The Big Picture

by Bob Braile, D.C. President ICA

Chiropractic is beginning to come full circle. I have read with interest many articles about chiropractic practice in the 90s and the situation with managed care and insurance. I find it interesting to hear some who predict gloom and the reduction of our numbers by half, while others write of coping with and working in the new system of managed care.

I have noticed however, that a large group of practitioners don’t seem to be bothered by the current state of insurance. The majority of these doctors are individuals who for the most part have been in practice far longer than my 17 years. In conversations with some of them it almost seems as if they knew something I didn’t about the current goings on. It almost seemed as if some of them had a smug confidence about the future that many of my generation and less could not understand.

It was only in temporarily stepping away from practice for the past six months that I have been able to clearly see the situation. The old saying of "you can’t see the forest for the trees" applied to me and many of my contemporaries. But with my new perspective, I now also enjoy the smug confidence about our future as practitioners. This new perspective is one that I readily share with the students I teach and the practitioners I speak to.

In order to understand our current situation we must examine our history. If we look analytically at the history of chiropractic practice we can see three distinct historical phases of our profession. Once we understand this we come to the irrevocable conclusion that we are entering the transition between the third phase and fourth phase of chiropractic’s history.

Without getting ahead of myself lets examine these various phases of chiropractic practice history and trace our steps as a profession to where we are now. It should be stated up front that the transition from one phase to the next may now be sharp, but is clear and obvious when viewed from an historical perspective.

 Phase One - Identity

This phase started on September 18, 1895. Our profession was discovered by D.D. Palmer with his first adjustment of Harvey Lillard. This event started a series of events that lasted for approximately the next 25 years. During this phase we see much of our history being spent on discovering what it was we had in this new healing art. Who were we, what were we. If one reads over the earliest of writings it becomes apparent that our founding fathers themselves were only beginning to identify to themselves what it was they had discovered.

The earliest chiropractors came from a spirit of curiosity as our educational base itself was only discovering how to teach this new science. It was only when B.J. Palmer became the clear leader of the profession that our profession began to take on a clear identity and voice. This first phase was truly the pioneer era of our profession.

For the average practitioner and patient this was an adventurous phase. Without a clear identity the patients weren’t sure what type of healer they were going to. Consequencially, mainly the desperate went to chiropractors upon strong referral, and only as a last resort. The chiropractor of the day had to have a strong belief in what he or she was doing, and the ability to convey that belief to the certainly frightened patient.

Phase Two - Survival

The second phase of our profession was clearly the longest and produced some of our professions greatest champions. This phase started roughly in the early 1920s. Since our profession now had a recognizable identity, we now posed a threat to the medical establishment. This phase of chiropractic’s history was characterized mainly by the state by state fight for licensure. For over fifty years our profession suffered the arduous fight of obtaining the basic legitimacy for our profession, a legal means to practice.

During this phase of our history many chiropractic heroes went to jail for their convictions. Many were incarcerated merely because they choose to help people with this thing called chiropractic. What is even more amazing is that in many cases it was the patients who rallied outside the jails to attempt to have their doctors freed. This strong dedication by the chiropractors to their profession and the patients to their chiropractors was characteristic of the time.

As the fight for legitimacy continued, the patients showed an amazing level of loyalty to "doctors" who in many cases did not even have a license. Many of today’s chiropractors started out as patients during this era. Even in the face of terrible adversity, the doctors who practiced under the threat of jail still speak with pride of the times they endured on our behalf.

This phase of our history continued until in 1974 Louisiana became the final state to grant licensure to chiropractors. It was also during the mid seventies that many other events occurred that issued in the next phase of chiropractic’s history.

Phase Three - Acceptance and Insurance

The massive amount of changes that occurred in the seventies to chiropractors and our practices can only be described and overwhelming. To recall some of the events of the time, we can start with the accreditation of CCE. This along with other factors saw a boom in the attendance at most chiropractic colleges. The entry of chiropractic into the Medicare program was probably the single biggest factor causing other insurance companies to start covering chiropractic. Next workers compensation programs around the nation started to pay for our services. Before long the fight for licensure just a few short years earlier was being replaced around the nation by a fight for insurance equality.

