Articles by JCS
Fake News & Medicare
The recent revelation about “fake news” in the media, Facebook Mounts Effort to Limit Tide of Fake News, may come as a shock to many unsuspecting Americans who believe what they read, but not to chiropractors who have been victimized by old fashion medical propaganda and yellow journalism from the Committee on Quackery in the 1960's, long before the advent of the internet and long before propaganda was called fake news.
Most recently we’ve seen two examples of fake news go viral with the pediatric chiropractic witch hunt Down Under and in the US we’ve seen the Katie May accident. In both cases, our image was impugned by the slanted, bias news reporting without any significant feedback from our leadership or by “fair and balanced” reporters giving our side to these issues.
In both cases, we were slam-dunked with our hands tied behind our backs!
Who wasn't disturbed by the "gotcha" headline, "Can your chiropractor kill you?" on the Dr. Oz show recently? Although the discussion was fine, the headline killed our image.
Now we see on December 20, 2016 another media attack in the NY Post, "How chiropractors can make your back worse" by Raquel Laneri, a writer who gets paid for the number of clicks by taking a cheap shot at chiropractors.
Once more we witness another assault on chiropractic in Medicare, “Medicare Paid Chiropractors Bone-Chilling Millions for Bogus Billings,” that went viral across this country when the OIG declared chiropractors defrauded Medicare by $359 million.
This article was painfully similar to the article two years ago in Forbes by Steven Salzberg (4/20/2014), "New Medicare Data Reveal Startling $496 Million Wasted On Chiropractors."
That article is not the first time Forbes has allowed Steven Salzberg to attack chiropractic, and it may not be the last time. He professes: “I cover pseudoscience and bad medicine, and sometimes good medicine.” It is uncertain what Mr. Salzberg qualifies him to attack anything, but medical trolls rarely have expertise in what they say, which is incidental to the number of hits they provoke to make money.
I responded to his first slam on chiropractic when he wrote, "Why does the government subsidize chiropractic colleges?", that you can read at Forbes Attacks Chiropractic. I responded to his second attack @ Forbes Attack #2.
In fact, Salzberg is among a new wave of internet writers who are paid for the number of hits, which can be quite profitable if their work goes viral. So, the juicier, meaner, or more salacious topics a writer can find, the better even if it is fake news. The more hits, the more profitable to the writer. So, when dozen of chiropractors reacted on Salzberg's blog, he smiled all the way to the bank.
The fact that fake news writers like Salzberg take aim at chiropractors seems odd considering the huge difference between chiropractic and medical fraud, but this remains an unknown issue to their readers and certainly is not the objective of these journalists to be "fair and balanced".
Let’s put this into comparison with medical fraud in Medicare. Since 2010, federal authorities operating as part of the “Fraud Takedown” initiative have arrested and charged roughly 1,200 people allegedly complicit in defrauding the Medicare and Medicaid programs of more than $3.5 billion.
However, the alleged "bone chilling" $359 million chiropractic fraud compared to $3.5 billion equates to 0.1%, but this goes unmentioned by the media.
If this 0.1% is "bone chilling", then the 99.9% of the $3.5 billion medical fraud must be bone-hard frozen.
Plus this $3.5 billion failed to make the same grade of national attention as did the chiropractic fraud and it certainly did not go viral. Where was Steven Salzberg to condemn his profession's own medical fraud to the tune of $3.5 billion?
No where to be heard, of course.
Perhaps just like the alt-right publication, Breitbart News, plays the race card in its articles to inflame readers, we see the same bias against chiropractors by some writers to inflame readers who carry the chirophobia torch of prejudice. Indeed, it's hard to find anyone who has a "fair and balanced" attitude about our profession, especially in the mainstream media where MD reporters control content and Big Pharma controls them.
However, there are a few professional journalists who take a "fair and balanced" view of chiropractic.
The following article came from Mark Schoene, editor of The BackLetter (Vol. 32, No. 1, January 2017). Mr. Schoene is undoubtedly among the most astute journalist concerning the spine profession who raised some important objections to the attack on chiropractic.
A US government agency has leveled dramatic but inaccurate accusations against American chiropractors—accusing them of overcharging the US government and its Medicare program by $359 million in 2013 alone. An investigation by the Office of the US Inspector General concluded that 82% of the chiropractic treatment billed to the US government was “medically unnecessary” and should have been disallowed.
This report led to some terrible publicity for chiropractic:
Misinterpretation of Claim Requirements and the Scientific Evidence?
