Hijacked Health Care

Our health care system has been hijacked.  When any patient, let alone a musculoskeletal expert such as a doctor of chiropractic, is forced to go to a family physician to get a referral for paramedical services, such as chiropractic care, massage therapy, acupuncture, etc., in order to get reimbursement for said services from a health insurance company, you know the system has been hijacked.

When that family physician asks “why” you need the note, and you say “to assist the health of my musculoskeletal system” and the doctor responds with, “No, I need a diagnosis”, you know the system is broken.  When that family physician simply asks the patient for the diagnosis, rather than perform an exam, of which he/she is not really trained to perform, you know the system is broken.

How have we let the insurance companies hijack our health care system?

The province of Ontario is trying to improve the health care system by making it more efficient.  One method of efficiency is encouraging Ontarians to go to chiropractors for low back pain.  In fact, a pilot project has placed chiropractors on the front line of diagnosing and treating low back pain in areas of the province where accessing chiropractic care would otherwise be underutilized.  Chiropractic care has been shown statistically to be the most cost efficient treatment of the most disabling condition: low back pain.  Don’t go to your MD, don’t pass go, and don’t pay with OHIP dollars.  Your family physician is a primary care physician who focuses on sickness and treats you with medicine or a referral to another medical professional.  Back pain, much like all the other musculoskeletal problems (neck, shoulder, elbow, wrist, hip, knee, ankle, etc.) is not a family doctor’s expertise.  It is the expertise of a different primary care physician: Chiropractors.  Primary care physician is a designation given to chiropractors so that patients do not require a medical referral.  And, yet, when an extended health care insured Ontarian has a musculoskeletal problem, they are often required by their insurance company to first go to their medical doctor for a referral (depending on which insurance company and plan you have).  This is an absolute contradiction of provincial policy.  The Regulated Health Professions Act (RHPA), 1991, was created to provide a more modern framework for the work of health professionals; provide consumers with freedom of choice; and provide mechanisms to improve quality of care.  Low back pain, treated by chiropractors and other conservative, musculoskeletal therapists like physiotherapists, and massage therapists is a perfect example of modern, more effective and cost efficient use of health care.  Requiring a patient to seek the care or guidance of a health care practitioner for a health problem outside their scope of practice is inefficient, costly in terms of time and lost work productivity (not to mention referral note fees now being charged by family physicians).  This is not the intention of the Ministry of Health and Long-Term Care, and yet the reality is that the insurance companies dictate the behaviour of Ontarians.  As our population ages the need and use of paramedical services has risen.  In turn, insurance companies have modified their plans to curb these rising usage rates.  Anecdotally, this was highlighted to me by a former senior-executive of a medium sized business who had tracked the use of insured services of his employees.  He illustrated to me that slight changes to the insurance plan from year to year greatly changed the usage of those services; when the medical referral “loophole” was required for paramedical services, the rate of usage dropped from approximately 80% to 25%.  It is not a mystery why insurance companies continue to impose these obstacles.

How have we let a financial corporation hijack our governmental policies?

The impact of this hijacking is extremely high, and speaks directly to the rising cost and burden facing our society.  Of the top eleven causes of global disability, neuro-musculoskeletal complaints factor in six:  Low back pain, by a wide margin, ranks number one on the list of disabilities.  Neck pain, “other” musculoskeletal conditions, migraine headaches, falls, and osteoarthritis are the five other musculoskeletal conditions in the top eleven causes of disability around the world.  Chiropractors treat these and other conditions everyday, without drugs, surgery and at no cost to the province.  And, moreover, those who seek care of a chiropractor not only get their condition treated, but learn how to prevent a recurrence and other problems in the future by learning about corrective exercise, healthy eating, proper lifting techniques, posture awareness, and other healthy habits.  When the patient is disabled, or in enough pain, they are motivated to go to the medical doctor to get the referral note so that the eventual treatment with the chiropractor or other paramedical service provider will be reimbursed.  And, at the cost of $35 per referral letter (my doctor’s fee) the patient is now on track to go get the treatment they need.  That’s right, there’s often the extra hurdle of paying the MD his/her “non-OHIP-covered service fee” (A rapidly growing trend amongst medical doctors is to charge patients out-of-pocket fees for referral letters and other administrative services.).  But, what about all the physical health conditions that are not “severe” enough to warrant a day off work to sit and wait for their MD to write them a referral letter?  I’ll tell you what happens: The patient doesn’t get the early treatment they require to ensure they nip their injury in the bud.  With direct access to musculoskeletal experts and no medical note required, patients are far more likely to get the timely care they require, as intended by the RHPA, leading to a faster, more cost efficient recovery with reduced or no short and long term cost to OHIP.  Those who cannot afford treatment or have time-consuming and costly obstacles to accessing their insured services typically forgo getting treatment.  The long term outcome is a worsening musculoskeletal problem that ends up being more costly to treat and more severe, thus landing it in the jurisdiction of OHIP services – MD visits, surgery, and hospitalizations.

Is this really the model of health care that Ontario intends to be effective and efficient at combating the leading causes of disability and cost to our public health system?

Don’t get me wrong, I don’t want to put the insurance companies out of business.  We need insurance plans because the public is not prepared to pay out-of-pocket for these services.  Ontarians rely on insurance plans that are provided by their employer in lieu of, or as a bonus to, their salary.  These plans, however, vary widely from person to person and contain a lot of small-print exceptions to access the funds.  Some common “loopholes” are:

• Covered for paramedical services, up to $750, but only after the first 5 visits.  This loophole stipulates that if you want to access your $750 insured dollars, you must first go to the therapist 5 times and pay out-of-pocket.  For many Ontarians, they only need to go 5 times.  And, thus, they never get to access their $750.
• Covered for custom orthotics, but must have a medical doctor’s prescription.  This loophole stipulates that if you want/need orthotics to improve your gait, reduce your foot, ankle, knee, hip, or back pain, you need your family doctor – who has no training, equipment, or time – to assess whether or not you actually need said orthotics.
• Covered for paramedical services, including chiropractic, massage, physiotherapy up to $500 per service, but must have a medical doctor’s prescription.  This loophole, as discussed in the body of this article, stipulates that access to your paramedical services requires a medical prescription.  Without a “diagnosis” from your MD, you cannot have a massage or get an adjustment.  You cannot “relax” with a massage, or get your back adjusted by a chiropractor without the approval of (and payment to) your doctor.

I think the Ministry of Health and Long-Term Care and the private, extended-health care insurance companies need to get on the same page to ensure Ontarians get fair access to their insured services.  If government wants to ensure Ontarians live well, they need to be part of the solution by making sure Ontarians get to the doctors and therapists they need to see in a timely fashion.  The current insurance company obstacles prevent Ontarians from accessing their insured services, increases unnecessary medical visits, and taxes the OHIP system.

Government has been working with insurance companies to ensure cost efficiency of the auto-insurance industry.  Government needs to start working with the insurance companies on improving access to insured paramedical services.  Ontarians’ access to my services and my colleagues’ services help them live better, longer, and happier.  Insurance companies are making a profit at our health expense.  Our public system is bleeding, and insurance companies are partly to blame.  Our health care model has been hijacked by insurance companies.  We need to fix this.

I began writing this blog, turn letter, as a concerned chiropractor, but I finished writing it as a mission statement by a concerned Ontarian.