The economic, political, and philosophical factors that impact upon chiropractic seem to be almost endless. They create much discussion and unfortunately much animosity within the profession. Perhaps no single issue among straight chiropractors brings these factors together more than the subject of payment for services.
The political aspect of it is, without doubt, the primary driving force for the major national organizations. Well in excess of 90% of their time, resources, and energy is devoted directly or indirectly to the political issues aimed at continuing, expanding and protecting the chiropractor’s ability to be paid by third-party payers, both private and governmental. Don’t take my word for this figure. Read their journals. I believe you will find that the 90% figure is probably conservative. It is a political issue because it is an economic issue. Many chiropractors depend upon private insurance, Medicare and other forms of third-party pay in order to make a living. There is no doubt that the stream of third-party dollars fueled the growth and prosperity of the chiropractic profession in the 80’s. On the other hand, the changes in the system as a result of the rise of HMO’s and similar institutions have created a concern within the profession in this new millennium. Despite some very prominent cash-practice seminars, I believe that most of the profession, at least the non-straight aspect of it, is convinced that the chiropractic profession cannot survive without third-party pay. They are probably correct in that conviction relative to non-straight chiropractic. Taking care of people for minor medical problems of a musculoskeletal nature, seeing people eight to ten visits (or whatever the average PVA is), not practicing lifetime family care, in other words, seeing people on about the same basis that the average medical practitioner does, probably necessitates being reimbursed on the same basis as him. However, that is not or should not be the straight chiropractic model of practice. Until recently, straight chiropractors were in the forefront of the cash-practice movement, although perhaps for different reasons than some of the practice management consultants. Those reasons constitute the philosophical factors in this discussion.
I am not going into the subject of “diagnosis” and the semantical discussion of whether filling out insurance forms is philosophically acceptable except as it relates to the really important issue in this matter. That issue is the unique chiropractic objective and how it affects or should affect everything that we do. The straight chiropractic objective, to correct vertebral subluxations so that the innate intelligence of the body can be expressed more fully, is what motivates or should motivate all our actions. It has been the thinking of the straight chiropractic movement that given the unique, non-therapeutic objective that we embrace, everything we do should be moving us as a profession away from the practice of medicine, the therapeutic model, and those activities associated with it. In other words, we should strive to look less and less like the medical profession. That is not always easy when we still function as a health profession and medicine is the accepted standard for what a “health” profession looks like. However, that is even more reason to distance ourselves from the therapeutic “look.” One natural result of our position is to separate ourselves from those organizations, groups and people who are striving to be more closely associated with the medical model or do not mind if they are associated with it. If moving away from the therapeutic/medical model is in the best interest of the future of chiropractic, then not moving away from it or supporting those activities that either tacitly or overtly are not moving away from it, would seem to me to be detrimental to the future of straight chiropractic.
The fee-for-service issue may very well be the most important issue in this non-therapeutic, objective approach simply because there are so many aspects of it to be considered. Why has it become such a hot topic recently and controversial enough to divide the straight chiropractic community? I think there are a number of reasons. First, it should be understood that the modern-day straight chiropractic movement has always been pro cash practice and negative toward third-party pay. We have always promoted the former and spoken against the latter. Why? Simply because one cannot get into third-party pay fully without practicing in the medical model, hence our opposition to it on general principles. Why get “slightly” into something that you cannot fully embrace unless you compromise your principles? Further, if “getting all the way in” necessitates compromise, at what point does the compromise begin? Second, we in the straight movement have felt that third-party pay was dying and speaking against it would only help chiropractors wean themselves from it and keep new practitioners from becoming dependent upon it. The bottom line is that until recently, cash practice was seen as being in harmony with objective straight chiropractic and insurance practice was not. That may be the major reason the straight movement has failed to attract large numbers of chiropractors. Apart from straight chiropractic, everything that has driven this profession in the past 30 years has been based upon money. Medicare, accreditation, AMA suits, insurance equality, CCE are all based upon being equal with medicine so we can have equal access to government money and equal pay. (Equal pay is only an issue if someone else is setting the fee and making the payments). Equal pay is not an issue in a cash practice.
So what happened? What changed? I believe there are a number of factors. Insurance did not dry up. Apparently, the political arms of the chiropractic profession are stronger than we straights believed and have been able to hold onto some aspects of insurance reimbursement. A second factor is that it is economically more difficult to practice any kind of chiropractic today including straight chiropractic. Many young practitioners feel they cannot afford to turn away insurance dollars. Consequently, we have convinced ourselves that you can practice on the fringes of an insurance practice without compromising. Further, many of our leaders have either stopped speaking against insurance practice or have actually said it is consistent with our chiropractic objective. (How can it be if it does not move us away from the medical model? It moves us closer to it). I believe some of our leaders have failed to take a stand against insurance for fear that we would lose members or not attract the new practitioners who feel they need to take insurance to pay student loans and just to make a living. They are probably correct in that assumption. So we have avoided or compromised on an issue that itself, at least on some level, represents a compromise of chiropractic principle. Will that stand take us down the broad path that leads to destruction? Some think so. Some think not. Some believe we need to be practical in this day and age and accept third-party pay. Others think that if we compromise a little (not taking a position against) on what is perceived as a small compromise (taking certain types of insurance) we have set back the straight movement. It is a tough issue. But then, it has never been the simple, easy, clear-cut issues that have given us difficulty as a profession. It has always been the difficult ones, the ones based upon principle. V19n4