In this second episode of a two-part series on Extended Health Care (EHC), Dr. Moez Rajwani returns to explore the rise of virtual chiropractic care or telehealth and how insurers, as well as patients, are responding. For this segment, he's joined by Dr. Amy Brown who shares her experience with virtual care and how she's using it in her Cambridge-based practice. Dr. Rajwani also highlights the perils of incentives and why you'll want to avoid them. For new chiropractic grads and early career practitioners, he offers specific EHC tips. He also revisits OCA's Extended Health Care Guide and as an example, outlines how you can use one of its unique templates. Finally, Dr. Rajwani discusses how the pandemic is affecting EHC, what its future may look like and how this may impact your practice. (22:36 minutes)
In this second episode of a two-part series on Extended Health Care (EHC), Dr. Moez Rajwani returns to explore the rise of virtual chiropractic care or telehealth and how insurers, as well as patients, are responding. For this segment, he's joined by Dr. Amy Brown who shares her experience with virtual care and how she's using it in her Cambridge-based practice.
Dr. Rajwani also highlights the perils of incentives and why you'll want to avoid them. For new chiropractic grads and early career practitioners, he offers specific EHC tips. He also revisits OCA's Extended Health Care Guide and as an example, outlines how you can use one of its unique templates. Finally, Dr. Rajwani discusses how the pandemic is affecting EHC, what its future may look like and how this may impact your practice.
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About Dr. Moez Rajwani:
Dr. Rajwani is Vice President of Clinical Services at North York Rehab Clinic (NYRC), where he manages and works with a multidisciplinary team of medical consultants overseeing complex medical evaluations. He also practises and manages orthopedic rehabilitation centres in the Greater Toronto Area (GTA).
He is also Executive Director of the Future Ready Initiative, which aims to increase the community’s preparedness, as well as its resilience in the face of disruptive changes in the area of the future of work.
An active volunteer, Dr. Rajwani serves as the Co-Chair of the Coalition of Health Professional Associations in Auto Insurance Services in Ontario and is a board member at Michael Garron Hospital. He is also on the Board of Directors for World Spine Care (WSC) Canada.
Dr. Rajwani is a recipient of the Queen’s Golden Jubilee Volunteer Award, the OCA Volunteer Service Award, and an award from the Ministry of Citizenship for 25 years of service to the community.
He graduated as a Doctor of Chiropractic in 1994 and has post-graduate certifications in Occupational Health and Sport Sciences.
About Dr. Amy Brown
Dr. Brown divides her time between Coronation Chiropractic, Massage, & Physiotherapy, her private community-based practice, and a practice onsite at Langs Community Health Centre.
She is also an Advanced Practice Clinician with Ontario’s Low Back Rapid Access Clinic (RAC) program and a treating chiropractor with Health2Work. The Heath2Work program provides chiropractic assessment and treatment for clients of the Ontario Works program who have MSK conditions.
In addition, she works as a consultant to the Ontario Chiropractic Association, contributing to health policy-related work, outreach and advocacy.
Dr. Brown graduated from the Canadian Memorial Chiropractic College (CMCC) in 2001.
Watch for Chiropractic Care for Patients with Arthritis - coming on November 15, 2021
Episode 4: EHC for Virtual Care, a Post-Pandemic World and More
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Introduction:
Welcome to ON Spinal Chat, where we explore what O-C-A is doing or supporting to help enhance your patient care, grow your practice or advance the chiropractic profession.
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Interview:
I'm Leslie, and today I'm speaking with Dr. Moez Rajwani in part two of a two-part series on how extended health care is evolving and what that means to chiropractors like you. Dr. Moez Rajwani practices and manages orthopedic rehabilitation centers in the greater Toronto area. He also chairs O-C-A's extended health care advisory council along with filling multiple other volunteer roles for several organizations.
Now in this episode, we'll explore virtual chiropractic care or telehealth and how insurers, as well as patients, are responding to it. For this segment, another O-C-A member, Dr. Amy Brown, will join us to share her experience with virtual care and how she's using it in her Cambridge-based practice. We'll also chat about E-H-C tips for new chiropractic grads and revisit O-C-A's extended health care guide, and one of its unique templates. And Dr. Rajwani will highlight the perils of incentives and why you'll want to avoid them. He'll also discuss how the pandemic is affecting E-H-C and what its future might look like and how this may impact your practice.
