Change the Incentives

Chiropractic’s Czechoslovakia

The recent US Supreme Court ruling on DOMA (Defense of Marriage Act) was a breakthrough for same-sex marriage advocates although the same court gutted the Voting Rights Act of 1965 that protected voters from discrimination at the voting polls. Apparently, equality remains a relative issue.

A classic example of voter rights violations is the story about a Mississippi literacy test that required voters to be able to spell in order to vote. When a white man came to vote, he might be asked to spell “dog.” But when a black person came to vote, he might be asked to spell “Czechoslovakia.”

Dealing with double standards is a way of life to minorities in the Deep South or to chiropractors who still encounter unfair barriers, double standards, and disincentives to patients who seek access to our care.

For example, I was shocked to learn that the co-pay for patients in the federal health insurance benchmark plan here in Georgia will be $60 per visit.

Yes, you read that right—a $60 co-pay that is twice my average office visit. Certainly, this is an illusion of any real benefit and a barrier most people cannot afford.

So, doctor, how many of your patients can spell “Czechoslovakia”?

[You can find your own state’s benchmark plan by clicking here.]

The Beat Continues

Perhaps it was wishful thinking that chiropractors would finally find any resemblance of free enterprise on a level playing field in Obamacare.

After all, the ACA/ACC fought gamely alongside our champion in Congress, Sen. Tom Harkin (D-IA), to include Section 2706, the non-discrimination clause, to protect CAM providers from exclusion.

As to be expected, the AMA countered with its Resolution 241 to fight this clause to maintain its medical monopoly with inefficient and expensive care, the very cause of the current healthcare crisis (see Bitter Pill: Part 2).

During a recent interview, I was asked my opinion of the impact of Obamacare on chiropractors. I mentioned the favorable issues surrounding Section 2706 and the Medical Loss Ratio provision of the Affordable Care Act, also known as the “80/20 rule”, that requires insurers to spend at least 80% of each premium dollar on medical care and quality improvement, rather than on administrative costs, advertising, or executive salaries.

However, the most obvious failure of Obamacare was its inability to break up the medical cartel as the government historically had broken up AT&T, Standard Oil, and Microsoft to encourage free enterprise, the cornerstone of American enterprise.

However, as the de facto fourth branch of government, the medical industrial complex has dominated without any semblance of checks, balances, competition, or accountability considering its own medical clinical ineffectiveness, outlandish expense, and corruption have led to the present healthcare crisis in America.

Although Section 2706 does prohibit discrimination “to participation under the plan or coverage against any health care provider who is acting within the scope of that provider’s license or certification under applicable State law,” this clause does not mention equal access for patients or equitable payments to providers, problems we still face.

Aside from prohibitively high co-pays, some managed care organizations (MCOs) still use unfair tactics as seen in the ACA’s current lawsuit against ASHN and CIGNA whose unreasonable policies include:

• Use of false and misleading Explanations of Benefits relating to chiropractic claims,
• Manipulating charge and payment data,
• ASHN’s restrictions of care via the pre-authorization process
• ASHN and CIGNA’s imposition of excessive co-pay requirements on subscribers,
• CIGNA’s improper prevention of DCs from providing services that fall within their scope of practice,
• ASHN and CIGNA’s violation of various state prompt payment laws

In every instance where chiropractors have fought to gain inclusion, we have been stymied by these covert medical tactics to “contain and eliminate chiropractic.” Although unable to eliminate us, the medical cartel’s “wither on the vine” policy certainly has contained us with unrealistic treatment parameters.

Equal Rights, Not Double Standards

Chiropractors have battled the medical monopoly for decades via legislation and litigation to gain access to public hospitals (Wilk v. AMA) and government healthcare systems such as Medicare, workers’ comp, DVA, TRICARE military health services, federal employee health benefits, and now we face a similar situation with PPACA, aka, Obamacare.

Despite achieving inclusion, there remain double standards that thwart patients’ ability to gain access to our brand of care to help them.

