Articles by JCS

Prosperous Club Med

Word count: 2535

Prosperous Club Med

It shouldn’t come as any surprise more realistic opinions of the problems with spine care come from experts across the pond in European national healthcare systems where their motive is less impacted by financial interests than here in the United States.

A study conducted by Deyo and Cherkin in 1994 compared international rates of back surgeries and found the startling fact that the rate of American surgery is unusually excessive and directly attributed to the supply of spine surgeons:

“The rate of back surgery in the United States was at least 40% higher than any other country and was more than five-times those in England and Scotland. Back surgery rates increased almost linearly with the per capita supply of orthopedic and neurosurgeons in that country.”[1]

Does this mean Americans’ backs are five-times weaker than people from Great Britain or does it mean U.S. surgeons perform too many unnecessary surgeries? Obviously the real difference is a profit-motivated healthcare system in the U.S. compared to the not-for-profit National Health Services in the U.K.

One of the most interesting analyses of the current medical spine care industry was written by F.J. Robaina-Padrón, MD, Functional Neurosurgery Unit, Dr. Negrín University Hospital, Las Palmas, Canary Islands, Spain. His abstract was very revealing of the “Controversies about Instrumented Surgery and Pain Relief in Degenerative Lumbar Spine Pain”:[2]

Abstract

Investigation and development of new techniques for instrumented surgery of the spine is not free of conflicts of interest…Even authors who have eagerly defended fusion techniques, it has been demonstrated that they are very much involved in the revision of new articles to be published and in the approval process of new spinal technologies. When we analyze the published results of spine surgery, we must bear in mind what has been called in the American Stock Exchange as "the bubble of spine surgery."

The scientific literature doesn't show clear evidence in the cost-benefit studies of most instrumented surgical interventions of the spine compared with the conservative treatments. It has not been yet demonstrated that fusion surgery and disc replacement are better options than the conservative treatments.

It's necessary to point out that at present there are relationships between the industry and back pain, and there is also an industry of the back pain." Nonetheless, the "market of spine surgery" is growing because patients are demanding solutions for their back problems.

The tide of scientific evidence seems to go against the spinal fusions in the degenerative disc disease, discogenic pain and nonspecific back pain. After decades of advances in this field, the results of spinal fusions are mediocre. New epidemiological studies show that spinal fusion must be accepted as a non-proved or experimental method for the treatment of back pain...

We still need randomized studies to compare the surgical results with the natural history of the disease, the placebo effect or the conservative treatment…

In conclusion, based on recent information, we must recommend to "abandon the instrumented pathway" in a great number of present indications for degenerative spine surgery, and look for new strategies in the field of rehabilitation and conservative treatments

       Dr. Robaina-Padrón’s abstract succinctly characterizes the many problems present in the “industry of back pain.”

The facts are indisputable and the need is obvious that medicine needs our help. Without doubt, medical spine care is a house of cards ready to crumble, and chiropractic care is standing ready to replace medicine as America’s primary spine care providers for the 80-90% of non-pathological problems, an opinion the medical spine industry will fight tooth and nail to protect this lucrative market.

Steven Brill, author of America’s Bitter Pill, spoke of the “healthcare gravy train:”

“We spend $85.9 billion trying to treat back pain, which is as much as we spend on all the country’s state, city, county, and town police forces. And experts say that as much as half of that is unnecessary.”[3]

“We can't do it this way”

To change this narrative will take more than a few ads, social media slogans, periodic celebrity testimonials or a few revealing newspaper articles. And certainly informative research studies fall on deaf ears among the public’s appetite for short sound bytes and social media slogans.

