Articles by JCS

Spoon in Knife Fight

                                                                                                   

Word count: 2600

Spoon in Knife Fight

Like many of you in this profession who have read my commentaries over the past 35 years, I hope you feel the same frustration as I do that we are forced to sell a tainted yet effective service that is sorely needed by a skeptical public.

It would be different if we were selling a marginal method for a small health problem, but we have an effective, low cost, non-surgical, non-drug, and proven treatment[1] for the #1 disabling condition in the nation and military that is approaching a $100+ billion industry in the US alone and, throughout the world, total costs were estimated at $267.2 billion annually in 2008.[2]

In terms of market share, our competition is not just the medical profession fighting chiropractic, but the entire medical industrial complex comprised of the AMA along with Big Pharma, the hospital association, imaging centers, device manufacturers, and the insurance industry—what can be dubbed the medical corporatocracy’—that has no interest in lessening its iron grip on this market.

In the Dynamic Chiropractic (Oct. 1, 2015) publication, the DC staff exposed what we all know—“Managed Care Subverts Chiropractic: Study underscores bias against chiropractic utilization”:

A study published in the American Journal of Managed Care underscores why so many chiropractic patients go out of network in order to get the care they need. Managed care may be effectively locking them out.

The same storyline can be written about workers’ comp programs, TRICARE, DVA, Medicare, and every insurance company that limits our care but gives green lights to ‘pain management’ clinics, spine interventionalists, and spine surgeons who all utilize unproven treatments that are known to be dangerous, expensive, and ineffective.

The present medical corporatocracy has created the most expensive and ineffective healthcare system in the advanced countries of the world according to the Commonwealth Fund Scorecard, Mirror, Mirror on the Wall, 2014 Update: How the U.S. Health Care System Compares Internationally.”[3]  

Medical Cops

Realistically, no one drives 55 MPH on the highway until they see a highway patrolman. The same is true about MDs not following guidelines or using meds improperly off-label. None seem to worry until lately with the recent fraud/abuse investigations.

Since its inception in March 2007, the Obamacare Strike Force operations in nine locations have charged over 2,300 defendants who collectively have falsely billed the Medicare program for over $7 billion.

Of course, that $7 billion doesn’t include similar fraudulent costs from unnecessary medical care in workers’ comp programs, group health insurance, or in the TRICARE or DVA military programs. Undoubtedly, the total fraud in all these programs is staggering to imagine with spine care being the most lucrative of all medical scams.

The inefficiency and exorbitant cost of American healthcare is no secret, and finally the payers police are starting to take notice. Because of Obamacare there will be requirements that medical interventions will have to have proven value (clear benefit at reasonable cost over the entire cycle of care) and/or quality.

The Secretary of Health and Human Services Secretary Sylvia M. Burwell announced on January 26, 2015, in a press release, “Better, Smarter, Healthier: In historic announcement, HHS sets clear goals and timeline for shifting Medicare reimbursements from volume to value,”  that CMS will use a new metric for 90% of reimbursement by 2019 and is heading in that direction even now.

“Whether you are a patient, a provider, a business, a health plan, or a taxpayer, it is in our common interest to build a health care system that delivers better care, spends health care dollars more wisely and results in healthier people.  Today’s announcement is about improving the quality of care we receive when we are sick, while at the same time spending our health care dollars more wisely,” Secretary Burwell said. “We believe these goals can drive transformative change, help us manage and track progress, and create accountability for measurable improvement.”[4] 

I love it when I hear leadership speak in these terms, but wish it had not taken 20 years to happen in spine care when the paradigm shift first began in 1994 with the ACHPR guideline #14 on acute low back pain in adults.

Fortunately, some private insurers such as the North Carolina BC/BS[5] now mandate conservative care like chiropractic manipulation before spinal fusion surgery. A lot of payers are following BC/BS of North Carolina's lead and starting to scrutinize spinal fusion, especially for DDD and disc herniation. 

According to data published on the Palmetto GBA website, a pre-payment review of 251 claims in North Carolina, Virginia, and West Virginia led to 168 claims either completely or partially denied. The total reviewed was $6,356,890 and $4,141,771 was denied, resulting in a charge denial rate of 65%.[6]

High Way to Dead End

There is also increasing pressure on MDs to moderate the use of prescription opioids and ESIs. Recently three evidence reviews cast more doubt such as the new Washington State guidance on opioids:

  1. Uncertain Long-term Efficacy, Clear Evidence of Harm.

While the earlier guidelines focused on how prescribers could safely and effectively prescribe and manage chronic opioid analgesic therapy (COAT), more recent data suggests that the focus should also be on preventing the inappropriate transition from acute and subacute opioid use to chronic opioid use and to avoid COAT altogether when other alternatives for treating pain may be equally effective and safer in the long-term.

Three recently published systematic reviews which examine the effectiveness of opioids for chronic pain provide little support for COAT: A review of randomized controlled trials (RCTs) of opioids for chronic non-cancer pain concluded that the overall effectiveness of opioids for pain was only modest, and that the effect on function was small.

