Bad for Business

Bad for Business,

but Good for People

By J.C. Smith, MA, DC

After attending the 1995 Chiropractic Centennial celebration in Washington, D.C., one experience in particular has stayed with me from the visit to our national capitol. At the Lincoln Memorial was imprinted the famous Gettysburg Address. While reading the wisdom of Abe, his words that “this is a country of the people, by the people and for the people” stuck in my mind with a bit of irony. While this may have been true over 130 years ago, today I believe Abe would have said something like, “This is a country of corporations, run by corporate attorneys, corporate politicians and corporate lobbyists for the betterment of corporations.”

It seems to me that the “power of the people” has been greatly diminished since the times of ol’ Abe. Examples are plentiful: the defeat of the tobacco legislation; the Republican veto of the PARCA bill; the defeat of health care reform; and the virtual dismantling of the AHCPR guidelines, to name but a few of the many pro-people bills that were defeated by the corporate powers. Although each of these bills had widespread popular support among average citizens, if implemented, they would have harmed the medical profession.

Considering the plethora of recent research that shows the cost and clinical effectiveness of spinal manipulative therapy (SMT) compared to the medical methods for the vast majority of back problems, I have been perplexed why the insurance industry hasn’t wholly embraced our profession. Knowing the back pain business is a $60+ billion industry in the U.S. alone, I believe if chiropractors were in the loop, we could slash this monstrous figure in half, if not more.

When the U.S. Dept. of Health and Human Services’ patient guide to Acute Low Back Pain in Adults, “Surgery has been found to be helpful in only one in 100 cases of low back problems,”¹ obviously there’s a new awareness about the in effectiveness of the medical management of these acute cases. Yet instead of increased referrals and acceptance by managed care organizations, we find ourselves still on the fringe of utilization.

Why this paradox? The societal skepticism from years of medical slander and the medical bias against alternative care providers may explain why some in the public are sill wary of our profession. But the bottom line mentality of the insurance executives would make one think they don’t give a hoot about old biases when dollars are at stake, especially the billions wasted on failed back surgery alone. I would have thought these cost-cutting claim-slashers would have jumped on our bandwagon to reduce these huge costs, yet for the most part, they haven’t. Again, why?

To answer my question, we’re bad for business! The fact remains that if insurance companies pay out less, they must charge in premiums. A workers’ compensation representative, when asked about their antipathy towards chiropractic, admitted that SMT was cheaper, safer, and quicker than medical methods but then said, “That’s exactly the reason why we don’t like you guys. If we pay out less, we must charge less in premiums. So, by sending patients in for surgery, there’s more money for everyone — the doctors, the hospital and us.” Yuk, yuk, wink, wink! Apparently economics, not patients, drive the engine. Ugh!

The same mentality surfaced in the tobacco debate: bemoaning the thousands of farmers, workers and retailers who would be hurt by limiting tobacco use. One senator from a tobacco state, when asked about restricting tobacco usage, had the same illogic in his opinion. In effect, he said that if we regulated everything that was bad for us, we would have to restrict junk foods, soda pops,and alcohol, as well as tobacco. His ineloquent conclusion was along the lines of, “Then whoosh, there goes the whole economy!”

Apparently any health improvement concerns are bad for the economy.In the same light, chiropractic is bad for the present medical/hospital economy. Research has shown for the same diagnostic code for low back pain that the average chiropractic case costs around $800;² a nonsurgical medical back case costs around $7,000; and a surgical back case costs $14,000.³ If you were a hospital administrator looking to maximize profits, would you be interested in an $800 case or a $7,000 to $14,000 case? Forgetting that surgery has been helpful in only one in 100 cases according to the AHCPR guideline,⁴ it’s painfully obvious why hospitals still boycott chiropractors. We’re too cheap.

Behind the medical bias and slander remains a more important issue to these medical professionals. We take money out of their pockets. Although pollsters like Gallup recognize that chiropractic care is more patient-friendly than medical care with three times the patient satisfaction rates,⁵ hospitals are less concerned about good clinical results than they are about increased profits. The same can be said about most attorneys who railroad unsuspecting auto accident clients into back surgery only because their settlement is higher. As I was rudely told by an attorney who sent a mutual client/patient to a neurosurgeon for three back surgeries after I initially dismissed her with great results: “Do you want 40% of $250,000 or 40% of 10,000?” Again, chiropractic is bad for their business.