In his TIME cover article, “Bitter Pill: Why Medical Bills Are Killing Us,” attorney/journalist Steven Brill discussed how badly the medical system is broken and spoke of the lack of free enterprise in healthcare in a lengthy 36-page exposé:

"It’s about facing the reality that our largest consumer product by far—one-fifth of our economy—does not operate in a free market…We’ve created a secure, prosperous island in an economy that is suffering under the weight of the riches those on the island extract. And we’ve allowed those on the island and their lobbyists and allies to control the debate…”[4]

I expect the Trump healthcare advisors such as Dr. Tom Price, an orthopedist, to control this debate by avoiding any questions that would impeach his medical profession or offend the AMA’s sugar daddy, Big Pharma.

Although his supporters tout his background as a surgeon as an asset, I see it as a huge conflict of interest—how can he possibly be objective about the downside of medical care or about the inclusion of alternative healthcare providers? I can’t imagine what the AMA would say to him if he were to give chiropractors equal access—it probably wouldn’t be pretty.

Dr. Price’s appointment is equivalent to putting an oil tycoon (or the past governor of Texas) in charge of the Department of Energy—do you think he would be open to solar energy?

Ralph Nader once remarked: “The use of solar energy has not been opened up because the oil industry does not own the sun.” Until the AMA owns chiropractic, equal access will not happen.

Trojan Horse

However, it may require an impactful human interest story to wake up the minds of a beleaguered American public to the shift in spine care and the damage of the present medical spine care of drugs, shots, and surgery.

According to Jonah Berger in his book, “Contagious: Why Things Catch On,” he speaks of building a Trojan Horse:

“So, how can we use stories to get people talking?

“We need to build our own Trojan Horse — a carrier narrating that people will share, while talking about our product or idea along the way.”

Presently we have no Trojan Horse to carry our message of spine care reform. Instead, we find ourselves in a war of words with the chirophobic media assaulting us with damaging stories as we’ve witnessed with the Witch Hunt Down Under or the Katie May accident.

In an interview in Medscape Medical News, “Hope for Hands-on Medicine in the EMR Era,”[5] Dr. Abraham Verghese mentions how the tipping point for social change might occur in medicine:

“A novel called The Citadel by A.J. Cronin about mining conditions in a Welsh town led to the National Health Service in the United Kingdom because of the shame surrounding what the book revealed. Uncle Tom's Cabin ended slavery in this country. It wasn't a politician. It wasn't a military guy. It was one novel that captured the public's imagination.”

The Trojan Horse narrative about the failings of “modern medicine” has been written by many authors, but none will not catch on until financial disaster strikes according to Dr. Verghese, which may be sooner than later considering medical care is already the leading cause of bankruptcy:

“So I think it's possible [in medicine], but we seem to be in a very polarized state in America. We have a lot of vested interests, and everybody is fighting for a piece of the pie. Healthcare is a big pie, $3 trillion worth, but I'm optimistic…

“I think that our GDP on healthcare is going to cross a line where it exceeds defense spending. At that point, people will wake up and say, ‘We can't do it this way’."

If Dr. Verghese believes the tipping point will occur when the medical spending exceeds military spending, well then he’s behind the times since that has already happened in terms of the percentage of the Gross Domestic Product (GDP).

In comparison, federal spending alone for healthcare was 22.6 percent of GDP for 2015 @ $1.4 trillion whereas federal spending for national defense was 12.9 percent of GDP in 2015 @ $0.8 trillion.[6] Moreover, the total annual U.S. healthcare spending (federal, state, private) hit $3.8 trillion in 2014,[7] and it’s projected to increase under the auspices of Donald Trump.