The CMS also requested a review of ESIs from AHRQ headed by Roger Chou, MD, that also touted there was no proven long term clinical benefit!

  1. Conclusions:

Epidural corticosteroid injections for radiculopathy were associated with immediate improvements in pain and might be associated with immediate improvements in function, but benefits were small and not sustained, and there was no effect on long-term risk of surgery. Evidence did not suggest that effectiveness varies based on injection technique, corticosteroid, dose, or comparator. Limited evidence suggested that epidural corticosteroid injections are not effective for spinal stenosis or non-radicular back pain and that facet joint corticosteroid injections are not effective for presumed facet joint pain. There was insufficient evidence to evaluate effectiveness of sacroiliac joint corticosteroid injections.[7]

Not only has the AHRQ admitted the lack of evidence for these expensive ESIs, the FDA has also jumped on the bandwagon concerning the dangers of these shots.

3.  FDA Orders New Warning for Epidural Steroids

Injectable corticosteroids must now carry a new label warning about the risks of severe adverse effects from epidural injections including death, stroke, and permanent blindness and paralysis, the FDA said. The agency decided that such a warning is needed after reviewing numerous reports in the medical literature and its own adverse event database.[8]

"Serious adverse events included death, spinal cord infarction, paraplegia, quadriplegia, cortical blindness, stroke, seizures, nerve injury, and brain edema," the FDA said in announcing the warning.[9]

"Many cases were temporally associated with the corticosteroid injections, with adverse events occurring within minutes to 48 hours after the corticosteroid injections. In some cases, diagnoses of neurologic adverse events were confirmed through magnetic resonance imaging or computed tomography scan. Many patients did not recover from these reported adverse events."

For the vast majority of Americans, they have no idea medical spine care treatments such as opioids and ESIs are ineffective, dangerous, and unproven.

They have no idea because few medical reporters are telling them! And the chiropractic profession is doing a poor job informing the public and media, too.

As more proof of the deceptive nature of Big Pharma, Steven Brill recently released an online ‘docu-serial’ examining the conduct of "America's Most Admired Law Breaker," Johnson & Johnson Pharmaceuticals, and its legal battles stemming from a CNS drug Risperdal that was only approved to treat schizophrenia in adults.

J&J decided that “schizophrenia in the United States did not meet the marketing requirements to make enough money for this drug,” so J&J persuaded pediatricians to use Risperdal off-label on ADHD children that caused some adolescent boys to develop breasts, gynecomastia. Of course, the resulting lawsuits were just a part of doing business for J&J. If you have time and like to read, this series is a fascinating tale of greed and corporate malfeasance.

The Untold Chiropractic Story

Sadly, we don’t have a Steven Brill to tell our story with access to widespread media distribution. However, we can certainly make a case that the suppression of chiropractic via a contrived imagery from the AMA and by way of the medical spine corporatocracy has hurt the public’s health almost as badly as anything Big Pharma has done drugging Americans.

Considering back pain is the #1 disabling condition in the nation, military, and in the world and opioid painkillers and ESIs are making billions for Big Pharma while causing addiction, death, and disability among unsuspecting patients, certainly Big Pharma, including J&J whose subsidiary makes OxyContin, has no interest to warn patients that perhaps these drugs are ineffective and dangerous.

We have a great yet untold story to tell starting with the closing comments by Judge Susan Getzendanner at the conclusion of the Wilk v. AMA antitrust that the defamation continues:

“The activities of the AMA undoubtedly have injured the reputation of chiropractors generally…In my judgment, this injury continues to the present time and likely continues to adversely affect the plaintiffs.  The AMA has never made any attempt to publicly repair the damage the boycott did to chiropractors’ reputations.”[10]

Usually when a federal court judge speaks, people listen, but not in this case. In a legal case comparable to the famous Brown v. the Topeka Board of Education, the Wilk v. AMA trial got little traction in the media and had no effect upon changing the chirophobia we still face.

So I made the mistake (no, not me) to ask lead attorney George McAndrews why the Wilk decision seemingly had little impact, to which I received a rather stern response:

“Her opinion was devastating to the AMA and its minions. It set the groundwork for charging MDs and hospitals with racketeering. It allowed fair-minded MDs to work with chiropractors. The chiropractors are the ones that have been remiss. They could have taken full page ads in every major newspaper, and given handouts to every single patient telling the story. Read the full presentation in my open letter to the Texas Medical Association and my recent letter to the FTC. I have DCs and MDs calling me all the time for information. They should already have it. Force the arguments before the entire public.”[11]

Spoon in Knife Fight

Perhaps we need to take his advice and force the arguments before the entire public and press. Indeed, as they say Down South, the chiropractic PR efforts seem to be ‘taking a spoon to a knife fight’.

For the last decade we’ve taken a position that was gentlemanly (i.e., F4CP’s policy of “billions of positive impressions”) and have refused to engage in “street fighting” tactics when attacked by political medicine’s dirty tricksters, such as we witnessed with the AHA stroke issue.