However, on further reading this report seems curiously off-base. For instance, it appeared to misinterpret the evidence—and documentation requirements—on extended chiropractic treatment (i.e. treatment lasting more than 90 days).
The report repeatedly implied that treatment for acute or chronic pain that lasted more than 90 days may be “medically unnecessary” and would qualify as “maintenance therapy,” which is not covered under Medicare policies.
Yet, extended treatment for appropriate indications is fully allowed under Medicare regulations—even if the Inspector General believes otherwise. Chronic pain often waxes and wanes for months and years—as do episodes of care.
The report from the Inspector General condemned dozens of episodes of care for not documenting the medical necessity of those claims. Yet, it did not provide concrete examples of the errors in documentation. Is the Inspector General trying to improve documentation or simply condemn chiropractic care? Did the failures in claims documentation simply stem from poorly written administrative claim forms, or complex documentation requirements—or something more sinister, as the Inspector General alleges? It is impossible to tell from reading the report.
And the report was sloppy. For instance, any claim for chiropractic services under Medicare has to be coded with an “AT” designation—AT standing for “Active Treatment.” This would be active treatment intended to improve patients’ symptoms and functional status. This designation can be applied to the treatment of acute or chronic pain.
According to Medicare policies, if a claim is not accompanied by an AT designation, it is automatically classified as “maintenance therapy”—which is not eligible for Medicare payment. But the Inspector General’s report erroneously defined the AT designation as “Acute Treatment,” which is misleading.
Cross-Section of Medicare Claims
The report from the Inspector General looked at a representative cross-section of Global Spine Care practice claims submitted to the Centers for Medicare & Medicaid Services (CMS), including 105 services.
Here is the segment of that report, which condemned chiropractic treatment lasting more than 90 days:
The chiropractors submitted claims for all 105 services with the AT modifier and initial treatment date, indicating that the services were for active/corrective treatment for subluxation and all documentation required by Medicare was being maintained on file.
However, the documentation provided by the chiropractors for 94 services did not support the medical necessity of the services; 37 of these services had more than 90 days (approximately 3 months) between the date of initial treatment and the date of service, which may indicate that the services were maintenance therapy.
The Passage of Time Does Not Dictate the Need for Back Care
But, as mentioned above, CMS does not make any requirement that chiropractic treatment services with an AT designation have to occur within a 90-day window to be acceptable. And that is not a valid reason for rejecting a claim. The mere passage of time does not determine what is active treatment and what is maintenance treatment.
Is the Inspector General’s Report Anti-Chiropractic?
The tone of the Inspector General’s report seemed anti-chiropractic. Just from the language, it appears as if the Inspector General would be more comfortable if there were much less chiropractic treatment under Medicare policies.
Yet, the real scandal in back care, and pain care, in the United States is the continuing mistreatment and overtreatment of acute and chronic pain in primary care medical settings with opioids—which have led to almost 30,000 deaths per year in the United States.
One of the best ways to keep patients away from opioids in primary care settings is to route them to complementary and alternative care, including chiropractic. And multiple commentaries in medical journals have recommended expanding back care to include complementary and alternative care.
Some have recommended employing specially trained chiropractors and physical therapists as the main, front-line providers for low back pain. [See Donald Murphy’s two books on primary spine care providers}
So why is the Inspector General so hostile to chiropractic?
The same report by the Inspector General was discussed in an article at Medscape.com by Robert Lowes. That feature also included a section with 45 comments from MDs, DCs, and other healthcare providers.
“How are We to Care for Our Patients?”
A comment from a primary care MD—a general practitioner—stood out. “So we are no longer supposed to treat painful conditions such as headaches and back pain with opioids, and we are being encouraged to direct patients to the previously discouraged complementary modalities….which Medicare won’t pay for. Seems like Medicare needs to be brought up to date. And in the meantime, how are we to care for our patients?” asked Laura Shulman, MD.
Ironically, spinal manipulation has a better track record of safety and effectiveness than opioids in evidence-based guidelines on back pain. Yet, the Inspector General’s Office is on the warpath against chiropractic.
CMS Response: Where is the Medical Evidence to Support the Recommendations?
CMS did not seem impressed with this [IOG] report—at least based on its letter in response. And CMS rejected one of the main recommendations (i.e. that CMS impose a limit on the number of chiropractic treatments it will underwrite).
The Inspector General recommended that CMS should “Determine whether should be a limit for the number of chiropractic services that Medicare will reimburse; if so, take appropriate action to put that limit into effect, and implement a system edit to disallow services in excess of that limit.”
