Articles by JCS

Chiropractic’s Golden Op

“Chiropractors Poised to Reduce Costs and Improve Outcomes.”

Chiropractic’s Golden Opportunity

by

JCS

HHS Secretary Kathleen Sebelius announced on April 12, 2011, that the federal government will invest up to $1 billion in federal funding from the Affordable Care Act to launch" Partnership for Patients" aimed to save 60,000 lives over the next three years by reducing millions of preventable hospital related complications and injuries and also save about $35 billion in health care costs including $10 billion in Medicare savings.[1]

Chiropractors need to be a part of this effort. The many recent newspaper articles, such as two articles in The Wall Street Journal about unnecessary spine surgery, and the announcement by the North Carolina BCBS not to pay for spinal fusion if the sole indication is disc degeneration or herniation may be the breakthrough the chiropractic profession needs to showcase its cost and clinical effectiveness.

Sec. Sebelius mentioned that “millions of patients are injured because of preventable complications and accidents,” but she failed to mention the millions of musculoskeletal patients who suffer from unnecessary drugs, shots, and back surgeries. Considering the nearly 500,000 spine surgeries and the enormous cost of $100+ billion in the spine care industry, the savings are obvious considering the majority of these cases could be helped with chiropractic care.

Nor does chiropractic care have the adverse reactions associated with medical care, such as the current epidemic of addiction to opiates like OxyContin, aka, “Hillbilly Heroin,” aided by “pill mills” owned by unethical medical drug pushers.

The many current guidelines for low back pain recommend “conservative care” for an extended period before spine surgery. The old AHCPR guideline on acute low back pain and the current guidelines such as Milliman, American College of Physicians, the American Pain Society, and even the North American Spine Society also recommend SMT before surgery.

The NASS guideline recommended spinal manipulation should be considered before surgery in the October, 2010, edition of The Spine Journal:

Several RCTs (random controlled trials) have been conducted to assess the efficacy of SMT (spinal manipulative therapy) for acute LBP (low back pain) using various methods. Results from most studies suggest that 5 to 10 sessions of SMT administered over 2 to 4 weeks achieve equivalent or superior improvement in pain and function when compared with other commonly used interventions, such as physical modalities, medication, education, or exercise, for short, intermediate, and long-term follow-up. Spine care clinicians should discuss the role of SMT as a treatment option for patients with acute LBP who do not find adequate symptomatic relief with self-care and education alone.[2]

Other important American guidelines also recommend spinal manipulation. The Milliman Care Guidelines® provide options that include chiropractic care prior to lumbar fusion.[3] The American College of Physicians and the American Pain Society published in 2007 a Joint Clinical Practice Guideline for the Diagnosis and Treatment of Low Back Pain that also concluded spinal manipulation to be effective for both acute and chronic low back pain.[4]

But the question remains: does HHS Sec. Sebelius know of these guidelines and this potential savings? If not, the ACA should make her aware of this information.

The new HHS effort speaks of medical errors and hospital infections, but another unaddressed problem is the thousands of necessary surgeries performed. For example, just in the past few years, comparative effectiveness studies have shown that most back surgeries[5], heart procedures[6], and knee surgeries[7] were no better than non-invasive conservative care, yet in each case, AMA, Inc. cried out “junk science” and screams, “we’re not going to let bureaucrats tell us how to manage our patients.” Apparently what the AMA really said was, “Don’t confuse us with the facts.” Well, now it appears this HHS initiative will mandate a change in this archaic attitude that has suppressed innovation in healthcare for too long.

Certainly the ACA can make the case against back surgeries as the recent change in NC BCBS policy has done. Now is the time to approach Sec. Sebelius with the challenge to mandate spine physicians to follow the guidelines to reduce the costs and failed back surgeries that are epidemic nowadays. Indeed, the guidelines are clear that no surgery for non-specific low back or neck pain case should be done before an extended period of SMT as the guidelines recommend.

Not wanting to appear as a neo-Luddite, there are, however, many indications for lumbar fusion in the cases of fracture, cancer, spondylolisthesis of 50% or more, scoliosis greater than 50 degrees with loss of function, persistent radicular pain or persistent neurogenic claudication unresponsive to conservative care, or serious infections such as spinal tuberculosis.[8]

But all of these pathoanatomical cases comprise only 3% of back pain cases. In fact, Richard Deyo, MD, MPH, believes 97% of back pain is “mechanical” in nature, and disc abnormalities account for only 1% of back problems. [9]  Indeed, nearly 80-85% of non-specific, mechanical low back pain problems are pathophysiologic cases that chiropractors probably can help. [10], [11]  Even if half of this figure is true, that is still a huge reduction in costs.