Throughout the late seventies and eighties chiropractors were discovering how to play the insurance game and obtain riches not even dreamed of just a few years before. Visit fees went from $2 to $5 a decade earlier to up to $50 and $100 or more at the height of this insurance phase. Chiropractors efforts began to shift from strong communication with the patient to proper communication with the patient’s insurance company in order to be paid.

The calamity of changes that took place in the average chiropractor’s practice is mind boggling. New computerized billing was needed. Record keeping became much more arduous. Extra staff was needed to keep up with the paperwork, and consequently most of our office overheads skyrocketed.

Since the health insurance phenomenon was developed during the age of $5 visits, it became obvious that the sheer weight of more patients at an average visit five to ten times that amount would surely catalyze changes. In an attempt to adapt insurance companies created review systems. These systems of reviews became more expensive and complex for the insurance company and the doctor who had to deal with them.

But the real tragedy of this phase of chiropractic’s history was that for the first time the patient wasn’t the sole concern of the doctor. In every chiropractor’s mind he had to be concerned about what the insurance company would say or pay for, in other word, was there "medical necessity". Even the insurance company spent more effort on the doctor and his claims than on the patient’s well being. This not only was a chiropractic problem. The insurance companies were unable to keep pace with the medical monster they had created with their insurance. But whether the fault of chiropractic or not, this insurance phase of chiropractic’s history was heading for an inevitable crash.

The end of Phase Three - Transition

In a last gasp attempt to save an ill-conceived system the insurance industry has given birth to managed care. This is an attempt to maintain a market for heath insurance while reducing costs. From a patient standpoint this system only has one condition, "give up your freedom and we’ll reduce your cost". This system is riddled with problems for both the consumer and the doctor. The major flaw of this system is that it is not consumer based. The patient becomes the least important player in this system as the doctors make deals with the insurance companies for ever shrinking crumbs from the table.

Because of this current system more patients are seeking services outside the system. More are turning to doctors who have their best interests in mind. It is those doctors in chiropractic who have broken free of the choke-hold of managed care and have begun to understand the smug confidence of those long timers in our profession who made their mark before their was insurance. As it turns out, the third Phase of chiropractic’s history, the phase of insurance and acceptance was the shortest lived and the wildest ride.

Phase Four - Consumerism

The insurances of the past two decades will mutate beyond managed care in the near future. What evolves will be a minimal hybrid of insurance and socialized heath care. This resulting beast will be able to sustain itself only at the expense of true heath care. What will occur is a shift in the consciousness of the public away from dependence on insurance and toward a self dependence for ones own well being.

Fortunately this shift has already begun. Look around your own neighborhood. Are more people jogging or playing sports? Are more people joining health spas? Is there not a GNC or health food store in your local mall? Do more people read the labels on the foods they buy in the supermarkets? Are more people taking vitamins, buying exercise equipment or sweating to the oldies? If you are at all observant you can see that society is heading straight for us? Not that we are in the market of selling all the things I’ve mentioned above, but the public is looking for, and paying for, natural health!

Chiropractic has always been a unique and separate voice for a principle of health. The successful practice of the future will market itself toward these basic principles at a fee that is affordable for the public. We have had the principle of correcting subluxations for the wellness of the patient for over 100 years, and now finally the public is ready to hear this message loud and clear. Now the consumer is ready and willing to pay a fair fee for our services without the crutch of insurance. All that is needed is for us to stick with the principle, and position ourselves as the leaders in the movement toward natural heath, through chiropractic.

The practice of the future will look remarkably similar to the ones of the past. But with the advances we’ve made and the acceptance we’ve gained, chiropractic will become the dominant profession in the health care arena.

Proud to be , Chiropractic