Seeing a chiropractor first saves Optum Health millions of dollars in the treatment of back pain.

Optum Health has collected data over the past two years regarding the cost of treating back pain at the NASEM (National Academy of Sciences ) titled: "The Role of Nonpharmacological Approaches to Pain Management," outlining the tremendous efficacy and cost savings associated with chiropractic and other forms of conservative care for spinal episodes; and the two-year plan to impact the 125 million consumers. Dr. Elton said that it is time to recognize we no longer need any data to show using a chiropractor or physical therapist as the first contact for a lower back pain episode is much cheaper than any medical specialist or primary care provider for lower back pain.   Using a primary medical doctor for the initiation of the episode segments the care, adds costs and medication, according to the Annals of Internal Medicine should be a secondary approach.

The data proves action needs to be taken now to make it less expensive to see a nonpharmacologic care provider.

Dr. Elton believes it is time for action on this data which shows the immediate need for patients to be steered to the most cost-effective providers with the least risk first.   He also believes that patients should be able to access those providers whose offices are convenient for them to get to quickly and easily through an online portal. We at Charschan Chiropractic applaud the efforts of Optum Health, who has been collecting this type of data for many years.   Chiropractors have traditionally been underutilized in our healthcare system as Optum's data shows, along with physical therapy.  The truth is, chiropractic methods, which include physical modalities, active care, and exercise regimens are a comprehensive approach to care management of back pain. The holistic approach chiropractors are trained in makes them unique in the back pain treatment space, because back pain is caused by numerous factors.  Evaluating and treating a patient properly, with the understanding that patients are unique mechanically is why a holistic approach that evaluates a patient thoroughly is the only way to properly diagnose a person's back pain.   The reasons for one person's back pain may be totally different for another person's back pain. As chiropractors have known for years, it takes a great evaluation to evaluate back pain, and x rays and MRI's may not be necessary in many situations. Unlike the physical therapy approach, which uses exercises, muscle work, protocols, and a prescription in most states to treat the medically diagnosed complaints, a chiropractic holistic approach to evaluation can lead to a more accurate diagnosis and chiropractors rarely require a referral to diagnose and treat a patient. Therapeutically, chiropractic physicians draw from numerous methods including myofascial release, instrument assisted soft tissue, foot orthotics, exercises, and manipulation of the spine and extremities.   From the original study from the Annals of Internal Medicine, chiropractors are likely using many of these methods to help them get their patients with back pain out of pain and back into their normal lifestyles which may be why they have such a high level of satisfaction as compared to other healthcare professions regarding back pain.

Optum Health understands that incentives are needed to increase the number of patients seeing a chiropractor first.

Most healthcare companies have made it more difficult to see providers who are more cost-effective.  If this leaves you speechless, it is because their business models are based on a percentage of billing which is why they have become so profitable.  The more healthcare costs, the more income they make.   It is likely one of the reasons that the runup into Obamacare over the past 10 years showed fantastic increases in the costs of care for patients and the companies who insure them.  Horizon's Omnia is a prime example of this, since 95 percent of chiropractors were placed in the second tier, which makes them more expensive to visit.   If we follow data-driven models, this approach to healthcare management has lead to opioid abuse problems as was the case of Partnership Healthplan in California a few years ago. Aetna has recently added Magellan/NIA to make chiropractors and physical therapists as well as OT's pre-certify their care to get paid.  Their system is obtuse, difficult to track, and designed to micromanage what these practitioners already do better than everyone; treat problems such as back pain cost-effectively.   Adding an administrative layer does nothing to improve quality, but it does have doctors thinking about or actually leaving the network.  Their new contract makes it impossible to leave their program for a year, which artificially stabilizes their network even though the program is bad for everyone.  If Aetna was interested in cost-effective providers who treat back pain being rewarded for the work they do which statistically saves them money as Optum demonstrated, why would they do this? Optum is promoting the idea that seeing a chiropractor or physical therapist should cost less and they are planning on implementing this idea in 2019 through lower copayments for the usage of these providers. Of course, they are also understanding that there are alternative healthcare models developing now that they must compete with as we recently read about by Warren Buffet, Jamie Dimon, and Jeff Bezos.

Optum's model comes with caveats for doctors of chiropractic.

