Chiropractic Practice Tends and Preparing for 2020
PERSPECTIVE
By Mark Studin, DC, FASBE(C), DAAPM, DAAMLP, and William J. Owens, DC, DAAMLP
Future Trends, initially written by John Naisbitt in the early 1980s, became the foundation for tremendous successes in business for over three decades and laid the groundwork for many successful sequels, equally proving to be true. “Trend forecasting is a complicated but useful way to look at past sales or market growth, determine possible trends from that data, and use the information to extrapolate what could happen in the future. Marketing experts typically utilize trend forecasting to help determine potential future sales growth. Many areas of a business can use forecasting, and examining the concept as it relates to sales can help you gain an understanding of this tool. Looking at data over some years and finding patterns, you can use this information to extrapolate future patterns. A trend means that the same series of events is happening over and over.” 1
Over the past 15 years, we have been market testing and documenting patterns related to our industry in the following areas: legal, medical, academic, insurance, chiropractic technique, and digital marketing. In the legal arena, we explored plaintiff lawyers, defense lawyers, and courts at both the state and national levels. In the medical arena, we have explored primary care medical doctors and medical specialists, including neurologists, neurosurgeons, orthopedic spine surgeons, general orthopedic surgeons, pain management, physical medicine, neuroradiology, general radiology, and emergency room physicians. Regarding the insurance arena, we have reviewed countless explanation of benefits (EOBs), peer-review denials, patterned coding and denials for long-term care, improper claim examiner authority, special investigative units (SIU) summonses, and details related to law firms hired to prosecute doctors for insurance fraud, as well as being involved in the systematic overturning of improper (and often fraudulent) independent examinations. In the academic arena, both authors teach at the doctoral and graduate level in both chiropractic and medicine. As a result, we have a unique opportunity to report firsthand on the current standards of instruction in both professions, ensuring that we function in an “evidenced-based” platform based on peer-reviewed, indexed scientific evidence.
There is a robust amount of resources required to stay current, let alone determine future trends in both professions. To work at the level needed, we employ and have strong relationships with many experts in each of the previously mentioned industries who report to us almost on a daily basis. Keep in mind, trends can be positive or negative and understanding the trend and how it will impact your personal and professional life will allow you to determine what to do and what to avoid. Capturing a positive trend will elevate your career and make things easier while embracing a negative trend will cause strife, stress, and often be the slow or immediate death of your career. In this article, we will illuminate trends on both sides.
Trend #1 Primary Spine Care
Primary spine care means that you are the first referral option for spine care short of fracture, tumor, or infection. Chiropractic has been and continues to be supported by literature to be superior to physical therapy and medicine as the first treatment option for the spine. To underscore that statement, one of the many articles on this topic, was written by Blanchette, Rivard, Dionne, Hogg-Johnson, and Steenstra (2017) reported, “When compared with medical doctors, chiropractors were associated with shorter durations of compensation and physiotherapists with longer ones. Physiotherapists were also associated with higher odds of the second episode of financial compensation.” (pg. 392) The authors also state, “These differences raise concerns regarding the use of physiotherapists as gatekeepers for the worker’s compensation system.” (pg. 382).2
The recent trend of chiropractic being seen as the first referral option (primary spine care provider) has been proven out in the marketplace nationally and will continue to gain momentum for the next few years. It is and will continue to be the single best solution for a sustainable business practice model where referral sources run after you. It is commonplace in today ’ s marketplace that once a doctor has the requisite credentials, knowledge, and business strategy, that they will acquire between 50 to 150 new cases per month (that is the range of what is already occurring nationally). This is all with no advertising, marketing, or selling. Your alignment as a primary spine care provider is about being a doctor, not a salesperson. Getting new cases is no longer a challenge for these doctors. What they are confronted with is the biggest obstacle for properly trained and positioned doctor of chiropractic: finding enough associates to support their growth. The need and access for chiropractic care are increasing in the primary spine care arena because chiropractors are the solution. To be a properly positioned and credentialed primary spine care provider puts the doctor of chiropractic in a leadership position.
Trend #2 Language
The language in spine care that you use drives both the perception and the reality of your business. Please note that we did not write “practice” since this entire commentary is about the business of your practice and not the delivery of health care. This language “of spine care” is derived from how you communicate what you do and, more importantly, whether you represent yourself as a doctor or as a therapist.
