Where Does Chiropractic (or Your Practice) Fit?

Where Does Chiropractic (or Your Practice) Fit?

McClelland, George C

During August and September 2004, I attended three separate, nationally based health care-related conferences. They helped me better undersgtand where the chiropractic profession, the care we give, and the patients we serve fit into the nation’s health care pro- ? grams. At this point, it is my impression we barely make a blip on the periphery of that radar screen!

The first conference was held in Boston on August 2-3, 2004, with about 350 in attendance. It was the Second World Congress Leadership Summit on Healthcare Quality and Pay-for-Performance Contracting for Employers, Providers, and Payers. Featured speakers included representatives from most major insurance carriers, large employers (e.g., the Leapfrog Group, UPS, Ford Motor Co.), medical centers, university public health programs, and multiple governmental or quasi-governmental agencies including AHRQ, JCAHO, NCQA, RAND, etc.

The conference emphasized that, in an era of health care cost escalation, employers and public purchasers are increasingly demanding transparency in health care costs and quality. It has been presumed that “pay-for-performance” strategies (similar to capitated managed care programs with an end-of-year bonus payout) potentially allow purchasers to distinguish quality among health care providers. Confusion still exists, however, over who defines the measures, which measures are meaningful, and whether implementing systems to track the outcomes from these measures is acceptable to health care providers and consumers. This program also addressed collaborative care models, which have integrated chronic care management with decision support tools to assist motivated patients in improving their health care outcomes. Additionally, presentations addressed measuring positive “Return on Investment” (ROI)-a buzz term in contemporary health care management-from incentive programs and physician scorecards. Next, a panel discussion considered the risk of public disclosure of provider quality data. Unfortunately, given the issues discussed, chiropractic-or any other CAM service-was not on the table at this conference.

At the second program, I made a presentation (prepared by Ms. Pat Jackson and her professional development and research department) to the International Association of Specialty Investigation Units (IASIU) in Pittsburgh, Pennsylvania, on September 13, 2004. I addressed issues regarding health care fraud, the ACA Code of Ethics, best practices, and quality control in chiropractic care, as specified in existing ACA policies. The seminar attendance was over 500, with at least 50 exhibitors.

The IASIU Seminar had multiple tracks. Ours was oriented toward health care investigation. While some of the questions were very pointed and were obviously biased, most were more objective, more basic, and exhibited the true ignorance that most of the investigators in the room (which was overflowing) exhibited.

The questions continued after the class ended. Ms. Jackson and I finally were escorted out of the room by one of the directors of the seminar, who expressed her great appreciation for our program and the interest we had generated. She then asked if we could present again at next year’s seminar. While I had to catch an early plane from Pittsburgh that afternoon to see patients the next day, Ms. Jackson stayed on that afternoon and had some interesting conversations with a number of the attendees. Several of these individuals expressed appreciation for the first objective presentation they had received on chiropractic utilization in the 19-year existence of the IASIU. In the immortal words of “The Governator”-we’ll be back!

The last program in this series, with more than 1,000 attendees, was the Ninth Annual Disease Management Congress and Exposition held in Boston from September 20 to 22, 2004. It featured approximately 120 speakers with several plenary sessions and 5 parallel tracks for health plan executives, hospital and health system executives, technology, case management, and Medicare/Medicaid. The exhibit hall with about 65 exhibitors, including several chiropractic networks, focused on disease management (i.e., education for the consumer and provider).

One of the more interesting presentations given during the 3 seminars I attended took place on September 21. This presentation focused on the new Medicare program, Chronic Care Improvement (CCI), which was funded under Section 721 of RL107-183 (the Medicare Modernization Act of 2003). This was the same public law that includes our chiropractic demonstration project. This CCI program will affect the “fee-for-service” care arena in a 3-year pilot project. The funding will come separately from CMS, which currently covers 35 million-plus subscribers at a cost of $250 billion per year, not including drug costs. This program will target congestive heart failure (CHF)-which affects 14% of Medicare beneficiaries at 43% of all Medicare costs and diabeteswhich affects 18% of beneficiaries at 32% of all Medicare costs. The program will also address the co-morbidities (e.g., asthma, depression, COPD, osteoarthritis, and musculoskeletal conditions) these patients may have. In other words, it will look at “whole person care.” The CCI program will have a “pay-for-performance” aspect that will be based on quality improvement, savings, and satisfaction (patient and provider).

The speakers pointed out that Medicare was historically designed to provide episodic care for acute exacerbations, mostly of infectious diseases-but poorly designed to provide longitudinal care for those with chronic diseases. They paraphrased the current head of CMS, Dr. Mark McClellan, that this program is about shifting cost from treating acute exacerbations of chronic diseases to preventing them. Gee, a wellness concept! How unique!!

One other program, about supporting patient/physician collaboration in chronic condition management, focused on patient needs and how to make the Medicare CCI program work. It highlighted care that was more knowledge-based, patient-centered, and systems-minded. It discussed the issues of value concordance so that patients can more properly weigh the outcomes they can expect versus the risk a procedure/intervention may have. This series of Medicare presentations offered information that all doctors of chiropractic should be aware of, even if they do not see Medicare patients.

David Brailer, MD, national coordinator for health information technology, spoke in another plenary session. He addressed the Feds’ progress-or more accurately, the lack of it-in developing standards and infrastructure for harnessing information technologies to promote safe, high quality, and efficient health care, which is a vision of President Bush’s.

Another plenary speaker, David Matheson with the Boston Consulting Group, addressed the progress of dis ease management from an employer’s perspective. This model has gained respect, and therefore interest, from more major employers over the past IO years. I then attended a “clinics” program that reviewed some of the disease management programs established at the Mayo Clinic and the University of Nebraska Medical Center. They had produced management procedures that developed health risk assessment measures for low-, medium-, and high-risk patients. They had lowered costs via electronic health records, teleconferences with providers, education (online and hard copy), counseling/coaching, and intervention when appropriate. These programs have focused on collaborative care and self-management processes to help patients make healthy decisions through internal motivation and empowerment. These procedures have realized 20 to 30% annual health care savings over the initial projections.

One other session addressed the case management return on investment (ROI), including its great variation, controversy, and the lack of existing standards across the country. The Health Insurance Association of America (HIAA) is currently conducting a survey of HIAA members to create some standardization in case management. So far, the survey has discovered that the strongest influence on the ROI is the case manager’s expertise, while the case management model itself is felt to be the weakest aspect. Does that sound like another profession we know? To date, they still have not determined exactly what hard or soft savings are and, therefore, cannot explain whether this process actually works to provide a ROI.

My purpose here is to let you know there is a lot of activity in the health care world, of which the majority of our profession has no understanding. So many of our DCs attend educational programs only to meet their continuing education requirements (CEUs) or to find out how to get more new patients. It is long past time for our profession to come out of its shell and find out what is happening in the health care world around us, especially if we continue to demand inclusion. While ACA, and a few other organizations within the profession, can provide some leadership in this direction, it is really up to us-the individual doctors of chiropractic-to make a presence in these interdisciplinary programs and learn firsthand what is going on. How else can we possibly consider integrating our profession and our practices into the emerging health care process here in the 21 st century?

Copyright American Chiropractic Association Dec 2004

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