CMS rejected this recommendation based on the existing scientific evidence. The following is an excerpt from the CMS letter in response to the Office of the Inspector General:
“CMS does not concur with the OIG recommendation. In order to implement this recommendation, CMS would need to develop a national coverage determination establishing a limit on the number of chiropractic services that are reasonable and necessary.
CMS is not aware of medical evidence that would support such a determination.”
Disclosures: None declared.
"War Path Against Chiropractic"
Certainly it is powerful when the most astute editor in medical spine care comes to our defense as Mr. Mark Schoene did in this article. You may have noticed he wrote:
“Ironically, spinal manipulation has a better track record of safety and effectiveness than opioids in evidence-based guidelines on back pain. Yet, the Inspector General’s Office is on the warpath against chiropractic.”
Mr. Schoene did ask a good question that went unanswered: “So why is the Inspector General so hostile to chiropractic?”
That question is probably impossible to determine, but a good guess would be Daniel R. Levinson, Inspector General, like many attorneys, suffers from chirophobia after years of hearing medical propaganda, rubbing elbows with MDs (including HHS nominee Dr. Tom Price, orthopedist), and fake news about the supposed horrors of chiropractic care.
Considering the evidence supporting chiropractic care in this era of back pain, wouldn’t this be a good time to go on the offensive by publicly asking in the media, “Why is the Inspector General so hostile to chiropractic?”
We should embrace a discussion with the IOG on this matter to clear the air and show them that chiropractic care is the best buy for the pandemic of pain and to diminish the opioid crisis.
Too High a Price
Not only does the head of the IOG appear chirophobic, we can expect the HHS nominee, Dr. Tom Price as an orthopedist also to be antagonist toward our profession . Unfortunately, his prejudice is compounded considering Dr. Price is from Georgia and well aware of the bad image created by Big $id during his reign of academic terror at Life U. in Marietta.
In fact, I can't think of a worse nominee for Sec. of HHS than an orthopedic surgeon from Georgia.
Also, consider the financial fact of life in Washington that orthopedic surgeons donated $928k to Dr. Tom Price over 12-year period and specialists have donated at least $3.1 million more over the past 13 years to Dr. Price's political committees.
It is obvious that Price is well embedded and financed in the medical war against chiropractors.
NM Hadler, MD, wrote in his book, “Stabbed in the Back”, “The pen may be mightier than the sword, but it is not mightier than the dollar,” and the AMA and Big Pharma has plenty of dollars to wield its sword on Capitol Hill.
As we know in Washington, D.C., money equates to power.
Little do people know the medical-industrial complex spends four times as much on lobbying as the No. 2 Beltway spender, the much-feared military-industrial complex, which explains one reason why Harper’s Magazine once called the AMA as “the most terrifying trade association on earth.”
According to OpenSecrets.org, the annual lobbying on health legislative issues in 2015 was $381,223,403 ($712,567 per congressman) of which Big Pharma alone spent $178,863,490 ($334,324 per congressman). The total spent in 2015 was down from $556,002,269 ($1,039,256 per congressman) at the height of the Obamacare debate.
The total contributions by health professionals to federal candidates and parties amounted to $70,377,772 ($131,547 per congressman) for the election cycle ending in 2014. The AMA alone contributed $19,650,000 in 2014 ($36,728 per congressman).
In comparison, all chiropractic contributions amounted to a paltry $527,832 ($986 per congressman).
There is simply too much money for Congress to criticize either Big Pharma or the medical dealers who pad their pockets. Combine this money with the ingrained chirophobia, and we face a huge political battle in the upcoming administration.
Unless there is a moral epiphany among Trump’s administration, we should expect the worse of times rather than the best of times in our future.
The only hope is to develop a first-class damage control PR effort to rehab our image and to stake a claim as a big answer to the pandemic opioid abuse with our nondrug treatments for low back pain, the leading reason for prescription opioid painkillers, a fact no one in Congress on Capitol Hill realizes.
It's past time to stop taking a spoon to a knife fight.
 Private communication with JC Smith, 3/19/2015.
 Spinal Fusion for DDD a Growth Industry for Two Decades—Despite an Uncertain Evidence Base, BackLetter: April 2015 - Volume 30 - Issue 4 - p 39–41
 Hadler, NM, Stabbed in the Back; confronting back pain in an overtreated society, University of North Carolina Press, 2009, pp. 88
 M Mayer, ibid. p. 76.