To Be In Network or Not To Be In Network

You get what you pay for.

The quick and short explanation is that, in my professional opinion, you are being conned. Yeah that may sound harsh but let’s be honest, you know that I’m right. There are very few people that are happy about the value of their insurance benefits.  Most of you don’t even have a clue what those benefits cover.

 

Who really has time to read everything covered in those policies?

Most of the time your employer picks a policy, often based on cost and not the quality of care. The point at which you see said policy is usually in right after you found out you just got the job.  Yay! You’re not unemployed! But wait. What are you really getting paid?

The days of expecting just a standard co-pay to get care are gone. Now the plans are redone, manipulated, reworked, altered, updated, or whatever you call it. They are often different and almost always not easily discernible. There are so many options and choices that you, instead of an apples to apples comparison, end up comparing rotten apples to outdated cheese in a can. Sure, both may keep you from dying in a pinch but neither is really going to improve your overall health. But to the insurance company, they’ve met their goals of providing a “meal” so that you don’t starve.

 

Don’t be fooled.

You may not starve to death today but you’re almost certainly going to have problems in the future if you continue to eat “food” that has little nutritional value and a high risk of disease. Part of the problem? Managed care. Many of you have no idea what this is.  If you think you’re insurance is there to protect you so that you can afford to be healthy, you are wrong. Look again at the rotten apple to outdated cheese in a can analogy. You need to realize that with managed care your options for eating healthy are not really there. Again, it will help prevent you from starving but after that, you won’t have access to the rotten food.

 

Managed care exists to help insurance companies reduce costs. ‘Period.’

I understand that they don’t want to pay for more care than is necessary, nor should they. The problem is that instead of looking at the “meal” doctors are providing to get you healthy and limiting it to a salad with fresh fruit and veggies and a few ounces of lean fish, you know a reasonable and healthy meal, they are limiting it to your rotten apple OR outdated spray cheese. Even worse, you only get it once or twice. You and I both know if you trying to nurse a patient who has been starving, back to health, it’s going to take more than one meal and certainly more than barely edible food to do it.

 

Unfortunately, Insurance companies make the rules.

And their rules clearly state food is food and once you’re fed then you are no longer hungry.  While your plan covers 30 meals, managed care doctors and their guidelines say when you’ve been fed sufficiently. Sorry but that’s what you signed up for. You’re expecting a decent meal 2-3 times a day for a couple weeks to get you back on your feet, your policy only covers “food” picked out of the trash that is likely to cause you to get sick in the not to distance future. Once you’re fed, you’ve reached what they call “Maximum Therapeutic Benefit”. You could have spent six years in a prison camp but that’s not their problem. Managed care is there to make sure insurance isn’t paying for rib eye steaks and sushi on a daily basis. At least, that’s their excuse when they refuse to pay for a turkey sandwich.

 

What am I actually talking about? Here it is.

In order to be in network with insurance, there are guidelines that are expected to be followed.  It varies based on insurance but suffices it to say these guidelines are based on making insurance money 1^st and your health a significantly distant 2^nd. If you disagree then please feel free to put your health in the hands of your insurance and the doctors they pay to manage your care. I doubt you’ll feel like their recommendations are based primarily on you getting healthy. If you do, more power to you.

I wish you the best but it breaks my heart to see people who truly need and would benefit significantly from chiropractic care that isn’t getting it or are getting bastardized version of it in the form of pain/insurance based care instead of corrective care. Kind of like if your insurance covered ridiculous “health care” procedures like gastric bypass but not national counseling or exercising training… oh wait, that’s exactly what they do.

 

This is yet another of the true mysteries of health insurance.

They’re willing to pay the hospital $50k-$100k for back surgery that is very risky and does not have the success rate of conservative chiropractic care. It’s rather strange considering most surgeons will tell you that once you have surgery it’s only a question of how long before the next one. They, like many structural chiropractors, know that fusing one or more segment(s) in the spine, solely to reduce the pressure and irritation causing pain on your nerves, comes at a price.