Leslie:
Thank you, Dr. Rajwani, for returning to part two of our series on extended health care. In our last episode, you mentioned the word fraud and how insurers continue to worry about it. Now, a related word is incentives. What about incentives? Should you or any other chiropractor offer incentives to patients?
Dr. Moez Rajwani:
Leslie, let's start by explaining what an incentive is. The best example I can give you is the orthopedic shoe. I'm giving free shoes if somebody gets an orthotic and that's not looked upon favorably at all by insurance companies, because although the argument may be well, I'm giving it free. It's not costing the insurance company anything. What it's doing is enticing patients to go for orthotics, and that concerns them. This type of incentive in the insurance sector is an absolute no-no because in their mind, this creates an incentive for insured patients to actually take a product or a good or a service that they may not require.
There is this potential that people are now taking, in this example an orthotic, just because they're getting a free shoe. And so when we look at many of our audits that chiropractors are getting, I would say a majority of them are around incentives. And the bottom line is in those cases where chiropractors were giving incentives, it led to de-listing. So the answer is, do not give incentives to your patients when there's a third-party payer involved.
Leslie:
Now, are there any exceptions to this?
Dr. Moez Rajwani:
Not that I'm aware of. Again, always look at it from the lens of the insurer. To them, the incentive means abuse. It means the potential of utilizing funding that's available that may not be required or medically necessary. And so from the insurance lens, incentives are an absolute no-no.
Leslie:
Now with the pandemic, we've seen a rise in virtual care or telehealth. Are you using virtual chiropractic care in your practice?
Dr. Moez Rajwani:
I am. I wish I could use it more, in the sense that more patients would be open to it, but absolutely I am using virtual care and I'm also doing what I would call hybrid care. And what I mean by hybrid care is I'll do some of the work virtually or telehealth. And so that the time that the patient spends in the office is minimal.
Leslie:
Okay, thank you. Given the rise of virtual care, I'm going to bring Dr. Amy Brown, another O-C-A member, into our discussion to share her experiences with it. Dr. Brown divides her time between Coronation Chiropractic Massage and Physiotherapy, her private practice in Cambridge, Ontario, and a practice onsite at Langs Community Health Centre. My first question for both of you is, how are you using virtual care?
Dr. Moez Rajwani:
I'm using virtual care around exercise and ensuring that they're performing the appropriate activation and active care that's required as they're going through their injury. So that's one area. Going online, giving them some tools to do series of exercises and then monitor them while I'm watching with them online, as well as demonstrating to them, how to do those exercises. The second type of virtual care I'm doing is education. I'm doing some education around hurt versus harm, posture, things like that. And then that's going into the workspace. So we're getting more patients that are saying, can you take a look at my workspace? I'm working from home for the first time, is my laptop in the right spot? Is my screens in the right spot? Should I buy a high-low table? What should I do? So there's this whole area of education moving into a little bit of ergonomics.
I have been doing a little bit of assessment work online and you know, there's more and more protocols that have come out on how can you do things? And so you'd say, how can a chiropractor do an assessment online? You have to palpate a patient. And absolutely I can't palpate their spine online, but I can do ranges of motion with, I can check the range of motion of their shoulder, their neck. I can ask them to do certain things. I can ask them to touch themselves on their hand and see if they feel the sensation on the hand.
So there are more and more protocols that are coming out in the virtual space. Neurologists, orthopedic surgeons, physiatrists, rheumatologists, and chiropractors are all learning as we go through this evolution that there's actually more than we thought we could do virtually, but we still can't do an adjustment virtually and we can't palpate them virtually. And that's why I end up doing a little bit of a hybrid where I might take the history online, get their information so that when they come in the patient time in the office is minimal and all the data points, all the medical history, what medications they're taking, all of that's been done before they come into the office.
Leslie:
What about you, Dr. Brown?
Dr. Amy Brown:
It sort of depends right now on what's going on in the community. Initially, we were using it just as a way to check in on our patients and see how they were doing and make sure that when things were shut down, that they were okay and that we were answering any questions that they might have. Over time, that's evolved. We definitely still use it as a check-in mechanism to make sure that people are doing okay with home management strategies. They have questions about exercises, we just need to touch base and that is the perfect way to do it.
