The B.C. Chiropractic Association ("BCCA") submits that the people of British Columbia require the following:
The cost of auto insurance must be stabilized;
The insurance product must deliver real value in an efficient and economic manner; and
Individual freedom in choosing health care and legal remedies must be preserved.
Chiropractic doctors throughout the Province are involved daily in delivering chiropractic services to patients who are personally injured victims of motor-vehicle accidents. In the interaction between auto insurance and health care, the BCCA is primarily interested in protecting the interests of patients.
The payment for health care and rehabilitation services to injured victims of motor-vehicle accidents is a significant component of the insurance product. The vast majority of injuries are minor claims involving neck and back symptoms, commonly referred to as the "whiplash injury". Clearly, the early rehabilitation of these people must be one of the predominant goals of any insurance system. Chiropractic delivers significant value both to patients and to the insurance system in this regard.
When insurance and health care systems interact, it is incumbent on the insurance system to recognize that the liberty of the individual within Canadian society includes freedom of choice in the selection of health care. The Supreme Court of Canada has affirmed the general principle that every person has the right to make decisions concerning his or her body and mind free from state interference, free from state imposed psychological and emotional stress, and voluntarily, in the absence of duress, coercion and deceit. No legislative insurance scheme should infringe these individual rights and freedoms.
The tort system helps to preserve the individual's right to choose appropriate health care because it allows the individual to seek recovery of the expense incurred for the chosen health care by legal action. The BCCA opposes any initiative that infringes the individual's right to choose appropriate health care and to make recovery for that expense.
The BCCA has a long history of cooperation, understanding, and responsiveness, in its interaction with ICBC. The BCCA continues in a spirit of cooperation to contribute to the process of developing an appropriate auto insurance product for British Columbians.
The BCCA submits that the current insurance product is adequate and the system providing the product is capable of functioning efficently and economically. The problem is not with the system or the product but rather with its management.
The BCCA recognizes that significant costs are driven by litigation and that there may well be too much litigation in our current system. However, the BCCA does not "blame the lawyers", nor does the BCCA attribute any particular litigious characteristics to the people of British Columbia.
Beyond question, the consensus of the members of the BCCA is that ICBC's attitudes toward claims, and in particular, the prevailing mentality of most adjusters at the claims management level, drives most of the costs in relation to litigation. Too often the people of British Columbia are confronted by niggling, meanspirited adjusters who are not willing to treat people fairly or to be reasonable in relation to the valuation of claims.
Interestingly, this attitude is often self-defeating because it manifests itself at the same time as ICBC adjusters are attempting to maintain "control". ICBC achieves "control" when the injured motorist does not consult a lawyer for assistance in the resolution of their claim: see Doan v. ICBC, BCSC, 1988. Any management system that is designed to keep people from knowing their legal rights must be inherently suspect. Certainly, ICBC's "trust account" with most British Columbians is far too low for it to have any success in this respect.
Many of our insurance system's problems could be solved simply by a significant attitude change at the claims management level. A consistent attitude of respect for the claimants, a refusal to marginalize the individual and their injuries, and recognition of and respect for the treating practitioner's clinical judgment would help to establish a trust within the system that in the long run would significantly reduce the amount of litigation and drive major cost-savings.
To the extent that any reforms to the auto insurance system are contemplated, it is very important that the system be modified to avoid the continuation of these problems. There will be no public acceptance of any program if the existing policies and actions of ICBC adjusters are allowed to continue.
The chiropractic profession plays a key role in the auto insurance system in British Columbia. Relying on and encouraging the use of chiropractic services in the treatment of injured motorists is completely compatible with major goals of the auto insurance system. However, there is a real danger that the value of chiropractic will not be recognized and, indeed, may be lost unless there is also a consistent commitment to change the current attitudes of the insurance system toward the injured motorist and chiropractic doctors.
The case for extensive chiropractic involvement in the rehabilitation of whiplash victims is compelling. The medical literature clearly recognizes the chiropractor's role in this context. The cost savings to the system are dramatic. It is imperative that proposals for the reform of the insurance system recognize and encourage the development of the role of chiropractic in the delivery of health care to the personally injured victims of motor-vehicle accidents.
In order to accomplish this objective, it is necessary to develop proposals and to incorporate measures into the system which will ensure that there is an attitude shift towards injured motorists and chiropractic. The short-sighted institutional bias that currently exists, must be terminated.
The institutional bias within the current systems manifests itself in two ways.
