If you ask ten people, you’ll likely get ten different answers. It’s easy to be confused. Some doctors (of chiropractic) quote new patients 12 visits, 36 visits, 80 visits, or maybe they recommend once a week, twice a week, or 3 times a week. Some insurance companies “cover” (contribute toward) 6 visits, 15 visits, 20 visits. Medicare says “until the patient reaches maximum improvement”, whatever that is. Patients figure they’ll go when they need it, i.e. only when they’re in pain. Other patients swear by a once-a-week or once-a-month maintenance.
They’re all wrong.
Why? Because these are generalities that do not realize that each case is individual. They also allow other motives to influence their decision. Money influences all the players, some more than most. The most obvious scapegoat is the DC. It’s easy to assume that when the DC claims the patient will need to be adjusted 3 times per week, or presents that patient with a 36-visit treatment plan, that it is all about money. For some doctors, that may be true; for others, not so much. Of course the doctors need to make money. That’s true for every member of every profession. But most doctors really have their patients’ best interests at heart; they’ve been through school, which includes a year-long (or longer) internship, and even when they’re fresh out of school, they still have experience with real live cases.
Money plays an even bigger part of the decisions of the other players. These are not nearly as visible, nor are they called into question nearly as often. The patient wants to save money; they’ll spend it if they realize it is an investment in the relief of their current condition and important for their future health, but if chiropractic care remains only a holistic substitute for an aspirin and they are never taught differently, they continue to think of chiropractic as the occasional maintenance of the absence (or minimization) of pain or discomfort. Some patients tend to live and die by what their insurance will “cover”. (I despise that word because although it stubbornly remains in the vernacular, it is a grave misconception, as insurance companies do not “cover” very much anymore; rather, they contribute toward some of the costs of care, and they are contributing much less toward any holistic/preventive care than ever before. End rant.)
Let’s talk about insurance companies and why people should not use their insurance policies to dictate their decisions regarding chiropractic. Insurance companies are in it for themselves. Like any business, they continue to exist because they turn a profit. This means they take in more than they give out. Like any publicly-traded (i.e. on the stock market) business, they have a board of shareholders to satisfy. These shareholders are not interested in you, the public, the greater good, the employees, or even the company. They are interested in one thing only: profit. And if they can’t make a profit with that company, they invest their money somewhere else. Thus, laws regarding “fiduciary responsibility” were enacted, which actually MANDATES that the company put the needs of the shareholders to make a profit above ALL others, including the patient. Including you.
What’s more is, not only does the company have to turn a profit year after year, but this profit must INCREASE each year. Last year’s billion dollars in profit just isn’t good enough this year. This year, it must be $1.1 or $1.2 billion. This means that they either have to raise your premiums (which irks its customers, but is still frequently done) or co-pays/deductibles, or, more insidiously, it must cut back on its “coverage”. These coverage cutbacks are often done behind the scenes, in the form of making it harder for doctors to file your insurance claims for you, or reimbursing them less this year for the same services they gave you. Think of it as an anti-raise. Think of your own situation: would you continue to work this year just as hard as you did last year if you knew your employer would be cutting your salary this year? Probably not. And even if you did, your morale, motivation, and perception of that employer would be quite low. You might even consider going free-lance and working with your customers yourself, with them paying you directly, instead of taking lower wages from your company for the same work.
So when the insurance company says it’ll only cover 6 visits or 20 visits per year, they are not setting this policy with you in mind. It’s not about your pain relief or your health or wellness. It’s about having hired statisticians to determine how many visits they can give in to contributing toward, without pissing off the shareholders by dipping into profits.
So far, what the insurance companies do is not necessarily a crime. The problem comes in when patients begin to use their insurance policies to make their healthcare decisions, only submitting to what the ins co will contribute toward. If insurance companies are constantly whittling away at their coverage, this strategy of using the policy to determine their healthcare does not bode well.