The comparison of medical costs to military costs also begs the question: how does the AMA justify its costly and ineffective system? In fact, the medical industrial complex has never been held accountable for its failings by Congress or the media, such as:

  • its cozy relationship with Big Tobacco from 1930 to 1986 that led to the current cardiopulmonary crisis,
  • to its sugar daddy relationship with Big Pharma that led to the current opioid and prescription drug overdoses, or
  • the 23,000 deaths annually from super-bugs due to the over-use of antibiotics that no longer stop their infections.[8]

The untold story about healthcare Americans have yet to hear is the fact we take more drugs than any society in the history of the world, yet the U.S. has the worst ranking of any advanced nation of the world in every category of chronic degenerative disease according to the Commonwealth Fund Scorecard, “Mirror, Mirror on the Wall, 2014 Update: How the U.S. Health Care System Compares Internationally.”[9]

According to the Scorecard, the U.S. ranks last of 11 nations overall while being the most expensive. Among the 11 nations studied in this report — Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States — the U.S. ranks last or near last on dimensions of access, efficiency and equity. The United Kingdom ranks first, followed closely by Switzerland.[10]

Without a doubt, if America spent on defense as much as the next fourteen countries in the world[11] and had the worst national defense system, there would be uproar. However, when American medical care ranks at the bottom while spending more than any country in the world[12], very little is said in the mainstream media.

Stranded on a Prosperous Island

Despite the “wonder drugs” and the high-tech image of medical care, outside of the emergency room, Americans are not getting much bang for their dollars for chronic degenerative diseases. After a century of touting the American brand of “scientific medicine” as the “best healthcare system on earth,” this notion is now seen as an expensive hoax.

 Dr. Ezekiel Emanuel, health adviser to President Obama, addressed the question whether or not America has the best health care in the world, a mistaken belief held by many people:

“Let’s bury this one once and for all. The United States is No. 1 in only one sense: the amount we shell out for health care. We have the most expensive system in the world per capita, but we lag behind many developed countries on virtually every health statistic you can name.”[13]

Feet to Fire

To illustrate the power of the medical industrial complex, while the Wall Street bankers and Detroit auto manufacturers were pulled before Congress to have their feet held to the fire to explain why their industries failed, the medical cartel escaped similar accountability and embarrassment during the Obama healthcare reform debate.

Here are a few questions Congress should ask about the “healthcare gravy train” during the next healthcare debate:

  • Congress needs to ask the AMA why two-thirds of its treatments were deemed by the British Medical Journal found 62% of 3000 medical treatments to be ineffective, unproven or too dangerous to use.[14]
  •  Congress should ask why medical errors are the third-largest reason for death among Americans according to the BMJ.[15]
  • Congress also needs to explore why MDs are among the highest paid professionals while Americans rank the lowest in the advanced world in every category of degenerative disease and longevity according to the Commonwealth Fund.[16]
  • Congress should ask the insurance industry why its premiums are rising at double-digit inflation annually. Like pouring salt in a wound, the HMOs take 25-55% profit off the top[17], the top six HMO health plans paid 37 executives an average salary of $7.5 million[18], and then implemented a policy of “squeeze care to expand profits” to deny patient care and overwhelm practitioners with paperwork as they cut fees.
  • Congress needs to ask hospitalists why every public hospital does not have a chiropractor on staff since federal guidelines recommend chiropractic before opioids, epidurals and surgery.[19]
  • Congress needs to know why there is virtually no free enterprise in healthcare to allow the best mousetrap to prevail. [20]


Triple Aim

Indeed, I seriously doubt the present medical system will ever achieve healthcare reform and diversity because they prefer the present medical monopoly just the way it is—only with fewer regulations, that is.

Many researchers and administrators alike now urge the use of chiropractors and other alternative/complementary providers to treat chronic pain patients with nondrug treatments and to replace the promiscuous prescribers who created this opioid pandemic.

Among those who recommend the increase use of alternative providers was Dr. Don Berwick, MD, who served as head of the Centers for Medicare & Medicaid Services (CMS). He mentioned his vision of the future of healthcare with his concept of the “Triple Aim — better care, better health, at lower cost — could improve healthcare by a full order of magnitude.”[21]

Within the Triple Aim framework, Dr. Berwick called for making acute care safer and reliable, making care more integrated, and increasing the nation’s investment in preventive care — all three objectives that could be implemented with chiropractic and CAM providers.