While our Republican leaders call for more free enterprise to improve services and lower costs, their cry falls on deaf ears in the sham marketplace of health care. The medical monopoly has little interest in increasing competition with non-MD providers, despite the fact that Eisenberg’s survey found over one-third of Americans actually made more office visits to alternative providers than they did to their physicians.⁶ Apparently, Republican economic theories extend to every segment of our economy except the medical establishment.

Maintaining a closed insurance system with medical gatekeepers has allowed the medical boycott of chiropractors to continue, much to the chagrin of patients. “Any willing provider” provisions may sound good in theory in our democratic society, but when it comes to the patients’ own health care, they are routinely denied any choice at all. PPOs and HMOs have made certain of that. Ironically, during the health care reform debate, the infamous “Harry and Louise” ads sponsored by the insurance consortium scared the public with the very same idea that Clinton’s plan would deny patients a freedom to choose their own doctors. After the bill was soundly defeated, the same insurance companies did exactly that: denied patients their freedom of choice!

Whether it’s a claims adjuster squeezing care to expand profits, or medical gatekeepers keeping patients stoned on drugs instead of referring to DCs, or Newt Gingrich and his Republican followers killing health care reform or the PARCA bill, the sham marketplace of medical care has little interest in lowering costs or improving procedures, especially if those procedures are rendered by non-MDs. Open competition and free market forces may be fine for industry, but in the medical world, free enterprise is an alien concept.

I’ve learned long ago one fact about our medical society. There are right ways to get treated and wrong ways, depending upon who profits. Forget about research and cost-effectiveness studies. Money is the driving force in health care today. The flap over the AHCPR guidelines, the gutting of the agency’s budget and the consequent lawsuits filed against the researchers clearly illustrates the wrath of the medical powers. You don’t fool with mother nature, and you don’t fool with the AMA.

Unable to accept expert criticism of spinal surgery, the North American Spine Society (NASS) immediately protested the research team’s alleged bias and ineptitude and harshly criticized its preferred form of therapy (spinal manipulation). Furthermore, they took their attack on the AHCPR to Capitol Hill. A NASS board member/surgeon created a bogus patient lobbying group called the Center for Patient Advocacy that deluged Congress with misinformation about the AHCPR. This effort led the House of Representatives to pass a 1996 budget with zero funding for the AHCPR. Only after great efforts in the Senate to expose the reasons for the attacks was it possible to salvage some funding for the AHCPR. Ironically, its guideline development work was curtailed even though it was originally ordered to do so by a 1989 congressional mandate.

Apparently, the AMA special interest groups were successful in eliminating the messengers who reported the many ineffective and costly medical procedures that have driven up health care costs to the trillion dollar range. A member of the AHCPR panel, Richard Deyo, MD, MPH, of the University of Washington Medical School, recently co-authored in The New England Journal of Medicine an article, “The messenger under attack — intimidation of researchers by special interest groups.” He wrote that “The huge financial implications of many research studies invite vigorous attack … Intimidation of investigators and funding agencies by powerful constituencies may inhibit important research on health risks and rational approaches to cost-effective health care.”⁷

Perhaps Dr. Deyo is feeling the same type of venomous response to the AHCPR’s guideline that the chiropractic profession has felt from other biased reports. Deyo has written many articles dealing with the ineffectiveness of spinal surgeries, especially spinal fusions. In the AHCPR’s clinical practice guidelines, the section on spinal fusion clearly summarizes the research. “There appears to be no good evidence from controlled trials that spinal fusion alone is effective for treatment of any type of acute low back problems in the absence of spinal fractures or dislocation …Moreover, there is no good evidence that patients who undergo fusion will return to their prior functional level.”⁸

The irony of the situation is the typical medical venom that spews from their mouths whenever they are held accountable and criticized: whether it’s the overuse of antibiotics in children leading to super-germ infections later in life; the belief that as much as 78-90% of all surgeries are deemed unnecessary;9 the gross overmedication of geriatric patients; or the fact that the Office of Technology Assessment reported that only 15-20% of medical procedures can be supported by research.⁸It’s obvious that research is ignored or condemned when it disproves the money-making methods of the medical professionals, as evidenced by the total avoidance of the AHCPR’s Acute Low Back Pain in Adults guideline.

For decades, medicine and its political machine have called for research from the chiropractic profession to prove itself, yet when it is finally done by the most universally accepted and acclaimed expert group of researchers ever assembled, the AMA still refuses to acknowledge their findings. Incredibly, the medical misinformers then published in May 1995, only a few months after the AHCPR’s low back pain guideline came out in 1994, their version of proper spinal treatments in a small booklet, AMA Pocket Guide to Back Pain, published by Random House.