Firstly, the attitudes of too many ICBC personnel have been tainted by the traditional policy of the medical profession toward the chiropractic. These attitudes have been allowed to foster and develop without any rational evaluation. Similarly, cost benefit analysis recognizes the effectiveness of the chiropractic. Notwithstanding these factors, frequently the BCCA has to contend with ICBC attempts to discredit chiropractic. Secondly, the institutional bias within ICBC is manifested by a systemic failure to effectively implement ICBC's own policy on rehabilitation and the role of chiropractic. Within the context of its obligation to deliver rehabilitation services, pursuant to Part 7 of the Regulations, ICBC has developed written policies in consultation with the BCCA which detail how ICBC will interact with the chiropractic profession. If these policies were followed and implemented, many of the concerns expressed by chiropractors and injured motorists would never have occurred. However, at the practical level of day-to-day implementation, chiropractors and their patients frequently experience attitudes and conduct contrary to ICBC's policy. As a result, chiropractors and injured motorists question ICBC's integrity and its intentions.
The principal tactics employed by ICBC involve termination of payment for treatment or the diversion of patients. These tactics have evolved over time. Basically, they have appeared in the following chronological order:
Terminating payment of Part 7 (no fault) rehabilitation benefits upon receipt of an opinion from a medical doctor that continuing chiropractic care was inappropriate, not indicated, or not helping.
Attempting to divert patients from their existing chiropractor to others who may charge less on the basis that patients had a duty to mitigate their damages by seeking out the least expensive care.
Attempting to divert patients from chiropractic doctor's care to therapists as a part of ICBC's Soft Tissue Injury Program.
Automatically terminating payment for chiropractic treatment benefits under Part 7 after a predetermined time or number of treatments without appropriate clinical information. Payment will not be resumed unless ICBC receives certification (usually from a medical doctor) that further treatment is necessary.
Of course, when the continuation of chiropractic treatment is dependent upon a favourable opinion from a medical doctor, the chiropractor-patient relationship is seriously jeopardized by the historic medical bias against chiropractic. ICBC understands this bias. ICBC probably encourages this bias even though there is an abundance of convincing evidence that chiropractic has better outcomes and is more cost effective than medicine in treating the whiplash injury and mechanical spinal conditions.
The current attitudes of ICBC are also short-sighted in the sense that they do not serve the long-term best interest of ICBC, the auto insurance system in British Columbia, or the people of British Columbia. The efficient economic management of a significant volume of claims necessitates the close involvement of chiropractors and the delivery of chiropractic services. Chiropractic is a significant cost-saver, and not a significant cost-driver.
Even more importantly, if the government of British Columbia and ICBC wants to accomplish public acceptance of the auto insurance program, either as it currently exists, or in any reformed mode, it must recognize that it cannot marginalize the individual. However, this is a constant theme in ICBC's conduct, and one which must be seriously addressed in any reform.
There is clear evidence that chiropractic contributes significantly to substantial economic savings to the consumer and the province in the delivery of health care.
The findings of the recent Canadian study on "The Effectiveness and Cost Effectiveness of Chiropractic Management of Low Back Pain" are particularly illuminating. After a review of approximately 400 studies and publications in search of evidence of "effectiveness", "cost-effectiveness", and "patient satisfaction" with regard to "Chiropractic Management of Low Back Pain", the authors find as follows with respect to economic cost:
"There is an overwhelming body of evidence indicating that chiropractic management of low back pain is more cost effective than medical management. We reviewed numerous studies that range from very persuasive to convincing in support of this conclusion. The lack of any convincing argument or evidence to the contrary must be noted and is significant to us in forming our conclusions and recommendations. The evidence includes studies showing lower chiropractic costs for the same diagnosis and episodic need for care.
There would be highly significant savings if more management of LBP was transferred from physicians to chiropractors. Evidence from Canada and other countries suggests potential savings of many hundreds of millions annually. The literature clearly and consistently shows that the major savings from chiropractic management come from fewer and lower costs of auxiliary services, much fewer hospitalizations, and highly significant reduction in chronic problems, as well as in levels and duration of disability. Workers compensation studies report that injured workers with the same specific diagnosis of LBP returned to work much sooner when treated by chiropractors than by physicians. This leads to very significant reductions in direct and indirect costs".
In summary, cost containment is one of the current and future primary needs, therefore serious consideration must be given to the proper utilization of the chiropractic profession as inherent to more efficient patient and corporate management.
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This paper was submitted to the B.C. Government ICBC Review Committee January 27, 1997.