The Lancet Elephant
Part 3: Follow the Money
Famed Washington Post investigative journalists Bob Woodward and Carl Bernstein describe the adage that kept them on the hunt of President Richard Nixon and his White House gang during the Watergate caper to not only, “follow the money but follow the lies.”
Certainly the spine surgeons, pain management clinics and the entire lot of medical spine cartel providers have a lot of money to follow, so now let’s follow their lies, too.
It would be naïve to address the pandemic of LBP without a realistic attitude about the money involved in this $100+ billion medical spine industry. Although in a normal free enterprise system, the cheapest mousetrap should prevail in terms of clinical and cost effectiveness, in fact, the opposite is true in American healthcare.
The panel addresses this sordid situation that remains a big hurdle to access and implementation:
Panel 2: What should well-informed policy-makers know about low back pain?
- Back pain and related disability are expensive problems that are difficult to solve and have not received adequate attention from policy makers
- Ineffective, low-value care should be eliminated [drugs, shots, surgery]
- Increased investment in implementation research could uncover why evidence is not being taken up in practice and identify and test strategies to ensure rapid uptake of evidence into clinical care
Although the panel asked great questions, it did not supply any great answers. Again, if there had been an American chiropractor on the panel, it might have been better able to answer its own questions, so let me take a shot for them in absentia.
Who’s on First?
If free enterprise on a level playing field were the case, unquestionably chiropractors would be the POE for all LBP cases as Optum and the Tennessee BC/BS studies have shown. Instead, we still see inept MDs as the POE who continue to railroad patients to drugs, shots, and surgery often leading to the inevitable train wreck of disability.
The proposal for DCs to become POE for MSDs was answered by two investigations. A 2013 internal analysis by Optum Health of 1.4 million non-surgical back pain episodes determined the best track to take for cost efficiency begins with a patient consulting a chiropractor first. When a chiropractor was the first provider, treatments were:
“well-aligned with clinical evidence; the least fragmentation of care; low rates of imaging, injections, and prescription medications; and low total episode cost when manipulation is introduced within the first 10-days of the episode.”
They also found when manipulation was not provided at any time during the patient’s treatment that it to lead to higher total episode costs when using only medical spine care methods.
Since MDs generally are not trained in musculoskeletal disorders, the Optum researchers also questioned, “Are the other specialties functioning as the portal of entry for spinal episodes prepared to manage spine patients?”
In terms of training and clinical effectiveness, absolutely not, but in terms of perverse financial incentives, they are happy to do so.
An investigation of comparative spine treatments by Tennessee BCBS issued a 2010 report that also found DCs were the most efficient portal of entry for LBP:
Paid costs for episodes of care initiated with a DC [chiropractor] were almost 40% less than episodes initiated with an MD [physician]. Even after risk adjusting each patient’s costs, we found that episodes of care initiated with a DC were 20% less expensive than episodes initiated with an MD.
Non-surgical spine care is relatively inexpensive on a per episode basis ($1,008) compared to surgical cost at nearly $35,000. The data also show non-surgical spine episodes starting with a DC have the lowest total episode cost compared to MD-PCP, MD-PMR, PT, or Ortho-Surgeon. 
Mark Schoene, a panel member and associate editor of an international spine research journal, The BackLetter, commented on the proposal by the National Pain Strategy (NPS) to use MDs as the portal of entry for chronic pain patients:
The draft report of the National Pain Strategy mentions the services of chiropractors and complementary/alternative providers—who play such a prominent role in the management of low back pain in the U.S. (They account for as many as 50% of back care visits.)
However, the report envisages a future where primary care physicians and pain specialists will play the most prominent roles in the prevention and management of chronic pain. Regarding low back pain, at least, this may not be a balanced and realistic view. It may exaggerate the capabilities of both primary care physicians and pain specialists—and downplay the potential contributions of other health professionals.
