I n my annual update of where chiropractic is trending for the next year. 2015.1 want to first review both the concept of "trending" and assess 2014"s trending predictions. To review last year's predictions, please sec: Studin. M. (2013). Megatrends in chiropractic: Circa 2013. Your success depends upon it. The American Chiropractor. 35(6). 40-48. "Trending" is a term that should be the guiding force for the future of every practice and business worldwide. Why is it that some offices seem to thrive in any economy, yet others arc always struggling to pay the rent, the staff, the bills, and often the chiropractor too? How many weeks a year do you not take a paycheck? In 1982. John Naisbitt wrote the Xew York Times bestseller Megatrends, which accurately prognosticated shifts in the world economy and changed the relationship of people to economics. The principles of success in foretelling the future that held tme in 1982 still hold true today. If you know where to look and how to interpret the economic or practice indicators, you will ensure success for years to come if you are willing to adapt based on the trends and indicators, and if you arc willing to take the action steps required. These changes have nothing to do with how you practice. You can be a "far-right conservative" practicing in a pure "tic" environment: a "far-left liberal" using every modality, treating extremities, using nutritioa and employing every othcravenue your scope allow s: or a practitioner who falls somew here in the middle like the majority of us. The rules are the same for all. Trends dictate how we triage, document, bill, and collect our fees, not how we deliver chiropractic care to our patients. When looking for trends in a professional setting, we must examine what the carriers, chiropractic boards, courts, and legislators are dictating through rulings and legislation First, we cannot be Pollyannaish and think that the carriers arc above influencing any of the previously mentioned entities because their profit base is purely derived from rules, regulations, and laws. When looking at trends, we look for bellwethers nationally. Currently, two states lead the pack. New York is the perennial first-place trendsetter and least desirable state to practice chiropractic in the United States. Texas is ranked second with New Jersey moving from last year's second place to third place. Last Year's Predictions 1. Mandatory evidence-based practice 2. Necessity for credentials and certifications Both of these predictions became reality as managed care, personal injury, and workers" compensation carriers have had legislation or regulatory changes to support denials for noncvidcncc-bascd procedures and practices. The carriers are now emboldened to deny care, citing evidence in the research from both chiropractic and disparate professions in their denials. This cliallenges you to come up with research to overturn their decisions, even in states where there is no legislation or regulators- mandates requiring research. Often, carriers will create procedures and review boards to maintain those denials, realizing that the courts would be unlikely to uphold their denials without this level of documentation. This is not a problem unique to chiropractic, although mam in the profession feel "singled out" (but please don't feel that way). We have much company in every specialty in medicine. In addition to the reimbursement issues, "cash-based" practices now also have to heed these standards as they relate to licensure issues because the e\ idence can play a role in the establishment of misconduct or innocence. The second prediction from last year comes with the follow ing three legal concepts and rulings: Frs'c: These are rules requiring expert testimony that must be based on scientific methods that are sufficienth established from the expert and accepted by the courts. Daubcrt: This standard presides a rule of evidence regard ing the admissibility of testimony by expert witnesses during United States federal legal proceedings. Voir dire: These are rulings that pertain to the process by svhich expert witnesses arc questioned about their backgrounds and qualifications before being allowed to present their testi- monies in court. Every state in the US has adopted one of these three standards for accepting testimony in court. As a result, you are judged by your credentials and the courts are becoming much more discriminators-. As I reported last year, states such as New Jersey have enacted legislation to mandate credentials in order to be able to testify in court. It now appears that in many other states lawyers and carriers are using the same arguments to limit expert testimony and preclude chiropractors from participating at the personal injury level. This sends an adverse message to lawyers who in turn can leverage their clients to avoid the use of the chiropractic profession and shrink the population of patients who need our sen ices. Understanding and meeting legal standards is integral to the success of our profession. If they receive income from managed care companies as a consultant that could be in direct conflict with making fair and equitable decisions and possibly affect the entire membership. 