Now that I’m done giving the insurance companies a well-deserved lashing, it’s time to address the behavior of some (NOT all) of my brethren. I went through the same schooling and the same education as they did. I take my continuing education each year, just like they do. And I’m here to tell you that any doctor who, on the first or second visit with you, says you’re going to need 80 visits (yes, some doctors are telling their patients this) are full of crap. The vast majority of patients don’t need an 80-visit treatment plan and even those who end up needing 80 visits (or maybe more), it’s nearly impossible to be able to predict this on the first visit. Any good doctor adjusts their treatment plan as they go along. Original diagnoses (i.e. what’s wrong) and prognoses (is it serious or does it look good; is the patient’s body responding well or not) will change over time, if the doctor is paying attention, if your case is appropriate for chiropractic care, and if his/her treatment is effective. So doctors, if you are sitting down with the patient on the 2nd visit and immediately telling them they’ll need 80 visits, stop. I’m 99.98% sure that you have NO IDEA that they’ll need 80 visits from where you sit on that second day. You have no clue how the patient will progress until your treatment plan gets under way. Patients, understand that you MAY end up seeing the DC for 80 visits, but that’s only if your case is serious or initially unresponsive, and if it is, that doesn’t mean chiropractic is ineffective or a sham–you might just have a difficult case. Be patient and give it some time to work.
Another issue is, the goals of the doctor and patient are often mutually opposed, money aside. The patient wants to be out of pain, and doesn’t yet understand the need for any care beyond pain relief. The doctor wants the patient to be not only free of pain, but actually WELL. The doctor knows that if the patient discontinues care too early, the pain might be gone, but the patient is vulnerable to re-injury.
So what’s the real answer?
The short answer is, it varies based upon each individual case, but to say that without following up with an explanation is a cop-out. So I’ll explain. There are indeed three stages to healing, and pain relief is only the first. This is why it’s so unfortunate if the patient only comes in when s/he is in pain; they’re missing the other two stages of healing.
These stages are:
- Relief – of pain or symptoms
- Rehab – the stabilization of the joint and surrounding soft tissues (muscles, ligaments, fascia, etc)
- Maintenance – now you feel GOOD. Wouldn’t you like to stay that way?
Now for some numbers…
For the majority of cases (though not all), here’s how it breaks down:
- Relief – about 6 to 12 visits to be free of pain or other symptoms.
- Rehab – about half as many visits as the relief phase to stabilize the joint. So if you needed 6 visits to achieve pain relief, you’ll need about 3 to stabilize the joint; if you needed 12 visits to reduce your pain, you’ll need about 6 visits to reach stability.
- Maintenance – about 2 to 12 times per year (give or take), depending on your wellness goals, your priorities, your lifestyle (stress level, posture, work environment, physical activity, diet), and your genetic tendencies.
This rule of thumb works pretty well for about 80-90% of the cases. Occasionally, someone will be much better after fewer visits. On the other end of the spectrum, we had a patient who was so locked up (and he was a bigger guy to boot), with problems so chronic that it took us about 3-4 months (3 times a week) just to get his joints to move. (We had ruled out everything else and determined it was indeed a case for chiropractic care, albeit quite a stubborn one.) Turns out it was well worth the wait, time, effort, and expense, though; he feels better than ever. And although it seemed like it, he didn’t need to come in 2-3 times a week forever; he’s now on maintenance himself, and doing very well.
So while the above formula is good and dependable, it’s not always an exact science. There are exceptions to the rule. But, the formula is a good starting point, and that’s how we run our practice.
The last point is communication. Doctors, you may feel you’ve educated your patients (and it is indeed education and not “brainwashing”; we’re not used to much education from conventional medical doctors because they can’t give us very much info when they spend literally one minute with us), but the fact is, the patients may nod in understanding or agreement, but that doesn’t mean that what you’ve said has sunk in. Put it in writing. Give them a written treatment plan, complete with stages (Relief, Stabilization, and Maintenance), the expected duration of each, the goals for each, and a re-exam when moving onto the next stage to gauge progress. Patients, if your doctor doesn’t give you this information, ASK THEM. Even the best of docs forget to tell some patients some things. And doctors, give your patients the choice – do they want ONLY relief care (do explain the risks of stopping care at the end of the Relief phase, but don’t pressure them), or would they like to see this through to the end of the Stabilization stage or beyond?
As for frequency of care… Patients, understand that if your doctor (of chiropractic) is going to get a good handle on a long-standing problem that started years ago, you’re going to need to see him/her more often at first. That doctor is going to spend 3 to 30 minutes with you two or three times per week. You are living your life, with all of its overworking, stress, poor posture, processed diet, etc, for many more hours per week than the doctor can spend treating you. Yes, this means things will be more intense at first, in terms of time and effort spent, home exercises, and financial investment. This should not go on forever, though, and if the doctor sees you three times a week for more than a month with no mention of an end in sight or progress made, you need to speak up and ask. Doctors, you need to speak up and explain.
And THAT is how often and how long you should see a DC.