For some of our more cautious patients, we also use it to minimize their time in clinic. Obviously as a chiropractor, some of the things that I do need to be hands-on. When I'm doing an assessment and definitely when I'm doing a treatment, there are portions that must be done with my hands, but pieces of it, like the history, don't need to happen in clinic. We're used to doing it that way, but if we're trying to minimize time in the office, we can sometimes do the history beforehand and then use that time in the office only for the things that need to be done in person.
Leslie:
What are you finding the biggest challenges when you are using it for history or other treatments?
Dr. Amy Brown:
I think one of the challenges is developing rapport with someone. It's definitely easier with someone that you already know versus someone that you're meeting for the first time. That can be challenging, but it's a heck of a lot easier than technology access. So for some of our patients, I might have to make do with a phone call, and that's definitely not as good as something with video, because we don't get that face-to-face connection. I can't always see inflection and tone in the same way as you do when you're looking at someone's face, so that's a challenge as well, is whether people have easy access and if they're comfortable with it.
Leslie:
Any tips that you can offer are other members who perhaps haven't gone this route yet?
Dr. Amy Brown:
First of all, is use the things on your own and figure out the quirks before you're doing it with a patient. My first interactions, I got someone in my house to log on to the platform first and said, okay, so we're going to do this. You're going to be downstairs and I'm going to check and see. And then the next one, I set something up with a patient that I knew well, so there was a comfort level. Also, I think that we sometimes underestimate our patients. Some of my seniors have actually been some of the easiest adopters. Where I thought that they might have been a little reluctant, they've actually been really enthusiastic. So don't tell your patient short, don't assume that people might not be interested or comfortable with it, because you might be surprised.
Leslie:
How have your patients responded to virtual care?
Dr. Moez Rajwani:
Initially reluctant sometimes, because when they think of chiropractors, they think of manual care, but after they experience it, they're actually pleasantly surprised and they realize that you know what? The chiropractors like my coach, they're like the person that's reassuring me, engaging me. And we're starting to see more engagement. Now, of course, you see it more in populations that are comfortable around the computer. You have somebody that spends most of their day on Zoom calls and Microsoft Teams, getting online with their chiropractor is just part of their day, and they're willing to do it.
Dr. Amy Brown:
Initially, they were a little bit apprehensive and fairly so. Most of our interactions have involved hands-on components. And so when you talk about doing a chiropractic visit virtually, I think you're met by a little bit of disbelief and a little hesitation, but I think people have been largely pleasantly surprised by what we're able to do. And the fact that sometimes we just need to keep them on track doing what they're doing at home. And if we're able to do that, then their capacity to adapt and get through a time that's maybe less than ideal is much better.
Leslie:
Now, have any of them requested it from you?
Dr. Amy Brown:
Now there are people who after hearing that other practitioners are doing this, do say, "So, are you guys able to do that? Can we?" Where again, 18 months ago that would not have been a request that we would've gotten. And for some of our assessments, again, depending on the timing, we offer it as an option and some people often say no, thank you. But other people are pleasantly surprised and say, "Actually, you know what, I'd prefer that because I'm not entirely comfortable." And then we'll make a decision about whether it's worth coming in for an in-person visit or not.
Leslie:
When you're talking comfort, you're thinking in terms of our current scenario with the pandemic and safety issues?
Dr. Amy Brown:
Absolutely right now, people are making decisions based on their personal risk level pandemic-wise. And that's changed over time. As things calm down between waves, people get a little bit more comfortable going out, and then maybe they hear something and get a little more cautious. And I like that we're able to flex with that and not have to be so rigid that you need to be comfortable coming to the office to interact with us.
Leslie:
Any tips in terms of what kind of technology you're using or how you approach that?
Dr. Amy Brown:
I think that the good thing right now is that there are a number of options and a number of different ways that we can use these things. And so it's about finding what's comfortable for you and what works well for you. It's not about strictly using whatever you happen to find first, and being able to talk your patients through that as well. You don't have to be on a desktop computer. A lot of my seniors are really savvy with their iPads. And so being ready to help talk them through some of the ins and outs, probably as practitioners we'd be well served to try things on different devices so that when our patients do struggle, we can pick up and say, "Oh, you're on this, and this is how you might deal with that." But finding the one that feels best for you, I think is fundamental, as practitioners, what we need to do.