Dr. Berwick admitted the obstacle that will hinder the Triple Aim was the medical prejudice against non-MD practitioners:

“It's a mistake to say that nurse practitioners, physician assistants, and other healthcare professionals [DCs] represent lower levels of function than doctors. They have complementary skills. They can give better care in some areas than we as doctors can give, and they allow primary care physicians to see more patients and have more time to focus on issues most in need of their expertise…It's not just a matter of filling in the gaps; there is a great deal of evidence to show that including other clinical professionals leads to better outcomes...”[22]

Of course, at the top of the list of “other clinical professionals” who will lead to “better outcomes” are chiropractors with nondrug treatments for the pandemic of chronic back pain to avoid the over-use and abuse of opioids.

If the American healthcare system has any chance to accomplish the Triple Aim and reduce the scourge of Pharmageddon, the government programs and private insurers must implement the guideline recommendations that call for conservative nondrug and nonsurgical chiropractic care.

However, it won’t come without a fight from Big Pharma, the AMA and Dr. Price who apparently like the status quo just the way it is making billions of dollars without any meaningful competition. Indeed, it’s fun on the prosperous island for those in the exclusive American Medical Club Med.



[1] DC Cherkin, RA Deyo, et al. An International Comparison Of Back Surgery Rates,” Spine, 19/11 (June 2004):1201-1206.

[2] FJ Robaina-Padrón, Controversies about instrumented surgery and pain relief in degenerative lumbar spine pain. Results of scientific evidence. Neurocirugia (Astur). 2007 Oct; 18(5):406-13

[3] Steven Brill, America’s Bitter Pill; Money, politics, backroom deals, and the fight to fix our broken healthcare system, Random House, NY, 2015

[4] Steven Brill,  Bitter Pill: Why Medical Bills Are Killing Us, TIME, Feb. 20, 2013

[5]“Abraham Verghese: Hope for Hands-on Medicine in the EMR Era,” John M. Mandrola, MD, interviews Abraham Verghese, MD, April 06, 2015, Medscape Medical News from the American College of Cardiology (ACC) 2015 Scientific Sessions theheart.org on Medscape

[6] usgovernmentspending.com, Christopher Chantrill. www.usgovernmentspending.com/us_health_care_spending_10.html  

[7] Dan Muro, Annual U.S. Healthcare Spending Hits $3.8 Trillion, Forbes, 2/02/2014

[8] CDC report Antibiotic Resistance Threats in the United States, 2013,

[9] http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror

[10] Jason Kane, Health Costs: How the U.S. Compares With Other Countries, PBS NEWHOUR, October 22, 2012

[13] Ezekiel Emanuel and Shannon Brownlee, “Myths About Our Ailing Health-Care System,” Washington Post, (November 23, 2008): B03.

[14] Nuts, Bolts, And Tiny Little Screws: How Clinical Evidence Works, British Medical Journal, http://clinicalevidence.bmj.com/x/set/static/cms/nuts-and-bolts.html

[16] http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror

[17] R  Kuttner, Market-Based Failure — A Second Opinion on U.S. Health Care Costs, NEJM, 358/6 (Feb. 7, 2008):549-551

[18] http://www.harp.org/hmoexecs.htm

[19] SJ Bigos, O Bowyer, G Braea, K Brown, R Deyo, S Haldeman, et al. “Acute Low Back Pain Problems in Adults: Clinical Practice Guideline no. 14.” Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; (1992) AHCPR publication no. 95-0642.

[20] Steven Brill,  Bitter Pill: Why Medical Bills Are Killing Us, TIME, Feb. 20, 2013

[21] Leigh Page, “Former Head of CMS Berwick Says, 'Things Will Never Go Back'”, Medscape Business of Medicine,  October 07, 2015

[22] Berwick Brings The ‘Triple Aim’ To CMS, Chris Fleming, September 14, 2010, http://healthaffairs.org/blog/2010/09/14/berwick-brings-the-triple-aim-to-cms/

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