January 2008

Hobson's choice

by Dr. Jeffrey Shay

My Funk & Wagnall's standard desk dictionary defines the term "Hobson's Choice" as a situation in which "one must take what is offered or nothing." The derivation of the term seems to have come from a 16th century English liveryman named Thomas Hobson, who required each customer to take the horse nearest to the door, or none at all.

The term is similar to the situation that chiropractors face in the insurance system. In spite of all the talk and debating, there are really only two choices for the future of health care in America, and one will probably eliminate our profession from coverage.

In the long term, health care system will either be government or corporate.

The governmental system may have private companies involved, but the structure and standards will be set by the federal government. The private system is similar to what is in existence now, but will probably become more exclusive and expensive.

I prefer the former.

One of the hottest issues in the upcoming election is health care. In the years since Hillary Clinton's health initiative failed, our health care system has been rapidly falling apart. Not only are 40 million Americans without any health care coverage, but millions more are underinsured. Michael Moore's new film, "Sicko" concerns itself with the second group, discussing the millions who think they have coverage, but are left holding the bag after an accident or illness.

The United States is the only industrialized nation that makes no provision for its people. Others have at least a semblance of a national health program. Estimates vary, but a minimum of 11,000 Americans die every year from lack of health coverage. Sadly, until now, hardly anyone cared. When 3,000 people were killed by terrorism, our government sent troops everywhere in the Middle East seeking vengeance. More than three times that many Americans die every year from insurance problems, and the reaction is deliberately muted.

Several Democrats, starting with John Edwards, have proposed a national health care system, which would provide both public and private options. Edwards' plan provides minimal standards for coverage provided by employers, and Medicare coverage for those who fall between the cracks, or prefer federal coverage. While such a plan wouldn't solve every problem, it's a good first step.

The Republican plan is to offer tax credits to purchase health insurance. Let's see, people are too poor to buy health insurance, so they will be offered tax credits to help purchase coverage. And what about those who are still too poor to be helped by this plan? Oh, they can get Medicaid. But wait, wasn't part of their plan to curtail Medicaid expenditures? The whole thing is not only cynical, but cruel.

And yet I've come across a number of chiropractors who support the Republican plan because they don't want government involvement.

But without a government program, we're faced with the capricious actions of the private health companies.

Corporate designs

Case in point: Wellmark Blue Shield of Iowa has attempted to create a new physical medicine program to hamstring chiropractic care. I can't remember Wellmark's name for it, but I prefer to name it "Death by Paperwork." On the surface, it's a tangled bureaucratic nightmare, but that's not the worst part. The paperwork is designed to create a massive authorization program that eventually will severely limit chiropractic care, and punish patients who opt for it. Patients who have a back problem will say to themselves, "Let's see, shall I go to an MD who'll be paid by Blue Shield, or to my chiropractor, who'll have to ask for authorization and beg for forgiveness for being born?"

Another case: United Health Care has announced that it will no longer pay for chiropractic treatment for children or for headaches, citing lack of so‑called evidence that such care is beneficial. (NOTE: Although several articles have appeared about the dangers of some statin drugs, there will be no problem getting checks out to the drug companies.)

A third example: A rapid rise in co-payment fees in most insurance contracts. The interesting thing is that $25.00 co-pays on chiropractic services make "regular" doctors comparatively more affordable.

Simply put, the health giants want to eliminate chiropractic from coverage. It's not going to happen all at once, but by gradual strangulation.

Advantage: Uncle Sam

Government health plans have their problems, too. Witness the limitations of the Medicare program, and the audit problems in recent years. And yet, government programs have one thing that private ones do not... representation. Both chiropractors and their patients can approach their representatives seeking coverage modification. The people represent a constituency.

Not long ago I was approached by an insurance representative who wanted me to sign up for a private Medicare program that, in essence, would pay only $5.00 for chiropractic services after a $30.00 co-pay, which was pretty much like signing up for a poke in the eye with a sharp stick. Her explanation was that their plans were based around coverage that people wanted.

"Then explain to me," I said, "why your program ignores the fact that over 40% of Americans go to alternative practitioners each year. Do people go to chiropractors so they can have their coverage denied?"

She just looked at the floor.

Don't expect any help from state insurance commissions. Most of them are shams, especially the one in this state.

Last year, the Iowa Supreme Court ruled on a case involving a woman who was refused coverage for knee surgery by her insurance company, in spite of her doctor's opinion. The woman complained to the Iowa Insurance Commission, who basically shrugged its shoulders, as it usually does. The woman had the surgery, and successfully sued her insurance company. She was so angry about the whole business that she then sued the Iowa Insurance Commission for failure to do anything but pass around the key to the executive washroom. She lost. The Iowa Supreme Court ruled that the insurance commissioner had too many responsibilities to worry about insurance coverage. And, no, I'm not making this up.

I feel her pain

I've had similar dealings with that department. My complaints about insurance companies ignoring claims have usually been answered, if at all, by a few sentences that, translated from the Latin, mean "the will of God." In one case, I had successfully sued an insurance company for my services to a patient. The company simply ignored the court decision. When I complained, the insurance commission wrote a letter that basically said that problems between me and the insurance company should remain between me and the insurance company. When I called the commission, I asked them if my calls interfered with their lunch breaks. I was then transferred to a dial tone.

In spite of Iowa's January first‑in‑the‑nation caucuses, political activity by the Iowa Chiropractic Society (ICS) has ranged between little and none. While I have met with a number of presidential candidates during this campaign, ICS activities in this area have been practically invisible (see earlier comment about the executive washroom). There seems to be no long‑range plan for the profession in this state.

In fairness, I should mention that ICS is now involved in fighting Wellmark's new chiropractic program, they have shown little initiative in the past, and have spent a lot of time in political infighting. Recently, ICS sent me a letter asking me to contribute to their upcoming legal fight against Blue Shield, temporarily forgetting that they told me that they didn't want me or any other member of the WCA to be a part of their group. I will cover the Wellmark action in other columns as events warrant.

The hard fact is that chiropractic faces a Hobson's choice of government health care, or possibly no coverage at all. I would hope the profession can make its choice the right one.

(Dr. Jeffrey Shay, a graduate of Palmer College of Chiropractic and the WCA's 1996 "Chiropractor of the Year," is the World Chiropractic Alliance Director of Insurance Relations. He welcomes comments or questions regarding any insurance‑related subject appearing in this column. Dr. Shay is available to speak to your state or local organization. Contact him at 1501 Mulberry Ave., Muscatine, IA 52761, or the WCA offices, FAX 480‑732‑9313.)