Leslie:
And how are insurers responding? Are insurers currently reimbursing claims for virtual care?
Dr. Moez Rajwani:
The OCA did a lot of work at the beginning to ensure that happened. We know that many insurers are covering virtual care, at least during this period of time. I'm not sure what will happen when we go back to some set of normal, whether they will continue to. My advocacy would be, yes, I see virtual care needs to still be there. And even though it may never be 50% or 75% of our practice, I can see it being 10, 15% or 25% of a practice where we are monitoring and managing some of our cases in a hybrid model where maybe once a week we're online, teaching them exercises, things like that.
Dr. Amy Brown:
Initially, there was sort of a, we're not quite sure how to bill for this. The codes didn't exist, and now there's much greater uptake with that. I see a mix of patients who pay full services out of pocket and benefits. And so we've been fairly fortunate in having that be pretty easy to deal with.
Leslie:
Is there anything else you'd like to add, Dr. Brown, in terms of virtual care and how you're working with it and evolving, as it were?
Dr. Amy Brown:
That the one final thought would be that when we first started doing this at the beginning of the pandemic, I think it was sort of seen as a stop-gap, temporary fix. And I think that the more that we use it, the more commonplace it becomes. I certainly don't think it will replace in-person visits, but beyond the pandemic, I do think that there is a place for this. And I do think that we're going to see ongoing use of it in various formats. So for those who haven't gotten comfortable with it yet, I would encourage you to take a look at it because I do think that you're going to see more of that kind of care moving forward.
Leslie:
Thank you so much, Dr. Brown, for giving an update on virtual care and how it's evolving at your clinic. Now back to you, Dr. Rajwani. This pandemic has been challenging for everyone and things have been rapidly changing. What do you see as key changes to extended health care when we eventually come out of this pandemic?
Dr. Moez Rajwani:
First of all, during the pandemic, I think they've seen less utilization in physical health-related things. They've seen an increased utilization in mental health services. And so I do think one of the things you'll probably see post-pandemic is a change in the way they deal with mental health services. Not specific to chiropractic, but I do think that you're going to see a change in the way they deal with that. I think that as remote work is becoming more common and will continue to be, employers are going to see the value, I hope, of the use of services like chiropractic services to ensure healthy backs and healthy necks and shoulders as people work from home. And so I do see that as a trend. I see cost containment and fighting for that dollar to still be there because employers are going to have less money for the next couple of years, at least many employers.
Dr. Moez Rajwani:
And they're going to be looking at cost reduction, and I'm worried that they're going to start looking at their health care plan and say, hmm, how do I make sure? So what you'll start to see is copayments. Right now, maybe you have a patient that gets 100% coverage. That will go down to 80% coverage or 50% coverage. And then the patient will have to pay the other amounts. I see those types of trends just because I think the economy's going to go through a tough period over the next couple of years.
Dr. Moez Rajwani:
And I think employers are going to be looking where can they save money. On the opposite side, as we go into the new economies, we look at the digital transformation and we get these digital tech companies. Their cohort of employees are going to want choice, and they're going to probably want that wellness money and they're going to want to spend it the way that they want to spend it. And so I see in corporations such as the Shopifys of the world and the Googles of the world, where you're going to start to see health spending and more autonomy to the employee on how they spend their money.
Leslie:
So there are some positive changes coming up, but there's a lot of scrutiny and a lot of eyeballs going to be on what chiropractors and other health care professionals are doing. What's keeping up with all these rules, I think is quite a challenge, and especially as you mentioned earlier, that it varies from provider to provider. How can a chiropractor best keep up with all the different rules for each provider?
Dr. Moez Rajwani:
So one, I'm hoping that we continue at the O-C-A to support you with that and give updated information as we receive it. The second is ask. Sometimes it's just a matter of asking, and if you're not sure, contact the insurance company and get the rules of engagement. I know it's automated and sometimes you don't know who to contact, and there's just an info email address. But many times, asking will help. And then my ask to all chiropractors out there, if you've seen something different, please share it with us. I know some of the contacts and conversations I have with many of you over the years, I've learned something new or a new trend has come and it's allowed me or the team at the O-C-A to then investigate and find out more about it. So when you do see something in your area or with an employer or a change, share with us, and we'll learn from that, and our commitment is that we will then do the due diligence and the research required so that we can share that learning with our membership.
