Chiropractic 2025 Divergent Futures. Research funded by:

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Jayson Bertram Barrett
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1 Chiropractic 2025 Divergent Futures Research funded by:

2 Introduction Thanks to NCMIC for funding IAF s 1998: The Future of Chiropractic 2005: The Future of Chiropractic Revisited 2013: Chiropractic

3 Background on the Institute for Alternative Futures Mission: Help communities and organizations more wisely choose and create the futures they prefer Wide range of clients including WHO and PAHO, DHHS, CDC, NIH, DoD, non-profits, many health professions, and Fortune 500 companies Focus on scenarios and creating preferred futures This is the third round of Futuring for Chiropractic Field 3

4 Constructing the Chiropractic 2025 Scenarios Reviewed prior IAF Health & Chiropractic Scenarios Developed forecasts for key drivers of chiropractic Conducted 66 Interviews: broad-, middle-, and focused-scope chiropractic leaders, researchers, academics, health system decision-makers Drafted scenarios & got feedback 4

5 Key Drivers in Health Care Movement of health care to integrated systems, ACOs, PCMH Move to value in health care Cost pressures Transparency of outcomes and value EHRs, big data, new knowledge Self-care tools, including digital health coaches 5

6 Key Drivers within Chiropractic Evidence of DCs efficacy and costeffectiveness DC s integration, particularly as spine health leader on PCMH teams Coverage and payment levels for DCs Internal DC splits focused-scope, middlescope, broad-scope Competition with and for other health professions DCs Income 6

7 IAF s Aspirational Futures Approach

8 Chiropractic 2025 Offers four Scenarios for 2025 One expectable future One challenging yet plausible future Two visionary yet plausible futures Appendix 2: Background and Key Forces Shaping Chiropractic summarizes research and background info that shaped the scenarios Report also offers insights and recommendations for the profession. 8

9 Using the Chiropractic 2025 Scenarios Consider the likelihood & preferability of each scenario Develop your own scenarios that are more likely or more preferable Test your strategies against these scenarios (personal & organizational strategies) Consider IAF s recommendations and develop/refine your own recommendations 9

10 Chiropractic 2025 Scenarios 1. Marginal Gains, Marginalized Field expectable future 2. Hard Times & Civil War challenging but plausible future 3. Integration & Spine Health Leadership visionary yet plausible future 4. Vitalism & Value visionary yet plausible future 10

11 Consider Likelihood & Preferability of Chiropractic 2025 Scenarios Scenario 1: Marginal Gains, Marginalized Field Likelihood (0% to 100% likely) Preferability (0 to 100; 100 = most preferable)?? Scenario 2: Hard Times, Civil War?? Scenario 3: Integration & Spine Health Leadership?? Scenario 4: Vitalism & Value?? 11

12 Scenario 1 Marginal Gains, Marginalized Field Health care reform partially successful; access to primary care grows; 40% in integrated care Majority of DCs come together as spinal health care providers Many (10,000) DCs successfully join PCMH teams 12

13 Scenario 1: Marginal Gains, Marginalized Field By 2020, all DC colleges have students training in integrated care settings DCs and colleges use new research approaches, patient registries to show value proposition Confirm chiropractic as treatment for LBP, neck pain, some headaches, and whiplash-associated disorders -- DC care shown to be far more cost-effective than conventional medical management 13

14 Scenario 1: Marginal Gains, Marginalized Field Greater acceptance of DCs in some settings But majority continue to be independent, challenged by low-cost providers; network constraints Cuts in fees by Medicare, Medicaid and private payors; DCs income varies widely DCs struggle to overturn insurance decisions that limit fees and # of visits 14

15 Scenario 1: Marginal Gains, Marginalized Field 2015, first state expands DC practice rights; Enrollments in chiropractic colleges fall to 9,000 by 2016 Colleges reduce costs slightly by developing a common core curriculum, some shared online courses Enrollments stabilize at 8,000 by

16 Scenario 1: Marginal Gains, Marginalized Field By 2025: 7% of U.S. population using chiropractic 63,000 practicing DCs 16% in integrated health systems and settings 14 chiropractic colleges/programs 8,000 total students enrolled Broad-scope DCs with Rx rights in 5 states 16

17 Scenario 2 Hard Times & Civil War 2015, another deep recession; by 2021 economy recovers but DC demand never fully recovers PPACA partially implemented, PCMH becomes the norm DCs position as spine and musculoskeletal health providers to join ACOs/PCMHs, 5,700 join PCMH teams by 2025 but uneven quality of DCs enables DPTs to win out 17

18 Scenario 2: Hard Times & Civil War Remarkable advances in science, new treatments that could decisively address many illnesses, but too expensive for most MyMobilizor - a threat to DCs or helpful advertisement? My study is better than your study on DCs ; Most public attention going to civil war -- decades old feud intensifies in 2010s; Plus public misconceptions / targeted misinformation against DCs from competing providers 18

19 Scenario 2: Hard Times & Civil War DCs remain largely solo & small group practices $20-40 visits dictated by insurers & the competition Fighting against growing low-quality/lowcost chiropractic industry Most DCs belong to networks that keep number of visits and fees low; Out of network DCs find their patients leaving for PCMH teams that include PTs 19

20 Scenario 2: Hard Times & Civil War Small segment of patients highly satisfied with and supports DCs Some DCs have successful suburban practices, but these are rarer and harder to set up More DC opportunities in DoD, VHA, PCMHs, ACOs, but not for new grads Young DCs opt for other career paths (e.g., NP, PA, PT) Chiropractic college enrollments drop 20