While chiropractic has saved Optum Health millions of dollars over the years, and they have the data to prove it, at least when it comes to back pain treatment, their one size fits all model places all the liability on the healthcare provider.   Optum for years has offered participating doctors opportunities to participate in their worker's compensation contracts which offered flat fees per visit regardless of the complexity of the problem. Unlike traditional insurance models that reimburse doctors for their evaluations and x rays if they are needed, as well as the services they provide on each visit,  Optum's current contracts treat doctors and patients as widgets of similar complexity.  Their current model ignores the fact that patient intake for an initial evaluation or reevaluation using an electronic health record system is time-consuming. Patients are different in size, shape, genetic background and complexity of history. Complex cases can require an hour for the initial visit and the first treatment and may require x-rays, however, doctors not being reimbursed for the service are likely to send the patient elsewhere even if they have an x-ray in their office since they are no longer being paid for the service.  Regardless of the time or complexity of decision making needed, the healthcare provider is paid the same fee as on any other visit under their current model.  This type of thinking by insurance carriers is why primary care providers rarely visit patients in the hospital anymore and defer to hospitalists who are paid much more for visiting the primary doctor's patients. When doctors were no longer paid for those visits, they stopped doing it and segmented the care, resulting in higher costs for all of us, without the reassuring faces we were accustomed to visiting us when we are hospitalized. Optum Health began rolling out its model for Oxford and United Healthcare plans the last couple of years which essentially paid a flat fee on the initial visit and follow-up visits.  It is the same model they used with their worker's compensation contracts our office rejected over the years. Their newest model of care ignores the fact that a new patient requires resources and it is time-consuming.  In NJ, their global reimbursement including x rays and evaluation has made us rethink our relationship with Optum, and we decided to drop their Oxford contract a year ago as a result.   We did this because too many United patients using their system would bankrupt our practice.  We did lose some patients as a result, but it was an appropriate business decision. Some practices have made changes to do as little as possible for Optum patients or to make it difficult for them to get an appointment. We know this because these patients call our office and tell us they had difficulty getting an appointment.  This is something that happens in the medical world all the time if you are a new patient wishing to enter as a practice from a poorly paying insurance provider. At the end of the day, the healthcare provider has rent, personal overhead, and other expenses plus employees that need to be adequately compensated.  Their model ignores that most chiropractic providers are not working in facilities, and are solo or small group practitioners, who are trying to do the right thing for their patients. Under their current model of care, a healthcare provider is punished if they treat frozen shoulder, chronic pain, plantar fasciitis, chronic hip, shoulder and neck problems and even knee problems which often involve gait and retraining movement in the body.   To treat these cases properly, it requires time and resources. Fewer doctors will spend the time to effectively treat these patients, which will show up statistically.   Why hasn't Optum Health shared their statistics regarding other conditions?  Perhaps, their model, which causes healthcare providers to skimp on needed parts of the care their patients with these problems experience shows the flaws in their current chiropractic funding model.  Again, their model works great if you spend little time with patients but if you are comprehensive and trying to work on complex problems with patients,  rehab active care practices that get great results with these problems are being financially harmed. While we applaud their efforts to increase chiropractic utilization for cost savings, chiropractors are not uneducated employees at Walmart, who work a cash register.  Why pay them as if they were the cashiers of the healthcare system, when they have proven their worth to Optimum Health and its financial and therapeutic goals. Cheaper at all costs when it comes to patient care is a dangerous precedent. Doctors who cut corners may help you save money, but is the patient and their potential future problems that are ignored by your current methodology. Poor primary musculoskeletal care will likely show up with other physical ailments, which may have been prevented as we commonly see in the allopathic management of many older patients with co-morbidities.  Data does not tell the whole story as care must be individualized to the patient to improve outcomes. On the other hand, the idea that chiropractic if used first saves so much is a great sales pitch.

Our recommendation for how Optum can make their current system work for everyone.

Optum is paying a reasonable reimbursement for an uncomplicated visit, however, they need to pay doctors for their evaluations and x rays if needed, which are essential to the health and welfare of those they insure.  They must also allow for a doctor to charge additionally if they need more time to adequately treat a particular case.  Many of us work within the insurance model which has recognized limitations however, I often put in extra time on Optum patients when needed, even though there is no additional compensation.   It is the right thing to do for the patient, but is this the right thing to do for a dedicated provider trying to resolve a case quickly and efficiently? Back pain can be caused by foot problems, shoulder problems, gait problems, upper back problems, active abdominal scars,  injuries, etc., doctors of chiropractic should be able to bill and be paid an appropriate amount for their time, and for the complexity of the case. A more comprehensive active rehabilitation approach aligns more closely with the recommendations by the Annals of Internal Medicine which is data-driven. Why financially harm doctors who are comprehensive in their approach with a global fee, which forces them to make financial choices rather than patient care choices? Optum Health, as they already know will still be saving a lot of money, and doctors of chiropractic would be thrilled to participate in a fair and equitable system. Will chiropractors who lose money or barely break even want even more United or Oxford patients in their offices with the incentives of lower entry costs you propose?   I cannot speak for others however, for our offices, if and when Medicare finally fully covers chiropractors for the services we provide, we are more than likely to either close our panel to new patients or leave altogether unless Optum allows Chiropractors to be paid for their evaluations and x rays when needed. Healthcare is a business.  Businesses like ours help thousands of patients annually.  We and many other chiropractic offices would love to continue to accept United Healthcare patients into our offices as they ramp up demand for our services.   To truly be partners in this endeavor, it has to work for everyone. Optum needs to recognize that reforming back pain practices is not just about dollars and cents, its about results and the proper treatment of those who get those results.