• First, as I’ve stated, it’s risky. Back surgeries fail, and by fail I mean they don’t reduce and in fact can make the pain worse. It happens so often that they now have a diagnosis code for “failed back surgery” to make it easily identified. FYI: no such code exists for failed chiropractic adjustment (wink, wink).

• Second, if you do in fact have a “successful fusion” you are now left with a spine that is unequivocally less functional that a normal spine.

Chiropractic is very successful in reducing the abnormal biomechanical and structural stresses that caused the disc to fail. Allowing the disc to heal and restore it to a state of normal motion, reducing the bulge and subsequent pain. You know, getting your spine back to a normal, healthy spine. Surgery, while sometimes necessary as a last case scenario will never restore the normal motion of your spine. Remember that word “fusion”? That segment(s) is often cemented in place. That’s why there is always an expectation of future surgeries. The other vertebrae now will respond by becoming hypo (less) or more often hyper (more) mobile to compensate for the, now abnormal motion in your spine.

 

I honestly do not understand how this is financially sustainable for insurance companies.  Maybe they don’t either and that’s why your rates are going to continue to go up while reimbursement for chiropractors continues to go down. Don’t worry though the cost per visit reimbursement that they are now transitioning to is going to save them money. Let me explain.

Instead of insurance paying for the services necessary to get you back to normal they are going to only pay a maximum amount per visit regardless of the care provided. Fortunately, I’d only have to take about an 85% cut in my fees for the first visit if I agree to their extortion, I mean completely reasonable reimbursements. I don’t see any problem with that, though. After all, If I’m making less than minimum wage that’s not likely to affect the quality of your care.

 

You may be wondering how this analogy makes sense. Honestly, most people in healthcare may not be able to follow this rather diatribe rant towards insurance.

Let’s break it down.

1. There is a significant difference in what insurance reimburses medical doctors compared to doctors of chiropractic. You might think that chiropractors clearly aren’t “real” doctors and thus don’t deserve to be put in the same category are the all-knowing and omnipotent medical doctor. You would be wrong. I have nothing against medical doctors. They are NOT the problem. They often have some of the same issue and challenges dealing with insurance refusing to pay for necessary and justifiable care. Just last week I had a patient tell how a friend of his at work died while waiting for insurance to approve his lung transplant. While I may disagree with the reactive choice of care that leads to a lung transplant, the simple fact remains. He DIED waiting for insurance to say whether or not they would pay for the surgery.

   1. The bottom line is this. Regardless of who is a “real doctor”, which is honestly the dumbest statement I’ve ever heard as the word doctor is really rooted in the word “teacher”, but I digress. The insurance company should really be concerned with who is going to get the patient healthy for the least amount of money. Raise your hand if you think you need more surgeries and drugs to be healthy. For those of you left, raise your hand if you think taking drugs and getting surgery will result in fewer drugs and surgery in the future. Alright, now anyone who raised your hand, sorry but you’re part of the problem.

   2. Chiropractic is far safer, has VERY few side effects and results in fewer drugs taken and fewer surgeries for patients. If insurance was interested in reducing costs and improving patient satisfaction they could do nothing better than to limit palliative, pain based care as a last resort after conservative chiropractic care. Oh, wait they actually say that, but there’s a catch.

   3. Some insurances will require a minimum of six weeks of conservative care in the form of chiropractic before covering the cost of treatments like facet injections. Great idea! Here’s the problem… Remember that managed care we were talking about? They are there to limit that conservative care in a highly aggressive manner. While you feel better for a little bit, your problem often still exists.

   4. Essentially you’ve gotten your rotten apple to hold you over but you are still very malnourished. This is funny considering they required you to eat that rotten apple to see if it would get rid of your hunger before they would pay for the “medical” route of feeding you intravenously. So, on the one hand, they say “you have to try to eat something before we’ll pay for extreme/medical intervention” while on the other hand, they say “we’ll only pay for that rotten apple and once you’re not hungry anymore you are no longer in danger of being malnourished.” Guess what eventually happens? The rotten apple offered (pain based/managed chiropractic care) helped but didn’t fix the problem. Your insurance then blindly pays for a very expensive and unnecessary procedure to prevent you from dying when they could have saved a ton of money by paying for more high-quality meals in the form of structurally focused chiropractic care for more than the 2-6 week maximum or 6 visit average managed care experts. After all, they expect this because it is the average that IN NETWORK chiropractors are giving patients. Jeez, I wonder why? Could it be the average is so low because that’s all they’ll pay for…?

