 1999-2002* |
||
|
Data |
AMI percentage utilization
vs. HMO |
AMI percentage reduction vs.
HMO |
|
Hospital-based
|
|
|
|
* Obstetrics admission
excluded from comparison percentages. |
||
The authors also compared patient outcomes from 1999-2002 of
patients enrolled in the AMI network versus those in the traditional HMO
setting. There were demonstrably fewer
hospital admissions among patients seeing a chiropractic PCP and fewer
outpatient surgeries, and the cost associated with pharmaceutical usage among
chiropractic PCP patients was approximately half that seen in traditional HMO
patients. These findings demonstrated the chiropractic network’s “apparent
superior clinical outcomes” compared to conventional managed care statistics
over the same time period.
One of the most dramatic differences between patients in the
chiropractic network and those in other HMOs was in terms of hospital stays. In
2000, chiropractic patients spent 115 days in the hospital for every 1,000
“member months” they were enrolled in the network. For patients of
medical/osteopathic PCPs, the number of hospital days per 1,000 member months
ranged from 171 days to 344 days.
In addition to favorable clinical outcomes, patients enrolled in
the chiropractic IPA gave it higher satisfaction scores than the rest of the
HMO network. For the first four years of operation, AMI satisfaction scores
were 100%, 89%, 91% and 90%. “Analysis of HMO member satisfaction surveys
demonstrates the AMI members consistently rated their experience with AMI above
the HMO network normative average,” the authors wrote. “The AMI experience seems
to indicate that a nonpharmaceutical/nonsurgical orientation can reduce overall
health care costs significantly and yet deliver high-quality care. These
results have been achieved not by decreasing or denying access to care but,
rather, by increasing the frequency of PCP prevention-oriented encounters.”
The Chiropractic Gatekeeper Model: The Health Care System of
Tomorrow? Several studies have shown
that of all the forms of complementary and alternative medicine practiced in
the
Instead of providing unfettered access to chiropractors and
other CAM providers, “a myriad of excuses, both by the private insurance
industry, and by the federal government, currently reduce one’s personal
freedom by restricting access to choose unconventional medicine, even when
practiced by licensed physicians in good standing.” A variety of excuses have
also been put forth as to why doctors of chiropractic are often considered
ineffective at being primary care providers, including a lack of training and
education and experience, and philosophical differences with the allopathic
model of care. The results of this study shatter the myth that chiropractors
cannot function effectively as primary care providers in a managed care
network, and shows they can diagnose, treat and refer patients as well as, if
not better than, their allopathic colleagues.
According to the authors: “At the very least, this article, for
the first time, has demonstrated that a select group of chiropractic physicians
successfully functioned in both a safe and effective manner as PCPs in a
classical gatekeeper HMO model. Second, it has demonstrated that these same
chiropractic physicians were capable of initiating and coordinating care for
patients with a broad spectrum of disease states, representing a wider variety
of diagnostic presentations than is commonly seen in most chiropractic offices.
Third, the magnitude of improvement in both clinical and cost outcomes compared
with normative values is so large that it is difficult to dismiss as purely
coincidental to population bias and nothing more.”
As with most studies that compare one form of care to another,
some limitations were noted in the analysis. The authors freely admitted that
the number of patients enrolled in the chiropractic IPA paled in comparison to
patient populations in the other HMOs, and that they were unable to determine
the exact effect the transfer of members into and out of the network had on
overall cost savings and clinical outcomes.
But despite these (and other) limits, the authors believe they may have
come up with a model that could revolutionize the way people are cared for in
the managed care system - one that could leave patients satisfied with the care
they receive while delivering significant cost savings:
“The traditional argument against coverage for
prevention-oriented medicine is that it will not reap immediate financial
benefits and that employee or insurance turnover is too high to wait for an
extended turnaround time. The AMI experience suggests that cost savings may
occur in the first calendar year of operations. “The magnitude of improvement in both clinical outcomes and cost
savings documented herein may not remain constant when the AMI model is
utilized on larger and more diverse populations.