Primary care physicians and pain specialists don’t have unimpeachable backgrounds in the management of chronic pain in the U.S. these are the medical professions primarily responsible for the opioid overtreatment crisis. Are the two professions that helped create the worst pain management crisis in history of modern medicine capable of leading the way forward? That remains to be seen.[i]
Erin E. Krebs, MD, MPH, also mentioned the intended audience of the CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016 were the primary care providers who created the opioid crisis with the focus on opioid prescribing for adult patients with common problems such as back pain and arthritis pain. She admitted lack of access for patients and the refusal to refer to non-MDs remain big problems:
“Lack of access to other pain treatments is part of the reason for opioid over-prescribing. We have evidence-based treatments for pain — mostly low tech, high touch treatments — that most people with chronic pain can’t access.”[ii]
This becomes a policy issue by payers as well as clinical bias by MDs who remain entrenched in their old ways of “a pill for every ill” and their relentless bigotry — chirophobia.
The panel’s sentiments were strikingly similar to those of an article in the July 29, 2013, edition of JAMA Internal Medicine journal that highlighted the Worsening Trends in the Management and Treatment of Back Pain, a rather shocking admission for JAMA to print, don’t you think? The authors spoke of the downside of medical spine care as well as the gap between evidence and practice:
“Back pain treatment is costly and frequently includes overuse of treatments that are unsupported by clinical guidelines. Few studies have evaluated recent national trends in guideline adherence of spine-related care.”
Recent meta-analyses and research35,36 of lumbar fusion surgery have not revealed improvement in patient outcomes and demonstrate that these procedures lead to significant adverse consequences, including 5.6% with life-threatening complications and 0.4% mortality.
We also found a 50.6% decrease in first-line NSAID or acetaminophen use accompanied by a 50.8% increase in narcotic prescriptions, including a near doubling among patients presenting with chronic back pain. A recent meta-analysis37 revealed that narcotics provide little to no benefit in acute back pain, they have no proved efficacy in chronic back pain, and 43% of patients have concurrent substance abuse disorders, with aberrant medication-taking disorders as high as 24% of cases of chronic back pain.
Finally, the significant increase in spine operations seen during the last decade is almost certainly related to the overuse of imaging. One study45,46 revealed that early MRI for acute back pain was associated with an 8-fold increased risk of surgery, whereas another found that regions with more MRIs perform more operations, with 22% of the variability in spine surgery rates explained by rates of spine MRI use—more than twice the predictive power of patient characteristics.
The study concluded:
Despite numerous published clinical guidelines, management of back pain has relied increasingly on guideline discordant care. Improvements in the management of spine-related disease represent an area of potential cost savings for the health care system with the potential for improving the quality of care.
Although The Lancet’s and JAMA’s assessments are spot on, we cannot change a tiger’s stripes, especially when this tiger is the most powerful predator in the medical jungle protecting its turf of $100 billion — the medical spine industrial complex consisting of spine surgeons, hospitals, anesthesiologists, MRI centers, device hardware manufacturers, pain management, rehab, etc.
And just as the NASS attacked the 1994 ACHPR guideline #14 on acute low back pain in adults that was highly critical of medical spine care, and just as primary care physicians have ignored the 2017 ACP and JAMA LBP guidelines, we can expect the same indifference to The Lancet conclusions.
In fact, they like the status quo just as it is now with MDs in charge of this huge market.
Not only are most MDs notoriously prejudiced against CAM providers, there is no incentive for them to refer to chiropractors since musculoskeletal problems account for up to 25% of general practitioner consultations.
There is simply too much money at stake to fill the gap between evidence and practice, which explains when the panel wondered:
- why evidence is not being taken up in practice and identify and test strategies to ensure rapid uptake of evidence into clinical care
After the ACP, JAMA, FDA and Joint Commission guidelines were disseminated, there was no rush by MDs to refer LBP patients to chiropractors for conservative care. Pride, prejudice and profit are just too embedded in the medical profession to refer patients to competitors, especially those damn chiropractors.
I believe the only way to stop this medical malpractice is to enforce the Informed Consent laws that require every provider to discuss the procedures, benefits, risks, and alternatives to his/her care.