• Despite the Wilk victory, only 6% of DCs have hospital privileges;[1]
• Medicare restricts chiro care to only 12 office visits per year for acute cases only while not allowing any care for chronic pain cases;
• Workers’ comp has a virtual boycott on chiro care;
• The DVA limits veterans to 6 office visits per year;
• TRICARE has yet to meet the law by implementing chiro care universally in the military health services; 
• Federal employee health insurance limits chiro care from 12 to 24 visits annually while allowing 75 to 90 visits to PTs.

Obviously these treatment limitations are arbitrary, ridiculous, and certainly not based on any “best practices” studies such as the Chiropractic Management Of Low Back Disorders: Report From A Consensus Process by Gary A. Globe, MBA, DC, PhD, et al., developed by the Council on Chiropractic Guidelines and Practice Parameters.[2]

Again, it is apparent these medical bureaucrats have chosen to marginalize chiropractors with clinical handcuffs rather than follow the realistic guidelines that would produce better outcomes to lower costs. “Squeeze care to expand profits” remains the mantra of these evil MCOs.

These double standards would be equivalent to allowing Jackie Robinson to play major league baseball, but demanding he play with one arm tied behind his back while racists spewed epithets at him.

Chiropractors know exactly how this feels fighting medical tyranny for equal rights while bound by double standards at every turn with medical trolls defaming our reputation.

Instead of being thrown under the medical bus as we once were before Wilk, now we have been forced to sit in the back of the bus waiting for our promised land that never seems to come.

But with Obamacare, there may be a change in who’s driving this medical bus.

New Bandwagon in Medicare: “Change the Incentives”

Obamacare includes Health Information Exchanges (HIE) that will download the massive amount of patient information from electronic health records uploaded to the cloud. These HIE will do comparative research studies to determine the “best practices” for each diagnostic code to improve outcomes and lower costs, a huge step in the right direction.

For example in spine care, currently there are 200+ various treatments available for low back pain, most of which have never been tested, and for those that have been tested, many have gotten poor results such as opioids, ESIs, and spine fusions.[3]  

[On a side note, considering the public is worried about privacy issues as we’ve seen with the alleged scandals at the NSA, IRS, and DOJ, just wait until the public realizes their health records will be on the internet. Don’t be surprised if the AMA, FOX News, and the Tea Party Republicans jump on this privacy issue to thwart Obamacare, not unlike the NRA’s reaction to gun control by suggesting the Second Amendment would be jeopardized if people were required to be licensed to own a gun.]

Once the HIE data accumulate millions of cases, the proof of cost and clinical-effectiveness will be undeniable for many conditions, foremost spine care.

Then even political medicine will not be able to shout down the results as it has done in the past with its arrogant attitude, “We won’t have government bureaucrats telling us how to practice medicine.”

We witnessed such a backlash to government regulation in healthcare in 1994 after the US Public Health Service’s Agency for Health Care Policy and Research (AHCPR) guideline #14 recommended spinal manipulative therapy as a “proven treatment” for acute low back pain before drugs, shots, or surgery.[4]

Of course, the spine surgeons went wild and immediately sued to block the study’s release, then politicked Congress with its Capitol Hill shill, Rep. Newt Gingrich (R-GA) who led the charge to gut the AHCPR’s budget and to discontinue its policy recommendations for best care practices as dictated by President George HW Bush and Congress in 1989. Yes, indeed, this was a Republican effort that so angered the spine surgeons.

After the NASS sabotaged this landmark study’s guideline, it attacked the members of the AHCPR panel, including Richard Deyo, MD, MPH, who later co-authored an article in The New England Journal of Medicine, “The Messenger Under Attack:  Intimidation of Researchers by Special Interest Groups.”[5] 

Dr. Deyo commented of such heavy-handiness to thwart progressive research:

“Attacks on health researchers are not new…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.”