On a national level, one of the most disturbing trends in relation to language in the legal arena relates to insurance carriers and defense lawyers using contemporary scientific literature to “trap” doctors of chiropractic into not understanding or being able to explain the evidencedbased rationale of how the adjustment works, or what a subluxation/bioneuromechanical lesion is and why you should be paid for your work. Unfortunately, our continued experience shows that even the most experienced doctors of chiropractic cannot describe what they do beyond a philosophical explanation. In today’s world, that results in a denial of reimbursement at the least, and at the most severe, accusations of insurance fraud. Conversely, in the medical arena, language relates more to your ability to diagnose and manage spine pain patients more so than how chiropractic works. Medical primary care physicians and medical specialists do not necessarily care why or how a chiropractic adjustment works; they want to know how you manage your patients both in the short and long term. Your language about the management of the spine patient is what gives the referring medical provider confidence. They will refer when they are confident their patients are being handled professionally and in an evidence-based manner. They want a doctor-to-doctor referral relationship, not a doctor-to-therapist relationship. The current trend in medicine is for primary care and medical specialists moving away from case management and moving toward procedural-based care.
Another significant trend for 2020 and beyond is your ability to demonstrate your expertise based on your training. This trend should endure for a decade or more while the scientific literature validates chiropractic care. Anyone who has heard a medical doctor say to a patient, “You need to see a chiropractor, but I don’t know any good ones,” understands why that comment is a growing trend. Proper training with educators at the top of their field and the correct language used to describe that training is a critical component of your validation in the eyes of both the legal and medical communities. When we look at consultant or chiropractic “quasi” academic sites, we see a potentially damaging word—certified. Currently, on a contemporary website for a whiplash organization, they advertise and ask the reader to become a “certified specialist in personal injury.” That phrase is problematic on many fronts. To trend part of the entire healthcare community, you must consider how that language is perceived outside of the chiropractic profession. To become “certified” in medical academia, a provider typically has completed a two-year fellowship program in the respective specialty. When the language “certified” is used to communicate your level of training to those in the medical profession to build a “peer relationship,” they know better, and this will erode, or in Dr. Studin’s case, destroy relationships. Many years ago, he took similar courses and used this phrase in his documentation, advertisements, and office literature. Additionally, in his formative years as an educator, he would refer to course graduates as “certified in...,” which was brought to his attention by lawyers, neurosurgeons, neuroradiologists, and those in medical academia as inflammatory and inaccurate. That was a very frank discussion, and that “rookie” mistake can no longer be made since, in the end, it hurts the individual practitioner and the profession.
Building a reputation and being legally defensible are two critical items standing out as a future trend. Properly positioning your training and the language you use to describe it will ensure long-term referral relationships into your business and not the office down the street. Generally speaking, if someone wants to offer you a credential to be “certified” in anything, move on since the lack of understanding proper language usually concurs with the content of the course work. This trend must be stopped and will only be done by boycotting those contributing to that demise.
Trend #3 Chiropractic Technique
The trend of advertising, communicating, or confirming that you specialize in any chiropractic technique or specific treatment is formally “dead.” No one cares, and that has been proven in every forum related to the practice of chiropractic. It has also been proven with surgeons and other specialists in medicine as well as in cross-examination in front of a jury. No one asks surgeons about their cutting technique; they refer for expertise assuming proper treatment will follow. The strategy is therefore never to discuss technique in any forum. Understand that medical and legal professionals will never say anything to you or correct you regarding technique, but they will happily accept your referrals and never reciprocate. If you or any of your colleagues have experienced this, it is based on your language, not your technique.
Trend #4 Credentials
Credentials and graduate-level training after your chiropractic degree are a trend that will endure for the foreseeable future. It will certainly be the case for the lifetime of your practice and is by far the most important piece of your business-success puzzle. Your credential is not simply letters after your DC; in fact, it is an accumulation of every legally defensible citation on your curriculum vitae. Legally defensible citations are the work that is centered on your professional degree relating to your work history, academic history, graduate-level coursework, teaching, publications, and other specific work that demonstrates expertise in your field. This defines you as a professional and reflects the level of expertise you have attained. The old adage “if it is not written, it doesn’t exist” comes into play here. In the legal community, this information is vetted by legal standards called Frye-Daubert and voir dire hearings. Those terms might be foreign to you, but you are held to those terms, which equates to the expert standards in our nation. In the medical community, you are vetted by your language and your reports. In the former, you will be asked to step down as an expert; in the latter, you will simply not receive a referral—ever.
Included in the “credentials trend” is where your credentials receive their formal continuing education approval. Both legal and medical referral sources are gravitating toward a doctor of chiropractic being crosscredentialed through both chiropractic and medical academia. This has nothing to do with your chiropractic education and licensure accreditation; it has to do with the approval bodies approving the level of academic validity of content. It is also important to understand, and perception of the courts and the medical establishment in where and how you were trained is important. Many doctors of chiropractic across the country already have these types of credentials since they are central to the decision-making process when medical and legal professionals are considering referrals. Remember, these trends have nothing to do with the practice of chiropractic; it is about the business of your practice.
Trend #5 Documentation and Your Fees
Documentation has been a challenging topic for all healthcare professions, not just chiropractic. However, the fallout of poor documentation is now catching up to our profession, as it has already decimated many in medicine for a quite some time. The utilization of travel cards has trended as dangerous for years, and if you choose to continue to use them, be prepared to lose, no matter the adversary. Travel cards are a “dead” trend and should never be used under any circumstances.
