I remember the “good ‘ole days” of chiropractic.
The days when it seemed that everyone in America had health insurance, when the typical deductible was about 100 bucks and the patient only had to pay 20% of the charges. And their policy limited chiropractic treatment to only “UNLIMITED VISITS.” Sigh…
When a new patient came in, we did the ortho/neuro exam we all learned in chiropractic school, found a few areas of pain, some radicular signs every now and then and recommended a treatment plan. Patients seemed happy to start, excited it was affordable (since their insurance paid for the bulk of treatment). They started feeling better quickly and referred their friends and family in. And let’s not forget our favorite Medicare patients! Once they felt better, many of them wanted to continue to come in for maintenance. Yep, we just kept on billing Medicare…for years.
For the personal injury patients, we’d examine, treat and bill, for pretty much as long as we wanted or until we got bored. No one ever challenged us. We’d send our bill in, and it got paid. All of it. Every penny. And no one ever asked to see our documentation.
Ahhh…the good ‘ole days.
That was about 30 years ago. I guess you can say it’s changed a bit since then. These days, patients may have health insurance, but their deductible is often higher than $5000 per year and co-pays are often more than our cash fee for an adjustment. Medicare is mad at us. Personal Injury is mad at us. Workers Comp, in many states, won’t even talk to us. Chiropractic offices are opening up all over the country, charging about $15 for an adjustment. Yeah, that helps.
We were taught in chiropractic school and by every consultant on the planet to perform periodic re-exams on each patient. We’d find that the orthopedic tests caused a little less pain, palpation seemed to cause a little less tenderness and range of motion seemed to be getting better, as far we could tell.
More and more, chiropractors are being asked to send our records to the insurance company so they can see if our treatment is appropriate. How rude. So, we send in a copy of our travel card, or even better, our fancy type-written notes from some EMR or EHR that we spent way too much money on or took more time to document than it did to adjust the patient. We send in our exam forms that show the patient is feeling less pain, less tenderness and seems to be moving better.
And then we get told that our care was not “medically necessary” and no more treatment is appropriate. What in the world are they talking about?
I know many doctors reading this are nodding their head in agreement. I got upset over the way I felt I was being treated, so I made it my mission to find out what the heck they were talking about. Apparently, someone changed the rules of documentation and no one bothered to tell us about it.
So, what did I discover? The health care industry (doctors, insurance people, even attorneys) love tests. More specifically, tests with numbers. Think about it – blood tests have numbers. Urinalysis tests have numbers. All kinds of tests have numbers. What does a typical report of findings sound like from a medical doctor? Think about it. “Well, Mrs. Smith, we had some blood work done for you, and this is what we found. This is normal. This is you.” The patient nods. The doctor explains what it means and recommends some medication that the patient should take three times per day for the next 6 weeks. The patient nods. The doctor continues that, in six weeks, we’ll re-do the blood tests and see if the patient is normal or, at least, on the right track or not. The patient nods. Hopefully, as the tests become normal, the patient feels better, too.
There was no selling involved. Just a doctor being, well, a doctor.
So what are we chiropractors supposed to do? I mean, it would be AWESOME if we had a blood test that shows that the patients have subluxations here, here and there. It would be FANTASTIC if we could test their blood again after we’ve treated them for a period of time and see that their subluxations are improving here, here and there. Maybe one day we’ll have those kinds of tests, but for now…
We don’t need them.
The health care world basically wants two things from chiropractors. They want us to show that we have relieved the patient’s pain and improved their function. That’s it. Pain and function. Medicare now requires ALL doctors to report certain measurements to them to show that the treatment is being effective. Luckily for chiropractors, they currently only require TWO things. That’s right – Pain and Function. As a reviewer for many personal injury cases, I can tell you we look for the same two things – Pain and Function. What do the Workers Comp carriers want? Yep – pain and function. Think about your cash paying patients. Sure, they love it that they’re feeling better, but don’t you get excited for them when they say that they were able to play on the floor with their kids for 10 minutes longer than they could before? Or they’re driving a golf ball 30 yards farther than they did a month ago? Pain and function. That’s what the health care universe is looking for.
Medicare takes it even a step further. They actually state in their documentation guidelines for chiropractors what they want. Unfortunately, this may be one of the best kept secrets in our profession. Medicare actually states that they want us to have the patient complete outcome questionnaires. That means, instead of asking individual questions like “How long can you sit before your butt goes numb?” or “How long can you read before your head feels like it’s going to explode?”, which are fine, by the way, Medicare wants us to use questionnaires that ask several questions about the patient’s Pain and Function. Awesome – less work for me.
There are outcome questionnaires for practically every musculoskeletal body part. There’s a great questionnaire for headaches. There are a few questionnaires for neck pain. For low back pain, there’s a questionnaire that’s great for acute/antalgic low back pain and another questionnaire that rocks for subacute or chronic low back pain. There’s even a questionnaire for sciatica, which very few doctors seem to know about. Upper extremity questionnaires? Yep. Lower extremity questionnaires? You betcha’.
They want us to give our patients a questionnaire or questionnaires (for patients with multiple symptoms) before we even start treating. That means the first visit when you do your exam. Get a measurable baseline, they tell us. It’s like getting the blood tests before the doctor prescribes the medication. We can then show the patient their scores. This is normal, this is you. The patient nods. We let the patient know if we think we can help them or not. We tell them what treatment we’ll do and that we’ll re-evaluate them with the questionnaires after a period of time to see if they’re normal or, at least, on the right track or not.
No selling involved. Just doctors being, well, doctors.
It’s not just Medicare who wants this, though. It’s everyone. Cash patients. Insurance patients. Workers Comp and Personal Injury patients. State Boards want it. Malpractice insurance carriers want it.
It’s not just about having patients complete the questionnaires, though. Remember, the power is in the numbers. The questionnaires must be scored, so we can see if the numbers are changing over time. In addition, we need to keep track of the dates we gave the patient the questionnaires and the scores. When we can show a measurable baseline that showed measurable improvement as a result of our treatment, well, that helps justify the care. If the questionnaires show measurable improvement, but is not yet normal or plateaued, that tells us that more treatment could be appropriate.
The health care universe requires us to document treatment plans and goals for our patients. The days of saying things like “reduce pain,” or “reduce spasm” are essentially over. That’s not what they want. They want “measurable.” They want us to tell them that our goal is to reduce the patient’s pain from a 7 to a 5 and to improve their scores on the outcome questionnaires by 15 points. They want us to tell them when we’ll be re-evaluating the patient and what function we plan on measuring to determine the effectiveness of our treatment. This is so much easier than most of us think.
It’s just two basic things. Reduce the patient’s pain. Improve the patient’s function.
Just doctors being, well, doctors.
Visit The Bulletproof Chiro at www.TheBulletProofChiro.com.