The cover of the pocket guide claims it contains: “The latest information on all treatment options, including medications, physical therapy and surgery.” Despite the fact that spinal manipulative therapy is recommended by the U.S., U.K. and Canadian studies (AHCPR,¹¹ Meade,¹² Manga¹³), neither chiropractic care or SMT are even mentioned, plus the AMA’s pocket guide includes many recommendations that contradict the findings of the AHCPR expert panel. Although it does state that “more than 100 separate joints connect the bones of the spine to each other and to other bones,” no mention of manipulative therapy is given whatsoever. It seems obvious that the AMA is willing to misrepresent the scientific research and governmental endorsements that conflict with its own vested interests despite the harm it will cause patients who naively follow this outdated, ineffective advice.

Apparently killing the messengers and misrepresenting the research comes easier to political medicine than listening to the message and acknowledging the guidelines, especially if it might take money out of their members’ pockets. Again, chiropractic is bad for their business and, in the sham marketplace of health care, this alone is enough to keep us locked out of their system. Don’t confuse their opinion with the facts, please.

So what will our future hold? Oddly, being the most effective, cheapest, fastest and safest method for spinal care has proven to be detrimental to our integration into the present medical system. Until enlightened MCO executives realize that the cost savings of chiropractic care is a benefit and not a handicap to their bottomline, I fear our pleas for admission into their programs and hospitals will continue to be ignored. Political action fighting AMPAC, the AMA’s lobby, is also fruitless with their vast resources. The only other solution would be to take an underground, guerrilla marketing approach and go directly to the public. With the trend to alternatives catching on, many informed Americans would be interested to know the benefits of our care.

The only problem then would be paying for such a PR effort. Unfortunately, the present Alliance for Chiropractic Progress has been led to believe the public is more interested in our educational requirements rather than the benefits we offer. When that campaign fizzles out, perhaps the next group of PR experts will take this approach and publicize the clinical and cost-effectiveness of our care. The proof is there, the public is needing, and our profession stands poised to offer an effective and inexpensive answer. While we may be bad for business, we’re great for people. Now all we need to do is tell them.

References

1. Bigos S, et al. Acute Low Back Pain in Adults, Patient Guide, Clinical Practice Guidelines No. 14. Public Health Service, U.S.Department of Health and Human Services, AHCPR publication no. 95-0642, Rockville, MD: Dec. 1994, p. 12.
2. Carey TS, et al. The outcomes and costs of care for acute low back pain among patients seen by primary care practitioners, chiropractors and orthopedic surgeons. New England Journal of Medicine 1995:333;913-17.
3. Mushinski M. Average Hospital Charges for Medical and Surgical Treatment of Back Problems: United States, 1993. Statistical bulletin. Metropolitan Life Insurance Company, Health and Safety Education Division, Medical Department. April/June 1995.
4. Bigos S, et al. Acute Low Back Pain in Adults, Patient Guide, Clinical Practice Guidelines No. 14. Public Health Service, U.S. Department of Health and Human Services, AHCPR publication no. 95-0642, Rockville, MD:Dec. 1994
5. Gallup Organization. Demographic Characteristics of Users of Chiropractic Services. Princeton, NJ: Gallup, 1991.
6. Eisenberg DM, et al. Unconventional medicine in the United States. New England Journal of Medicine January 28, 1993;328(4):246-252.
7. Deyo RA, Psaty BM, et al. The messenger under attack –intimidation of researchers by special interest groups. NEJM April 17, 1997;336(16):1176-79.
8. Bigos S, Bowyer O, Braen G, et al. Acute Low Back Pain in Adults. Clinical Practice Guidelines No. 14. AHCPR Publ. No. 95-0642. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services, December 1994, p. 90.
9. Payer L. Disease Mongers. How Doctors, Drug Companies and Insurers Are Making You Feel Sick. Wiley & Sons, 1992.
10. Eddy D, Billings J. The quality of medical evidence and medical practice. Washing: National Leadership Commission on Health Care, 1987.
11. Bigos S, Bowyer O, Braen G, et al. Acute Low Back Pain in Adults. Clinical Practice Guidelines No. 14. AHCPR Publ. No. 95-0642. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services, December 1994.
12. Meade TW, et al. Low back pain of mechanical origin: randomized comparison of chiropractic and hospital outpatient treatment. British Medical Journal June 2, 1990;300(67137):1431-37.
13. Manga P, et al. The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low-Back Pain. Ontario Ministry of Health, 1993.