2014 - 2015 Future Trends The first trend is a continuation from last year regarding credentials, but much more stringent. Trial lawyers in Texas have reported that the standard for crcdentialing a doctor as an expert has become much more difficult to meet. Trial lawyers in Idaho. California. Massachusetts. New York. New Jersey. California, and Georgia also have reported tliat this is occurring in their states. We have witnessed this trend with a direct cause and effect relationship. It comes down to poor versus appropriate credentials: it is becoming more difficult to simply use sour DC degree. It is no different than it is in medicine. The MD with no specialty is having the same increased difficulty of acceptance in the courts. We also are seeing an upssving of chiropractors seeking more meaningful continuing-cducation opportunities that go beyond the fulfillment of licensure requirements. DCs are starting to get the message that research is changing their practice paradigms and helping to clarify their diagnoses, prognoses, and treatment plans. The days of solely taking "technique courses" arc long behind us for chiropractors who want to bring the profession beyond the 1895 practice model without giving up our roots or identity. Failure to do so w ill be the continuance of the downward slide we have experienced in utilization. The second trend, and the most concerning, is the direction medical specialists arc taking. It has been reported in more than a dozen states that medical doctors are now focusing on personal injury and taking unprecedented steps to "woo the lawyers" who historically have worked with the chiropractic profession on "soft tissue cases." Neurologists, physiatrists. anesthesiologists, orthopedic surgeons, etc.. who in the past have relied on their MD status and the prejudices of the courts to have lawyers literally beg and/or pay large sums for their expert opinions, are now being hurt financially by the managed care and svorkers" compensation systems. As cvnical as it sounds, if you follow the money, you will find the trend. Carriers nationally arc working very hard to pay the Medicare standard and. in some states, private insurers, such as Blue Cross and Blue Shield. Aetna, and other major carriers who have already adopted the standard. Orthopedic surgeons, as an example, are now paid approximately $800 for spinal disccctomics. but just a year ago. they were paid $4,000 to $5,000 for the same procedures. The problem is that orthopedic surgeons have malpractice fees totaling more than $200,000 per year and the global fee for surgery, which includes almost one full day in the operating room and three months of postsurgical care, makes this a financial loss for the surgeon. As a result, many of our best surgeons are not accepting those cases and instead referring them to hospitals where, in many cases, orthopedic surgeons are accepting full-time positions for approximately $175,000 per year, which includes their malpractice. Unfortunately, it has been reported that many of these hospital-based surgeons aren't the "best of the best." However, these are the doctors who will survive in the system should this trend in medicine continue. On various scales, the same scenarios are happening with neurologists, anesthesiologists, and professionals in every other medical specialty that touches trauma patients. As a result, it perpetuates this trend. The personal injury system is one of the last places a chiropractor can consistently earn a higher level of income nationally. Because we do not have an emergency room or a hospital system feeding us patients, chiropractors have been forced to be both entrepreneurial and aggressive in learning how to get new patients. Meanwhile, an increasing number of medical specialists are now in a similar position (see above for the reasons), one that we have been in since the onset of our careers, and they are starting to compete for the same referrals. Medical specialists are wining and dining lawyers, taking them to ballgames. and offering to testify at reasonable fees, which historically was something lawyers only experienced with the chiropractic profession. In the past, lawyers would also comment. "Surgeons would never do this because they don't have to." They do now. and they arc. For the average chiropractor, this trend could be devastating and. coupled with the first trend of the DC having no credentials other than his or her doctorate, will eventually result in a downward spiral of personal injury patients and resultant lowered income. However, if doctors of chiropractic position themselves properly by having the right credentials and by understanding the needs of the "medical legal process" from an honest and ethical position, then their personal injury practices will grow regardless of what the medical profession does. Too many doctors, consultants, entrepreneurs, and influences on our practices arc still trying to win us over in a "race to the bottom" with shortcuts and "get rich quick" schemes. In the short run. these programs will generate some new patients and income for the doctor, and significant income for the consultant-entrepreneur. However, if the program is not based on scientific evidence, credentials, and a doctor of chiropractic being the "best of the best" through clinical excellence, then it will hurt chiropractic and every practicing chiropractor in the long run. This falls under the category of caveat emptor. or "let the buyer beware." The choices you make today can and often do affect you for the balance of your career, so choose your relationships wisely. The best place to start is with the curriculum vitac of the person making the recommendations to sec first if he or she is the "real deal." If not, then pass! The third trend, and the most promising, is that primary care physicians have already started increasing their referrals and are more willing to collaborate with chiropractors because of the opiate epidemic (in part created by these same physicians). Research shows that, if chiropractic were the first line of referral, opioid use would decrease with both better short-term and long-term outcomes than if the MD specialists continued to be the first line of referrals. This trend was created in part with last year's trend in mandating evidence-based care—if the research doesn't support your care, it will become nonreimbursable. Although many in the profession don't appreciate or understand the application of research and hold on to the belief that the positive effects of the chiropractic adjustment is all that is needed, one only needs to look at the statistics in the downward decline