Leslie:
Okay. So the best way for them to share it if they don't know you is through the OCA members self-serve portal because we would pass that on to you then.
Dr. Moez Rajwani:
Absolutely.
Leslie:
Now chiropractors just graduating, just starting out, what's the most important thing that they need to keep in mind in terms of extended health care?
Dr. Moez Rajwani:
I think one, as you graduate, make sure that you're following the rules of engagement from the college in terms of your standards of practice and practice guidelines. Number two, if you're working for somebody else and they're using your registration number, ask the questions, regarding how they're billing, how they're dealing with you. Don't just let them say your job is just to come in and treat patients. We take care of everything. Your registration number is critical. And so if they're using it in that clinic and sure, you know how it's being used because ultimately you're accountable when your name is on that invoice. And so if you're seeing that that's a challenge in that company or organization, then you need to ask a second question if that's the right organization you should be working for.
If you're an owner-operator, sole proprietor, part of a multidisciplinary team, but you're the owner, make sure you know the rules of engagement, make sure you understand, and you train your staff properly, because your staff reflects on you, and so if they're doing something that's not correct, it ultimately will reflect upon you. So invest in time in your staff, train properly, have oversight, and be a good mentor to your staff. To be able to understand these, join the OCA and, and hopefully we can support you through your journey.
Leslie:
Great. I know our E-H-C Advisory Council will keep O-C-A members up to date about new trends or changes that are going to impact their practices, and members can find O-C-A's extended health care guide online. Do you have any final recommendations on how members can use this guide to attain maximum value from it?
Dr. Moez Rajwani:
First, just read it. I think it's important to just take a few minutes on your iPad or whatever tool you're using and read it. I think it's important that you just go from A to Z. It's not a long read. It's hopefully a reasonably interesting read. And then once you've read it, identify the areas of that guide that would be most useful for you and for your team and then share it with your team. Share it with other chiropractors in your practice if there's associates or people that you're working with, share it with your staff. What I did is actually we have our own staff meetings and I oriented my team on the guide and said, look, this is where all your information is. Before you ask me, read the guide and see if there's an answer there. So that's the best way, I think, Leslie, to use the guide.
Leslie:
Now there's a lot of tools and templates in the guide. Do you have a favorite tool or template that you think is wonderful from a really practical perspective?
Dr. Moez Rajwani:
I would be biased because a lot of those we've developed together. For me one of them is the compassionate letter. You know, we as chiropractors, many times give care to our patients at a reduced rate for whatever reason, but we think that's good enough. And I like the compassionate letter because makes both the chiropractor and the patient accountable. And it has a record of why you did what you did. And so not only does it help you on an audit, it's a great conversation with your patient because they realize what you're doing for them is to help them. And that you're going above and beyond your normal rates because you understand their need for chiropractic care and their personal or their family or economic situation of today. And that this is part of the service you offer the community, and yet there's accountability.
Leslie:
Okay. And that's one that they would prepare and send to the patient and they can customize, correct?
Dr. Moez Rajwani:
Yes. All of these forms are tools that can be customized to your practice.
Leslie:
Okay. Any final recommendations you've got in the current climate we're in for either new chiropractors or seasoned chiropractors?
Dr. Moez Rajwani:
We've talked a lot about some of the challenges, but the wonderful thing is that people are recognizing the value of chiropractic and insurers are paying for it. Yes, they want us to be accountable. Yes, they're looking at it and making sure that the care that's being provided is appropriate and reasonable. But the fact that our patients can get reimbursement for their services, I think is a positive.
Dr. Moez Rajwani:
So my view is you got to embrace it. You got to be a participant and engage, and not have an adversarial relationship with insurance companies. It's like anything else. You have to learn how to operate in that space, but ultimately try to make that insurer your partner, not the person that you're always debating and arguing with. And I think that will make it a better experience for everybody. And I think you'll show insurance companies that chiropractors are here for their patients and they're willing to work with them where it's reasonable and that they're not asking for unreasonable expectations from us.
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Outro:
Leslie:
Thank you Dr. Rajwani, for sharing some extended health care tips and cautions with us. Our thanks also go to Dr. Brown for stopping by to share her virtual experiences and insights.
In our next podcast, due out on November 15th, we'll focus on chiropractic care for patients with arthritis and how your clinic can best support them. I hope you'll join us.