   5. One thing is for sure, and this was made very clear to me by the insurance company I spoke with. Their expectations are NOT based on the ICA Best Practices and Guidelines which clearly state that and have mounds of research to support the need for care far beyond what the in-network “guidelines” dictate. But don’t worry, I’m sure they have your best interests at heart and have no reason to limit necessary care.

 

Let me explain another way.

Insurance will not pay for chiropractic care to stabilize the primary cause of your pain. Well, what does that mean? Let me give you an example. You have a heart attack. EMS races you to the hospital where they administer nitroglycerin and God knows what else, remember I’m a chiropractor, not a medical doctor. That nitro acts fast to open up those blocked blood vessels so you don’t die and that feeling that an elephant is sitting on your chest subsides. If your medical doctors were reimbursed like your chiropractor you would be immediately discharged from the hospital, after you’re out of pain and the secondary symptoms of chest pain are over.

They will not monitor you or keep you there overnight to make sure that your problem is resolved. They will not do further testing like to evaluate for other potential risks. If they do that’s fine but your insurance will not pay for it. After all, that’s considered “corrective” and at that point, your patient needs to switch to a cash fee because insurance has done their job and got you out of pain and it really doesn’t matter what caused it.

As a structurally focused chiropractor, we take full spine x-rays from the front and the side to evaluate the spine for structural abnormalities that are often present despite a lack of symptoms.  This is similar to how a medical doctor will do additional tests beyond an ECG to determine the extent of the problem.

For example, they may take an x-ray to evaluate the size of the entire heart, an echocardiogram to identify heart damage, an angiogram that uses dye in the arteries to reveal blockages or a stress test to see how your heart responds to stress or even a CT or MRI. No one would ever think to look at only ONE chamber of the heart because there are only symptoms coming from that one area. The spine is one contiguous structure that should be treated as one organ. You would not expect your medical doctor to examine only one chamber of your heart. However, these are the restrictions that chiropractors deal with on a regular basis.

If there isn’t pain there then it will not be paid for.

Structurally focused chiropractors understand the current research and even the old research, which supports the benefits and necessity of taking full spine x-rays with any spinal complaint to determine spinal subluxation, spinal degeneration (which is highly likely most patients with an abnormal structure/posture, yes even young patients), congenital anomaly, etc. There is a laundry list of reasons to take x-rays especially x-rays of the areas of the spine where there isn’t a symptom.  Let me give you an example.

I recently had a patient come in complaining of mid-back pain and shoulder pain. The patient had no neck pain or previous low back pain which was not currently a significant issue. If I had ignored the rest of his spine as an In-Network insurance provider requires I would have missed the ½” short leg on his left side that is the reason for his lumbar spine leaning to the left and the thoracic spine leaning to the right. I also would not have been able to see the “S” curve in his cervical spine that is not only causing his head to jet forward but his mid-back to hyperkyphotic (too much curve) and shifted backward.

You see, the spine is connected. Imagine that.

As a result, structural problems in one area often lead to problems in another. Pain is not a diagnostic tool that should be used to dictate where and when healthcare is needed. Pain is the last thing to show up and the first to go away. That heat attack was on its way long before the chest pain got there and the treatment does not stop just because the pain has. Most patients will be prescribed, beyond the “diet and exercise” recommendations, some type of prescription drug(s) and other surgery to remove the blockage. Sadly the reason for the blockage, which is often undervalued, is not paid for but the crazy expensive drugs and surgery that treat only the symptoms are.

At least the medical doctor is able to get to the heart of the problem, the blockage, instead of just ignoring it because the pain is gone. Ethical and effective structural chiropractic care cannot be performed with in-network regulations dictating what is necessary because what is necessary to them is only that you are not in pain and even if your structural condition is not changed and you get a little better they’re done paying. Yes even if the pains comes back in a few days they want the chiropractor to change what he is doing instead of doing what is necessary to fix the problem.