All physicians are still legally and ethically required to mention chiropractic care is a recommended alternative before acquiring written consent from patients and before treatment is rendered according to the New Jersey Supreme Court.
According to a case Jean Matthies v. Edward D. Mastromonaco, DO, argued before the Supreme Court of New Jersey on February 19, 1999, a unanimous decision was handed down when a doctor was sued for lack of informed consent.
The Supreme Court of New Jersey ruled on the need for full disclosure for Informed Consent in the case of MATTHIES V. MASTROMONACO [Supreme Court of New Jersey. 160 N.J. 26, 1999]:
“For consent to be informed, the patient must know not only of alternatives that the physician recommends, but of medically reasonable alternatives that the physician does not recommend. Otherwise, the physician, by not discussing these alternatives, effectively makes the choice for the patient… By not telling the patient of all medically reasonable alternatives, the physician breaches the patient’s right to make an informed choice.”
This decision extended the rights of the patient with regards to alternative medical treatment in general:
“Like the deviation from the standard of care, the doctor’s failure to obtain informed consent is a form of medical negligence. Recognition of a separate duty emphasizes the doctor’s obligation to inform, as well as treat, the patient.”
Unquestionably, the lack by the physician to mention chiropractic care as a reasonable alternative in spine care during Informed Consent has led to the current rampant use of opioid painkillers, epidural steroid injections and spine fusion.
TRICARE regulations also speak of the importance of Informed Consent according to TRICARE® Provider News, Feb. 2017, “Improving Patient Safety through Informed Consent:”
The process of obtaining informed consent is an essential component of patient safety. Informed consent is “a process of communication between a clinician and a patient that results in the patient’s authorization or agreement to undergo a specific medical intervention”… In addition, the consent form itself may lack basic information, such as the nature of the procedure, risks, benefits, and alternatives.
Perhaps in countries with nationalized healthcare without a strong profit motive such recommendations may be possible, but it’s a horse of a different color here in the USA where medical spine care is out of control as the largest expenditure in all healthcare.
Obviously there is absolutely no motivation for MDs to refer to DCs when profit rules over principle. Perhaps Ralph Nader put it best when he said, “The use of solar energy has not been opened up because the oil industry does not own the sun.”
As an attorney once told me at a workers comp conference explaining why DCs are boycotted by WC insurance companies even though we’re legally covered, “You’re too cheap.”
Stay tuned for Part 4: Minimal Mass Media where we’ll follow more medical lies
 Thomas M. Kosloff, DC, David Elton, DC, Stephanie A. Shulman, DVM, MPH, Janice L. Clarke, RN, Alexis Skoufalos, EdD, and Amanda Solis, MS, Conservative Spine Care: Opportunities to Improve the Quality and Value of Care, Popul Health Manag. Dec 1, 2013; 16(6): 390–396.
 Liliedahl RL, Finch MD, Axene DV, Goertz CM. Cost of care for common back pain conditions initiated with chiropractic doctor vs. medical doctor/doctor of osteopathy as first physician experience of one Tennessee-based general health insurer. J Manipulative Physiol Ther. 2010;33:640–643 [PubMed]
 John N. Mafi, MD; Ellen P. McCarthy, PhD, MPH; Roger B. Davis, ScD; Bruce E. Landon, MD, MBA, MSc. Worsening Trends in the Management and Treatment of Back Pain, JAMA Internal Medicine, September 23, 2013, Vol 173, No. 17
 J Nixon MA FRCS, Intervertebral disc mechanics: a review, Journal of the Royal Society of Medicine Volume 79 February 1986
 Jean Matthies v. Edward D. Mastromonaco, DO. Supreme Court of New Jersey [A-9-98], Pollock J. Judgment dated July 8, 1999.
[i] Why Should the National Pain Strategy Be MD-Centric? BackLetter: February 2016 – Volume 31 – Issue 2 – p 16
[ii] “What the CDC’s Opioid Prescribing Guidelines Mean for Primary Care Physicians,” Clinical Pain Advisor, February 19, 2016