of chiropractic utilization during the past 10 years. Virtually every day. more positive research is published about the effects of chiropractic care, and organized medicine is starting to take a hard look at chiropractic as the solution for mam negative trends (opiate and other drug addictions) in society. Two years ago. the State University of New York at Buffalo. School of Medicine and Bio-medical Sciences was the first to take a bold stand and introduce a chiropractic clinical rotation for their primary care medical residents. The program is not intended to teach medical doctors how to adjust patients, but to facilitate an understanding for the next generation of primary care doctors about what could be gained from a chiropractic referral. The program is based on the scientific literature show ing positive outcomes for spinal related issues without the use of opiates and being able to correct the underlying cause of spinal pain of current patients addicted to opiates. This program has been so successful that the medical school has instituted a "chiropractic day" for all of its medical students (not just primary care residents). This trend, in part because of this program, will continue to grow in the next year. Based upon the literature and success of this program, it will mark the foundation of the education of primary care medical doctors worldwide to considcrchiroprac-tic as the first line of referral for all spinal related problems. In the near future, the chiropractor will be considered the "primary care giver for all things spine" if we position ourselves properly. This trend does not mean that we will see a flood of new patients from primary' care physicians nationally over the next year. However, it is the beginning, and. in this author's opinion, the long-term solution for a significant increase in utilization of chiropractic over a relatively short period. The fourth trend, which is possibly the most disturbing, is the continual lack of unity within our profession. There arc approximately 13 states that still have multiple organizations. and nationally, we are perpetually saddled with two competing organizations. Whether it is at the state or national level, unless we become one unified group (infighting is encouraged as it keeps everyone honest), we will not flourish as a profession at the level we could achieve if there were one organization. The reasons for the splinters are ego. power, control, and. too often, supporting self-interests. The key to expediting the process is transparency. It should be mandated, through formal organizational mandates, by-laws, etc.. that the salary of even staff member of the organization should be published or made readily available, including gross payments from the previous fiscal year (not just W-2 information). It should be mandatory for each executive officer to give full disclosure on any ancillary source of income beyond his or her personal practice. For example, if they receive income from managed care companies as a consultant that could be in direct conflict with making fair and equitable decisions, could that affect the entire membership? Once the members see that duplicate expenses, such as those for offices, supplies, conventions, salaries paid. etc.. could be spent on lobbying or educational programs for the public, the outcry will be to consolidate. Should any organization not be willing to create transparency and divulge the gross amount paid the previous fiscal year to any employee, or see the financial influences (potential conflicts) on the officers who arc repre- scnting them, doctors should consider leaving that organization. If you do not leave the organization, then you are part of the problem and help perpetuate that negative trend to the detriment of all of chiropractic. As a member of the organization, you are paying their salaries and you are entitled to know. These arc the "blind items" where personal agendas potentially overtake the best interest of chiropractic and the members. Solutions In order to meet the trends for today and the future, we all must meet the "highest standard" in the nation, regardless of our individual state's rclicensurc requirements, and continually seek to increase our credentials. We must also realize that if we do not increase our credentials, the medical specialists will hurt the average DC in his or her personal injury- utilization in a very short amount of time, which for too many will be devastating fiscally. This can be prevented if you position yourself properly. We must fuel the debate for one organization, both within each state and nationally, because there is very little commentary in our publications and no apparent plan to help us achieve a unified profession, which is bad for our future health and the growth of chiropractic. Again, under one umbrella, all philosophies and practices can coexist with infighting mandatory to "keep everyone honest." We must continue to produce and share research with medical primary care physicians at every opportunity because that is the solution to the significant increase in chiropractic utilization in a relatively short amount of time. If we ignore these trends, we. as a profession, will lose, and it will be felt in every office across the countrv. Dr. Mark Studin is an adjunct assistant professor in clinical sciences at the I University of Bridgeport College of Chiropractic and a clinical presenter for the State of New York at Buffalo, School of Medicine and Biomedical Sciences for post- doctoral education, teaching MRI spine interpretation and triaging trauma cases. He is also the president of the Academy of Chiropractic teaching doctors of chiropractic how to interface with the legal community (www.LawversPIProgram, com) and teaches MRI interpretation and triaging trauma cases to doctors of all disciplines nationally (www.TeachDoctors. com). He can be reached at [email protected] or at 631-786-4253.