Another comparative study (ALLHAT) on hypertension met a similar fate when research showed simple diuretics were the best blood pressure medicines to start with instead of medications.[6] Unfortunately, the drug companies “ganged up and attacked, discredited the findings,” according to Curt Furberg, the early leader of the trial.[7]  Once again political medicine and Big Pharma maintained control in healthcare by thwarting scientific progress.

Keep Hope Alive

Today the problem isn’t proving that our brand of spine care is effective for the epidemic of back pain since the comparative research studies beginning in the early 1990s have confirmed that conclusion.

Tony Rosner, PhD, said it best when he testified in 2003 before The Institute of Medicine: “Today, we can argue that chiropractic care, at least for back pain, appears to have vaulted from last to first place as a treatment option.”[8]

Scott Haldeman, MD, DC, PhD, affirms that every credible guideline on spine care now recommends “conservative care first.”

“The paradigm shirt has already taken place. Non-surgical, non-invasive care is already the first choice for treatment for spinal disorders in the absence of red flags for serious pathology in virtually all guidelines.”[9]

A recent publication by the ACA-ACC-COCSA-ICA, “Chiropractic Physicians: A Low Cost Solution to High Cost Healthcare,” also chronicled the most recent studies favoring chiropractic care. As this paper concludes, “These results suggest that insurance companies that restrict access to doctors of chiropractic may, inadvertently, be paying more for care than if they removed these obstacles.”

Say Goodbye to Fee-for-Service

If Obamacare prevails, there may be hope to circumvent such antics by political medicine. The health insurance industry may be finally listening to the researchers now that American healthcare is nearly broke.

In a concerted effort to lower costs and improve outcomes, Medicare plans to pay less to underperforming physicians and hospitals, which may be one avenue for DCs to shine.

According to a recent article in The Washington Post, Medicare plans to provide “resource use” reports to doctors nationwide. The goal is to reward improved outcomes by paying more to doctors who provide quality care at lower cost to Medicare, and reducing payments to physicians who run up Medicare’s costs without better results._^[10]

Of course, this is music to our chiropractic ears. Now we DCs need to jump on this bellwether bandwagon to end the bottleneck in American healthcare—the fee-for-service reward system that emphasizes perverse economic and practice incentives such as:

• volume over quality care;
• high-priced surgical procedures over low-cost non-invasive, conservative treatments;
• non-evidence based practices over best-practices,
• including “inefficient” medical spine care over chiropractic care.[11]

This call for reform has been echoed recently by the USA Today’s Opinion debate over healthcare. “Fee-For-Service Rewards Volume: Our View” by the Editorial Board of USA Today on July 7, 2013 clearly attacks “a health care system that’s already riddled with waste and costs too much.”

 “And yet, as a USA TODAY investigation found, patients continue to be wheeled into operating rooms tens of thousands of times a year for operations they simply don’t need… At worst, such surgeries can kill or disable patients, or leave them in chronic pain…Even when unneeded operations go well, they cost money that patients and insurers don’t need to spend, further stressing a health care system that’s already riddled with waste and costs too much.

“What to do?

“In some cases, the answer is obvious. The most notorious unneeded surgeries are done by physicians who are so greedy, incompetent or crooked that they shouldn’t have a medical license. State medical boards can be lax about cracking down on them, and this should change.

“But those failings are just a very small part of the problem. Much more pervasive are the unnecessary surgeries (and tests and other procedures) that occur every year because of the way most Americans and their insurers pay for health care.

“This fee-for-service model rewards volume rather than outcomes. The more procedures that physicians, hospitals and other providers perform, the more money they make.

“Ideally, doctors do no more than a patient needs. In practice, with incentives pointing exactly the wrong way, it’s just too easy to do more, whether it’s to pad a bill or simply to resolve a judgment call where surgery might not be the best answer.”