21 Scenario 2: Hard Times & Civil War By 2025: 4-5% of U.S. population using chiropractic 45,000 practicing DCs (down from 55,000 in 2012) - 13% in integrated health systems and settings 8 chiropractic colleges/programs 5,000 total students enrolled Broad-scope DCs win Rx rights in 3 states 21

22 Scenario 3 Integration & Spine Health Leadership PPACA is effective, 85% of care through integrated capitated ACOs and PCMH teams Payers reward for prevention and personalization, and achieving optimal health outcomes while reducing costs Zettabytes of data + "big data" applications Patients become assertive in their care and choosing providers, aided by their digital health coaches & social networks 22

23 Scenario 3: Integration & Spine Health Leadership Research confirms value of DC care & defines manipulation s role in affecting gene expression via chaperone molecules Rising demand for chiropractors & chiropractic care Major agreement on DC as spinal health leader; success in joining PCMH teams DCs and DPTs screen and triage NMS patients (21,000 DCs; 42,000 DPTs on PCMH Teams in 2025) 23

24 Scenario 3: Integration & Spine Health Leadership 2/3s of DCs largely self-employed in solo/group practices, thrive due to growing public acceptance and cultural authority, collaborate more effectively with MDs and other providers Independent & integrated DCs shape population health; encouraging movement, activity; DCs get recognized for their work 24

25 Scenario 3: Integration & Spine Health Leadership By 2025: 9% of U.S. population using chiropractic 68,000 practicing DCs 31% in integrated health systems and settings 17 chiropractic colleges/programs 12,000 total students enrolled Broad-scope DCs win Rx rights in 10 states 25

26 Scenario 4 Vitalism & Value Contemporary vitalism research pursued by DCs and other healing traditions Major health care changes: By % of population have full, capitated HC coverage; 40% rely on self-care and high deductible catastrophic plans. Both seek value and buy on that basis Local health marketplaces, social networks & digital health coaches reinforce value seeking 26

27 Scenario 4: Vitalism & Value Focused-scope community matures, evolves, has generational changes & new leaders Move their science & practice forward They don t agree with broad scope efforts, but halt their vehement opposition in favor of advancing their science of why for manipulation. Rise of research in science of healing and selfhealing; DCs with other healing traditions 27

28 Scenario 4: Vitalism & Value Chiropractic practice research advances - DCs adopt EHR systems, take part in registry development and whole practice research Other major findings reinforce earlier studies on DC care (therapeutic efficacy for LBP, neck pain and spine issues) Research identifies other conditions where DC care is effective; pathways, protocols and digital health coach advice incorporate this research 28

29 Scenario 4: Vitalism & Value Chiropractic thrives - Respected for its value in supporting body s natural healing capacities & cost effectiveness DCs part of most ACOs, integrated care (14,000 DCs) & DCs serve as PCPs, in rural and underserved communities DCs build successful practices for pediatrics; sports injuries & performance, obesity, nutrition and others beyond spine health. DCs join community health movement; participate in or lead initiatives to improve social determinants of health. 29

30 Scenario 4: Vitalism & Value But chiropractic limited by # of visits and flat or declining fees for independent DCs dictated by: Medicaid, Medicare, and insurance companies, Price & outcome transparency consumers know most cost effective pathways & best providers 30

31 By 2025: 8% of U.S. population using chiropractic 66,000 practicing DCs 21% in integrated health systems and settings 17 chiropractic colleges/programs 12,000 total students enrolled Scenario 4: Vitalism & Value Broad-scope DCs win Rx rights in 10 states 31

32 % of pop. using DC services Comparing the Scenarios Scenario 1 Scenario 2 Scenario 3 Scenario 4 7% 4% 9% 8% Practicing DCs 63,000 45,000 68,000 66,000 DCs in integrated health systems 16% 10,000 DCs 13% 5,700 DCs 31% 21,000 DCs 21% 14,000 DCs Broad-scope success DC colleges or programs Total enrollment (# DC students) 5 States 1,500 DCs 3 States 750 DCs 10 States 3,100 DCs States 3,100 DCs 8,000 5,000 12,000 12,000 32

33 Consider Likelihood & Preferability of Chiropractic 2025 Scenarios Scenario 1: Marginal Gains, Marginalized Field Scenario 2: Hard Times, Civil War Scenario 3: Integration & Spine Health Leadership Scenario 4: Vitalism & Value Likelihood (0% to 100% likely) Preferability (0 to 100; 100 = most preferable)???????? 33

34 IAF Recommendations Integrate chiropractic into health care systems. ACOs, PCMHs, VHA, DoD; Increase clinical training in chiropractic education; Especially train together with other types of providers Accelerate research. On practices & outcomes, self-healing & vitalism; Promote & facilitate data collection; Publish in peerreviewed journals; Anticipate EHR changes Develop geriatric chiropractic. Identify and promote roles in public health and population health for individual chiropractors and chiropractic organizations to assume. 34

35 IAF Recommendations Continue to strive for high standards of practice. Support local reporting of outcomes Promote best practices & guidelines Stop false advertising Better police the profession Anticipate and engage consumer-directed care plans and tools. Engage with the development of self-care tools, particularly their decision-making rules Avoid misleading arguments 35

36 IAF Recommendations To Focused-Scope Chiropractors: Pursue more scientific research on vitalism; link with other healing traditions & with quantum biology, epigenetics. Develop outcome measures for focused-scope practices and providers. To Broad-Scope Chiropractors: Pursue expanded practice rights, but develop a conservative pharmacology practice that supports selfhealing. Develop and maintain outcomes research on all broad scope practices. 36

37 Thank You!! Chiropractic 2025 Report available at 37

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