However, even a small percentage of the AMI outcomes would still
have significant implications, given a $1.3 trillion national health care
budget. At such a high price, AMI’s initial results should warrant additional
funding for a larger and better controlled replication of these findings.”
[Editor’s note: DC would like to acknowledge National University of Health
Sciences and Elsevier for making this JMPT article available free of charge to
the profession. The complete paper is available online at: http://tinyurl.com/6m916.]
Q & A With Drs. Sarnat and Winterstein
We interviewed Drs. Sarnat and Winterstein to learn more about
their study findings and the potential ramifications for the chiropractic
profession:
Dynamic Chiropractic (DC): Comparing the AMI model to the other
HMOs in the analysis, what was the most surprising outcome of the study -
reduced hospital stays, fewer surgical procedures, reduced use of
pharmaceuticals, or something else?
Richard Sarnat (RS): I have always believed that the
overutilization of pharmaceuticals and surgery and the underutilization of more
natural healing techniques, such as chiropractic, has been the cause of great
suffering. Yet, I had no idea that the magnitude of both clinical improvements
and cost effectiveness would approach 50% in both cases. Previous studies have shown these types of
savings when chiropractic has been used as a first-line treatment for NMS
ailments, instead of traditional conventional medical care. But to see this
level of effectiveness across the board for literally all types of clinical
presentations within a primary care setting is surprising to me, and good news
for the rest of the world.
DC: What does the study say about the ability of chiropractors
to function in the managed care environment and deliver quality patient
care?
RS: As already mentioned, AMI’s outcomes clearly demonstrate
that chiropractic belongs in a primary care setting within the managed care HMO
model. However, it is important to remember that the chiropractors who
functioned as primary care physicians (PCPs) within the AMI model are not
necessarily representative of the profession at large. Having personally been
involved with the credentialing of hundreds of chiropractors, I would guess
that less than 50% of the profession is prepared to take on the enormous
legal/medical responsibilities given to PCPs in an HMO gatekeeper model. Yet,
paradoxically, that is where chiropractic can be most effective.
DC: We understand that your article was submitted to several
medical journals, including JAMA and the Archives of Internal Medicine, but
that they decided not to publish it. Why do you think those publications would
not publish it?
RS: Actually, we did not submit to JAMA. We submitted to the
American Journal of Health Promotion and to Annals of Internal Medicine. To
quote one of the response letters written to me, “We cannot publish an article
whose conclusions are so hostile to conventional medicine.” The journals also
objected to what they felt was “editorializing,” even though I restricted my
subjective opinions to the “conclusion” section of the publication. Clearly,
both the scientific and political ramifications of our outcomes are something
that the conventional medical journals did not feel comfortable with. So much
for science...
DC: What do you hope members of the chiropractic profession and
the medical profession will take from the study?
RS: The study really shows the enormous power and benefit of two
things:
1) The utilization of chiropractic in a primary care setting;
and 2) the magnitude of outcomes, both clinical and cost, that can be achieved
when all members of the health sciences work together as a team for the
betterment of the patient; putting aside all interprofessional rivalries. Hopefully, these results are so dramatic
that they will “wake up” the health care system (or lack thereof) to the
immediate need for true integration among all qualified health providers.
DC: Any final comments you’d like to add?
RS: Yes. There has been almost no research relating to the
utilization of the chiropractic physician in the PCP role prior to this, and as
a result, the tendency of those in decision-making positions, both within the
profession and especially outside of it, and the conclusions drawn,
particularly by those of the medical research community, are that chiropractic
physicians are “back doctors.” While there is still much to be learned about
the application of broad-scope natural chiropractic care, this study could not
be more timely, and clearly points to the outstanding potential for utilization
of the chiropractic physician in a primary care setting while clearly valuing
the concept of allopathic, osteopathic and chiropractic integrated medicine.
DC: Do you believe every doctor of chiropractic would qualify to
be credentialed in the AMI program, and if not, why?