Compliance is now trending more so than any time in the past. The carriers want your money, and they have found the easiest way to get it—just look at your notes. There is a caveat: not only are the carriers demanding repayment, but they are also now involving the licensure boards and the courts in fraud allegations. In too many cases, they are also invoking RICO racketeering charges. Why RICO? The doctor at fault is using a paper instrument (claim forms and reports) to defraud a financial institution (insurance carriers), and they are winning. In fact, they are winning a lot.
Part of our relationship with doctors in the profession is to provide advice and guidance based on the trends we see emerging and taking hold. In regards to documentation and building your fee schedule, we urge you to have an internal compliance review. This will provide friendly advice and opportunities to fix problems as opposed to waiting for the insurance carriers to do the same. They are much less friendly and want your money, your license, and, in some cases, your freedom. This is not about billing for services not performed (another no-no); it is about having deficient documentation for the services that you legitimately billed and deserve reimbursement under a legally defensible fee structure. The development of your fees is one of the most current trends across the country and has resulted in allegations of insurance fraud for doctors in almost every state. You must have legally defensible fees, and there are industry publications that geographically adjust your fees to usual and customary in your community. I suggest you do an Internet search and type the phrase “medical fees in the United States.” Many services have recognized publication to support your fees as usual and customary; use them because they are defensible.
Trend #6 Cross-Training DCs, MDs, and PTs in Primary Spine Care or Whiplash
Many consulting and educational companies have business models that include involving many professions, and, as a rule, that is good. However, the caveat comes with who should be the primary spine care provider. For reasons of greed, many companies are inviting DCs, PTs, and MDs to join the primary spine care “rush.” How can multiple professions fight for the same job as primary? If you look at the reference above, it is clear that chiropractic, as per the literature and clinical outcomes, should be the first choice for mechanical spine issues, and anything to the contrary potentially creates a public health risk. There are also seminars that are sponsored by insurance carriers, and, as a result, create a clear public safety conflict since they outline the carrier’s policies, which is to limit necessary care and increase profit. These negative trends must be avoided because you will be part of the problem if you support a poorer clinical outcome with PTs and MDs being the first choice for mechanical spine issues. If medicine and therapy were the answer to spine care, we would not see spine care fall behind virtually every other organ system in the human body in outcomes. The current trend is in finding another way, and that way is through a properly trained doctor of chiropractic.
The concept of training PTs and MDs in whiplash issues results in them being the first option for treatment when they have little to no formal educational training in spinal biomechanics. Additionally, PTs cannot diagnose by scope in most of the country and must be directed by a medical doctor who has little to no training on spine mechanics. Dogmatic care paths have led to results as reported by Mafi, McCarthy, and Davis (2013) on medical and physical therapy back pain treatment from 1999 through 2010, representing 440,000,000 visits. Studies revealed an increase of opiates from 19 to 29% for low back pain with the continued referral to physical therapy remaining constant. In addition, the cost for managing low back pain patients (not correcting anything, just managing it) has reached $106 billion ($86 billion in healthcare costs and $20 billion in lost productivity).
The previous quote from Blanchette et al. continues to verify chiropractic as the best choice for primary spine care based upon many variables of outcomes. Consultants are more concerned with the “bottom line” and are trending upward because of an unsuspecting trend of customers (you) looking for solutions and supporting the wrong places financially. If you understand the trends, you understand where you need to be. These six major topics are trending for 2020 and should you not “heed them,” it
will be done at your own peril.
References:
1. What is Trend Forecasting (2018), Retrieved from: https ^/smallbusiness, chron.com/trend-forecasting-61347.html
2. Blanchette, M. A., Rivard, M., Dionne, C. E., Hogg-Johnson, S., & Steenstra, I. (2017). Association between the type of first healthcare provider and the duration of financial compensation for occupational back pain. Journal of occupational rehabilitation, 27(3), 382-392.
3. Mafi, J. N., McCarthy, E. P., Davis, R. B., & Landon, B. E. (2013). Worsening trends in the management and treatment of back pain. JAMA Internal Medicine, 173(17), 1573-1581.
Mark Studin, DC, FASBE(C), DAAPM, DAAMLP, is the president of the Academy of Chiropractic teaching doctors of chiropractic how to interface with the medical and legal communities and studies trends in health care on a national scale (www. TeachDoctors.com). He can be reached at DrMarkff Academy ofChiropractic.com or at 631-786-4253.
William J. Owens, DC, DAAMLP, is presently in private practice in Buffalo and Rochester, New York and generates the majority of his new-patient referrals directly from the primary care medical community. He also works directly with doctors of chiropractic to help them build relationships with medical providers in their community.
He can be reached at dr.owensaacademy of chiropractic, com, via www.mdreferralprogram.com, or at 716-228-3847.