It appears our ‘though leaders’ want to be polite and collegial rather than accept the fact we are still in a fight for survival when only 14% of Americans use our services and PTs are now breathing down our necks eager to become America’s primary spine providers.

Even the PAs in Georgia have positioned themselves to serve as spine care providers in a very effective radio ad. Regrettably, the GCA did nothing in response.

Rather than taking a spoon into these fights, we should take a big knife with a sharp cutting edge to get the public’s attention and to stake our claim as America’s primary spine care providers.

Instead of weak defensive rebuttals to attack, we have the supportive research and evidence-based guidelines to go on the offensive with articles such as Chiropractors Blame AMA,  Chiropractors Cry Foul, Back Surgery Not Needed, or ACA Requests Apology from AMA. That would get more attention in the public and press than a sports celebrity WOC testimonial.

The most obvious topic in spine care now to promote is the Hillbilly Heroin epidemic created by Big Pharma and MDs who hand out narcotic painkillers for chronic pain like Halloween candy that has created more monsters than Dr. Frankenstein could ever imagine.

Few people in the public or press remember that Thomas Frieden, MD, Director of the Centers for Disease Control (CDC), admitted that physicians had essentially supplanted street corner drug pushers as the most important suppliers of illicit narcotics.[12] It’s rather shocking when the chief of the CDC accuses his medical colleagues of pushing drugs, but it’s true.

TheBACKLetter (Volume 30, Number 10, 2015) also makes the case for us that primary care medical practitioners are actually dangerous to patients:

One can make the argument that the most perilous setting for the treatment of low back pain in the United States is currently the offices of primary care medical practitioners—primary care MDs. This is simply because of the high rates of opioid prescription in these settings.

As anyone who follows medical news is aware, excessive prescription of opioids for back and other forms of chronic pain has prompted a destructive epidemic of overdoses and deaths, with more than 17,000 deaths per year. And the opioid overtreatment epidemic has in turn kicked off a terrible wave of heroin addiction and overdose deaths.

Low back pain has helped trigger a lethal and growing heroin addiction epidemic in the United States. How could that be? Unfortunately, it is easy to connect the dots.

Yet, when has our chiropractic PR specialists ever connected the dots? Instead, the F4CP, ACA, and ICA seem more concerned not to offend than to go on the offensive.

There appears to be reluctance by our chiropractic leadership to talk openly about the ineffectiveness of medical spine care and the drug abuse that leads to addiction and suicides. Never before has so much evidence abounded and the time is right now to make our case by connecting the dots to chiropractic care.

We need to talk about how a lack of alternative approaches has created the present $100 billion back pain epidemic with opioid addiction, ineffective ESIs, and a tsunami of back surgeries based on a debunked ‘bad disc’ premise as the Mayo Clinic review recently found but went unmentioned in the mainstream media.

We have an obligation to the public to use this valuable information that there are non-drug solutions to chronic pain that the guidelines recommend before narcotic painkillers, ESI, and fusions. Indeed, it does no good to take a spoon to a knife fight as we’ve done for years.

Litigation and legislation have been won to protect our scope, comparative studies have confirmed our clinical and cost-effectiveness, laws have been enacted to broaden our market, yet the public and press continue to think lowly of our profession that slowly grows at a snail’s pace.

I readily admit that I am impatient (if waiting 35 years for change is being hasty), and some would say I am perhaps extremely opinionated (no, not me!) always pushing the envelope on attitudes and approaches. 

However, what I am not wrong about is the fact that we have an great opportunity with the latest research supporting our profession to make a loud affirmative statement.

All we now need is a PR plan with muscle to connect the dots.

 



[1] 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.

[2] The Burden of Musculoskeletal Diseases in the United States Bone and Joint Decade, Copyright © 2008 by the American Academy of Orthopaedic Surgeons. ISBN 978-0-89203-533-5, pp. 21.

[5] http://www.bcbsnc.com/assets/services/public/pdfs/medicalpolicy/lumbar_spine_fusion_surgery.pdf

[6] Todd Schuck,  The Future of Spine Surgery: Pervasive Scrutiny & Shifting Trends Create Uncertainty for Inpatient Spine Procedures, Senior Director-Business Development, Specialty Healthcare Advisers | Monday, 13 January 2014

[7] Chou R, Hashimoto R, Friedly J, Fu Rochelle, Dana T, Sullivan S, Bougatsos C, Jarvik J.

Pain Management Injection Therapies for Low Back Pain. Technology Assessment Report ESIB0813. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. HHSA 290-2012-00014-I.) Rockville, MD: Agency for Healthcare Research and Quality; March 2015.

[8] John Gever, FDA Orders New Warning for Epidural Steroids, Deputy Managing Editor, MedPage 4/23/2014

[10] Getzendanner, Memorandum Opinion and Order,  p. 10

[11] George McAndrews, private communication with JC Smith, 9/4/2015.

[12] Centers for Disease Control and Prevention Press Release, CDC Vital Signs: Overdose of Prescription Opioid Pain Relievers—United States, 1999-2008; 2011: http://www.cdc.gov/media/releases/2011/t1101_presecription_pain_relievers.html.


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