Changing Marketplace, Changing Terms of Engagement

At the point of completing his first year in place as president of Northwestern Health Sciences University, Dr. Christopher Cassirer offers a kind of report of findings and environmental assessment on the profession in July/August issue of the Minnesota Chiropractic Association’s MCA Journal. He lists a number of observations and proposes what I’ll call ‘design principles’ for solutions to the challenges the profession is facing. He notes that:

  • The US health care system delivers very poor outcomes for the enormous sums of money spent.
  • Novel delivery system processes (accountable care organizations, etc.) are going to be used as payment vehicles for many efforts.
  • Scope of practice competition requires an ongoing legislative effort, while at the same time demands for more data supporting and detailing chiropractic clinical contributions will only increase.

He notes pointed concerns, as well, calling out intraprofessional squabbling on differences that perhaps consigns us to a ‘Nero fiddling while Rome burns’ position as health care reform goes forward.

Does he offer a blueprint for solving some of the profession’s concerns and issues?

Dr. Cassirer suggests that the profession would benefit from better education on ‘higher-level’ market forces than what it takes to run a clinic, such as how to align similar business interests as a profession, even as individuals compete in the marketplace. He suggests this may help the profession see a ‘greater good’ in blending cooperation and competition (more on the concept here). Noting the importance of uniting efforts by the school, the MCA and field doctors, he closes with what are essentially five proposed professional strategic goals:

  1. Find common ground and work together;
  2. Re-unite as a community, set aside differences, identify core strengths and pursue a collective research agenda that helps the profession;
  3. Cooperate and compete in a manner constructive to the profession;
  4. Remain committed to improving population health and wellness through non-invasive, conservative treatments; and to
  5. Assume [local] responsibility for professional leadership.

It’s hard to argue with any of his observations and suggestions. He suggests that a critical dynamic for improving the position and business opportunities for doctors of chiropractic requires that we have a seat at the table to be part of the solution. A similar argument drove a lot of decisions by chiropractic leadership in the mid-1990s when the constraints of managed care contracts chafed many providers. Many of us felt that if we weren’t part of the solution, we were part of the problem. And being part of the solution (system) certainly had some benefits: initially broader availability of chiropractic services (despite network membership limitations); initially higher compensation (such as when BCBSMN paid you more than you billed); and initially greater opportunities for inter-professional cooperation.

And, as the seminal leadership from ACN/ChiroCare established and is now being carried forward by Dr. Dave Elton and others, data analysis illustrates that there are clear benefits for chiropractic care. However, this was also true back in the late 1990s when the MEDSTAT study clearly contrasted cost outcomes across millions of patients–and chiropractic care so outshone medical and PT options it was almost laughable. Everyone thought then it was just a matter of time before the floodgates opened and ‘the system’ was ushering patients through our doors. Yet neither the MEDSTAT data nor the much more sophisticated recent ACN/Optum data have, on their own, moved the peanut on the profession’s position. It can be argued that, instead, because of it the chiropractic profession’s been tied to the stake of economic minimalism rather than being accorded broader responsibilities. For many, if not most DCs, network provider compensation for services is often below the cost of providing those services. We thought the price of admission was to prove we were cheaper; we did, but we didn’t understand the consequences of framing our services in terms that were financial, not clinical.

So we should be ‘at the table,’ but I would point out that we have been. And it’s tempting to claim the terms of engagement have changed, reset the target and say that the new barriers are that we need better control over professional variance, greater unification, coherence on messaging, and on and on. I wouldn’t disagree with any of that cuanto cuesta viagra. Versions of those needs were true in the 1990s, before and since.

But I will state unequivocally that I don’t think it will make a difference, because of two reasons: one, we permitted ourselves to be co-opted in terms of how the system frames issues of health and disease, playing unwittingly into the clinical (systemic) paradigm of minimizing disease instead of maximizing health. Our own research dutifully followed orthodox mechanistic models, and we have not learned to change the kinds of questions we’re asking of ourselves. As a result we have more and more elegant data that proves beyond a doubt we can improve functional outcomes more effectively and efficiently than others. What we can’t answer are larger (or even mechanistic) questions about whether or not chiropractic can contribute to individuals’ overall health and well being and demonstrate down-stream savings–even though every doctor of chiropractic who’s ever been in practice knows this to be true. And two, the system itself isn’t going to survive much longer in its current form; the terms of engagement are being rewritten in marketplace forces, and the system’s own controls are falling apart.

So what do we do? Do we marshall our forces, revise our research agenda, redouble our efforts to position ourselves as public health advocates and necessary resources? Absolutely. Will it help the profession? Not likely.

The huge, confounding factor here is that the marketplace is under intense disruption. No one knows what the end game looks like, but there are discernible elements. Among them:

  • Most ‘patients’ will be (and see themselves as) health care consumer/purchasers who are working from high-deductible health benefits where most money comes out of pocket.
  • Employer contributions for sponsored benefits will limited (“defined”), and few employers will choose even a set of options for their employees.
  • Instead, people (estimated to be more than 70 million per year by 2018) will be purchasing their services online through public and private exchanges (online shopping portals).
  • With the economics supporting health plan maintenance of PPO networks eroding, the networks will dissipate and providers will be free agents, able to preserve existing contractual ‘discounts’ or to revise them.

I suggest there are three ‘higher level’ market and professional forces–and required responses–at work here that will affect the profession’s future.

  1. The ‘system’ doesn’t control access to providers or services any more. PPOs are available to people with benefit structures, but those contractual discounts can be easily duplicated by any willing provider. A health care consumer only has to ask. The profession can’t stop market-driven tiering of its prices and services, but it can work to support providers operating in those tiers with better business training, revised delivery models that lower the cost of professional education, etc.
  2. New delivery models will not include DCs on any appreciable scale. They simply won’t; a shrinking pot of dollars for population health models means that the knives will come out, and chiropractors’ documented claims of efficacy and efficiency won’t be enough to overcome the power disparity in clinical or organizational decision-making. So the profession needs to create its own demonstration models on its own terms, inverting the medical version of health homes and ACOs, creating demonstration projects framed in chiropractic clinical value, not costs.
  3. The profession won’t be healed; its divisions are permanent. After 130 years of factionalism, the chiropractic profession isn’t going to set aside its internal differences. There is too much meaning and identity built into the profession’s schizophrenic DNA, and that’s not going to change. But the profession can be organized; a coherent model that gives practitioners the ability to define their place on a ‘paradigm spectrum’ from mechanism to neo-vitalism is absolutely relevant, and offers opportunities for coherent messaging and descriptions of value. It’s an inclusive, ‘bigger tent’ approach that offers a framework for participation and depersonalizing divisive rhetoric.

Dr. Cassirer’s strategic goals are certainly relevant to the profession and its future. But when the marketplace is under such disruptive change, we should stop thinking that being ‘at the table’ will yield material benefits. There is little, if any, history to support that entirely understandable hope. In my view we should hold those same goals but apply them to the marketplace and not the system, because the system itself isn’t going to be able to fix what’s in place now. In fact, it’s faced with its own dire reconciliation with market forces, and we aren’t even on the radar.

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