In this era of evidence-based healthcare, we chiropractors now have the research to support our position unlike ever before. The research is also clear the rampage of drugs, shots, MRIs, and spine surgery is neither cost nor clinically effective.

Perhaps the ACA could ask for a few hundred thousand dollars in a grant from HHS to spearhead a PR campaign to the medical profession, to every insurance company, workers’ comp, the military health service medical treatment facility, and to the public concerning the guidelines that recommend our care before drugs, shots, MRIs, and spine surgery. It is past time to get this truth out, and the opportunity to do it is now golden thanks to Sec. Sebelius.

A HHS grant to the ACA could be used to produce news releases that “Chiropractors Poised to Reduce Costs and Improve Outcomes.” This could be a stepping stone to the mass media as well to position the chiropractic profession as the leader in non-drug, non-surgical spine care that will reduce costs, disability, addictions, and poor outcomes now associated with the medical management.



 



[1] “HHS takes aim at medical errors, health care costs,” CNN.com, April 13, 2011

 

[2] MD Freeman and JM Mayer "NASS Contemporary Concepts in Spine Care: Spinal Manipulation Therapy For Acute Low Back Pain," The Spine Journal 10/10 (October 2010):918-940

[3] Milliman Care Guidelines for Lumbar Fusion, “Low Back Pain and Lumbar Spine Conditions—Referral Management, Clinical Indications for Referral,” www.allmedmd.com

[4]  R Chou, et al., “Diagnosis and Treatment of Low Back Pain:  A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society,” Low Back Pain Guidelines Panel, Annals of Internal Medicine 2 147/7 (October 2007):478-491

[5] JN Weinstein, DO,  Jon D. Lurie, MD, MS; Tor D. Tosteson, ScD; Jonathan S. Skinner, PhD; Brett Hanscom, MS; Anna N. A. Tosteson, ScD; Harry Herkowitz, MD; Jeffrey Fischgrund, MD; Frank P. Cammisa, MD; Todd Albert, MD; Richard A. Deyo, MD, MPH, “Surgical vs. Non-Operative Treatment For Lumbar Disk Herniation: The Spine Patient Outcomes Research Trial (SPORT) Observational Cohort, JAMA, 296 (2006): 2451–9.

[6] William E. Boden, M.D., Robert A. O'Rourke, M.D., Koon K. Teo, M.B., B.Ch., Ph.D., Pamela M. Hartigan, Ph.D., David J. Maron, M.D., William J. Kostuk, M.D., Merril Knudtson, M.D., Marcin Dada, M.D., Paul Casperson, Ph.D., Crystal L. Harris, Pharm.D., Bernard R. Chaitman, M.D., Leslee Shaw, Ph.D., Gilbert Gosselin, M.D., Shah Nawaz, M.D., Lawrence M. Title, M.D., Gerald Gau, M.D., Alvin S. Blaustein, M.D., David C. Booth, M.D., Eric R. Bates, M.D., John A. Spertus, M.D., M.P.H., Daniel S. Berman, M.D., G.B. John Mancini, M.D., William S. Weintraub, M.D., for the COURAGE Trial Research Group, Optimal Medical Therapy with or without PCI for Stable Coronary Disease, NEJM, 15/356  (April 12, 2007):1503-1516.

[7] Alexandra Kirkley, MD, Trevor B. Birmingham, Ph.D., Robert B. Litchfield, M.D., J. Robert Giffin, M.D., Kevin R. Willits, M.D., Cindy J. Wong, M.Sc., Brian G. Feagan, M.D., Allan Donner, Ph.D., Sharon H. Griffin, C.S.S., Linda M. D'Ascanio, B.Sc.N., Janet E. Pope, M.D., and Peter J. Fowler, M.D.,  A Randomized Trial of Arthroscopic Surgery for Osteoarthritis of the Knee,  NEJM 359/11: (Sept. 11, 2008): 1097-1107

[8] Milliman Care Guidelines for Lumbar Fusions, “Low Back Pain and Lumbar Spine Conditions—Referral Management,” www.allmedmd.com

[9] Deyo RA, Weinstein JN. Low back pain. N Engl J Med 2001 Feb 1;344(5):363-70.

[10] G Jull, et al. Whiplash, Headache, and Neck Pain, (Churchill Livingstone, 2008).

[11] RA Deyo, Conservative Therapy for Low Back Pain: Distinguishing Useful From Useless Therapy,” Journal of American Medical Association 250 (1983):1057-62.

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