The answer to this medical exploitation is stated in the subtitle of this USA Today article—“to curb unnecessary surgeries, change the incentives”:

 “Medicare conducts after-the-fact audits of surgery and other procedures to see whether what doctors did was necessary, and private health insurers may require stricter pre-authorizations for surgery commonly overused, such as operations for back pain. Doctors are also increasingly being pushed to follow evidence-based guidelines that can dictate when surgery makes sense and when it does not.

“Finally, one of the most effective ways to cut down on unnecessary operations is for doctors to share the decision-making with their patients by pointing out alternatives and encouraging second opinions.”

A top Medicare official recently told the Senate Finance Committee that “it will take about five years before the federal government’s much-maligned fee-for-service formula for paying doctors can be fully replaced.”^[12]

Changing the incentives, punishing abusers, implementing “best practices” guidelines, and offering CAM alternatives are great recommendations that we chiropractors should also publicly endorse.

Incentivise the Patients

Another recommendation to lower costs in spine care is to incentivise conservative chiro care as the first option in spine care.

By encouraging patients via incentives to seek “best care” spine practitioners like DCs, the nearly $300 billion spine care annual costs could be cut in half. Considering Elliot Fisher, MD, of the Dartmouth Institute for Health Policy & Clinical Practice admitted 40% of spine surgeries are unnecessary, the savings chiropractic care offers will be in the billions.[13]

Just as some insurance companies give non-smoker incentive discounts, insurers should also make it financially favorable to patients to see a chiropractor first with financial incentives such as lower co-pays. For example, health insurance companies could establish a $10 co-pay as an incentive to encourage patients to seek our conservative care first as it should be according to the current guidelines.

This tactic would also be in compliance with Sec. 2706 that also clearly states in the rarely-mentioned second paragraph:

“Nothing in this section shall be construed as preventing a group health plan, a health insurance issuer, or the Secretary from establishing varying reimbursement rates based on quality or performance measures.”

On the other hand, the most obvious disincentive to improving spine care and lowering costs would be to allow the proposed BCBS $60 co-pay that will discourage patients from seeking our care. Certainly this flies in the face of the policy recommendations by the IOM and Medicare to incentivise best care.

This accumulating evidence is now changing policy at some insurance companies like North Carolina BC/BS that announced it will no longer pay for disc fusion if the sole criterion is a bad disc.[14] They consider a “bad disc” diagnosis to be a clinical finding, but not a diagnosis since “bad discs” are ubiquitous in pain-free people.[15]

Another positive policy change concerning chiropractic care for chronic low back pain occurred when the University of Pittsburgh Medical Center Health Plan announced as of January 1, 2012 candidates for spine surgery must include verification that the patient has “tried and failed a 3-month course of conservative management that included physical therapy, chiropractic therapy, and medication.”[16]

When chiro care becomes the first resort instead of the last resort, it will help millions and save billions. The key may be to hold the policy makers to the research: are they going to follow the evidence-based guidelines or cave into the medical opposition once again?

In the meantime, the chiro coalition of ACA/ACC/ICA/COCSA and the F4CP should be shouting these policy changes from the top of the Washington Monument.

Regrettably, many people in the public and press, politicians on Capitol Hill and some providers in the medical profession remain convinced back pain is primarily due to “bad discs” (pathoanatomical) instead of mechanical dysfunction (pathophysiologic).

Until this paradigm shift from discs to joints occurs in regards to this outdated misunderstanding, there will not be a paradigm shift in clinical care that emphasizes SMT over drugs, shots, and spine surgery. Without such understanding, people may see guidelines promoting conservative care first over medical spine care as just another intrusion into their privacy.

Just as the Voting Rights Act enabled millions of minorities to vote without hindrance, it’s past time we DCs enlightened the public to the new research and guidelines that support our brand of spine care. As Scott Haldeman confirmed, “the paradigm shirt has already taken place.”[17]

Indeed, just as black voters no longer have to spell “Czechoslovakia,” it’s time to end the hoops and hurdles our patients and chiropractors now face in healthcare.