James Winterstein (JW): Unfortunately, not every doctor of
chiropractic would qualify to be credentialed in the AMI HMO program. This
program requires graduates who see themselves in the role of chiropractic
physician - those who are willing and able to engage in broad-scope diagnosis
and in broad-scope natural medicine. These are chiropractic physicians who see
spinal manipulation as a valuable tool that is part of chiropractic practice,
not synonymous with it. These are physicians who recognize the need for
prescription drugs when clinically indicated and will refer the patient for
those prescriptions.
The HMO credentialing process itself is quite rigorous and
involves responses to case presentations, the kind of practice protocols which
are typically utilized by the physician, and an evaluation of office equipment,
procedures and practices to ensure that they meet the requirements of the NCQA
[National Committee for Quality Assurance]. All offices are visited and must be
compliant with NCQA requirements prior to the awarding of the AMI credential. A
significant percentage of chiropractors, and certainly those who choose to
engage in what is known as “subluxation-based practices,” would not qualify for
this program unless they could meet these requirements and would engage in the
kind of practice outlined above.
DC: Do you see this type of program spreading across the
country? If so, to what extent?
JW: In a modified form - a PPO format; this program is beginning
to spread across the country as AMI promotes the use of chiropractic physicians
to both governmental agencies and large self-insured corporations which are
seeking ways to cut costs of health care. The credentialing process is not as
rigorous as that required for the HMO, and doctors in various states are being
credentialed and are functioning in the AMI PPO in order to promote improved
health through preventive care, rather than simply addressing the disease
state. The extent to which this spreads will depend on a number of factors,
including:
Willingness of chiropractic physicians to accept the
responsibility and the accountability needed for this kind of practice. Education of the insurance industry
regarding the potential for this kind of care. While there is a constant hue
and cry about how bad things are, the status quo is difficult to change. Willingness of the allopathic and
osteopathic communities to recognize the education and resulting ability of the
chiropractic physician to function in this kind of setting. In this regard, it
is interesting to note that the diagnoses made by chiropractic physicians in
this group were in agreement with those of the allopathic specialists just
about 94% of the time. This is exceptional concurrence, in my opinion.
DC: To what extend do you see this model moving chiropractors
away from the more traditional, spinal-care-only types of practices?
JW: Actually, I think the real “more traditional” kind of
practice was closer to that provided by this AMI’s HMO experience. I certainly
learned that kind of practice in the ‘60s and practiced that way then. I
believe that reimbursement issues and the necessary research initiatives which
have concentrated on musculoskeletal concerns, for obvious reasons, have moved
the profession into the “spine care” arena within the past two decades. Because
we excel in the treatment of back pain, in my opinion, we have followed the
line of least resistance and are now seen almost exclusively in that role, to
the detriment of humanity, I believe. We have much more to offer the sick and
suffering, and I hope we will reclaim our opportunity and our responsibility in
the primary care arena.
DC: To what extent do you see the doctor of chiropractic as the
gatekeeper to other CAM therapies?
JW: In those integrated practices of which I am aware, the
referral, by chiropractic physicians, to other CAM practitioners is a routine
matter. Unfortunately, what I see
developing at the present time is a whole new turf battle. It is not enough
that DCs and MDs have engaged in this turf war for a century; now we have new
entities beginning the same thing.
This is exactly why, after reading Warren I. Salmon,
PhD—Alternative Medicines (1984), I concluded that we must find a way to work
in concert with other CAM providers and become colleagues, rather than
competitors. Fortunately, the Board of
Trustees of National University of Health Sciences saw this as well, and the
result is that we changed National College of Chiropractic into National
University of Health Sciences, precisely so that we could form an environment
in which various CAM providers could learn together and could develop a
collegiality.
Will it work? I can only hope so, for it is the patient we must
be most concerned with and I do not think competition among various types of
providers serves patients well. I am most grateful to Dr. Richard Sarnat, who
had the vision to make this HMO and subsequent PPO experience a reality, and to
his partner, Mr. Jim Zechman, who supports [Dr. Sarnat’s] vision for a potential
“new day” in health care delivery.