Medical Merry-Go-Round

by

JC Smith, MA, DC

 THE INSTITUTE OF MEDICINE (IOM) IS AGAIN CRITICIZING the American healthcare delivery system, this time in an April, 2001 article blasting the healthcare system as a “tangled, highly fragmented web that wastes resources to provide safe, high-quality care to millions of Americans.” Didn’t we hear the same sentiments about waste, fraud and greed in 1994 when Clinton started the Health Care Reform Act? Indeed, the more health care has changed with managed care, the more the same problems still exist.

“The system is failing because it is poorly designed,” says William C. Richardson, chair of the committee that wrote the report and president of the WK Kellogg Foundation. Whether it’s poorly designed or riddled with junk science using too many outdated, ineffective methods with greedy practitioners and biased administrators ignoring the better mousetraps such as chiropractic care, there is no doubt the trillion dollar plus health care industry in the US needs urgent critical care.

As we all know, the state of healthcare in our country is in dire straits—costs go up while access and quality care goes down. Last June the World Health Organization announced that the United States ranked 37^th in the world in healthcare delivery systems, allthewhile costing over $1.2 trillion. Strangely, France and Italy were first and second on their list, while the UK was 16^th, still better than the US by far, and costing a whole lot less. (In fact, only the US and South Africa healthcare systems still work on a for-profit system; the rest have all turned to some type of socialized system since the expenses were so huge beforehand.)

Previously on March 2, the Institute of Medicine, a part of the National Academy of Sciences, a private organization chartered by Congress to advise the government on scientific matters, released its report, “Crossing the Quality Chasm.”

“Despite the major advances in medical research and disease treatment, the American healthcare system is failing to improve the care of patients,” according to these experts. This former report also states, like the latest IOM report, the most troubling aspect is that proven methods that can save lives and improve patient outcomes are not being used in everyday practice.

When he tells chiropractors this, he’s merely preachin’ to the choir. After the release of the AHCPR guideline on acute low back pain in adults, the “proven method” of SMT was ignored by the medical society, government agencies and insurance companies. Indeed, what good is research, controlled studies, or clinical practice guidelines if everyone ignores them?

What the IOM fails to realize is the “perverse motivation” of the cost-plus for-profit system of the American insurance industry that profits by preferring surgery to non-invasive methods. Indeed, there is little interest on their part to lower medical expenses that, in turn, would lower their profit margin. Until this perverse motivation is solved (via socialized medicine), the powers-to-be will continue to ignore proven methods that are cheaper. Only in healthcare is the better mousetrap shunned.

The IOM continues to push steps toward quality care that will probably be ignored by the medical profession just as they ignored the federal guidelines recommended by the AHCPR, Manga (Canada), Clinical Standards Advisory Group (UK), and other prominent research bodies. Although the IOM’s conclusions are well intentioned, they will also fall on deaf ears just as the AHCPR’s guidelines were ignored. The medical status quo likes the present system just the way it is—very lucrative and under their complete control. Changes be damn is their motto, or so it seems. Thinking out of the present medical box is just not their cup of tea, nor is admitting that chiropractic care is better than medical care for most back problems.

This recent article by the IOM suggests a few recommendations to assure system-wide quality care:

1. The Agency for Health Research and Quality should identify at least 15 common, chronic health conditions that require ongoing care and monitoring. [No doubt chronic spinal problems would fall into this very nicely]
2. Health plans, healthcare professionals, hospitals and purchasers should develop strategies to improve care for each of the identified conditions over a five-year period.
3. The Department of Health and Human Services should monitor and track quality improvement in six key areas: safety, effectiveness, responsiveness to patients, timeliness, efficiency and equity.
4. The HHS secretary should report annually to Congress and the president on progress made in the six areas.
5. Public and private purchasers should develop payment policies that reward quality.
6. The federal government should use input from relevant public and private interests to test and evaluate payment options that agree with quality improvement goals.
7. Patients, plans, providers and purchasers work as a team united by information technology
8. Patients and healthcare professionals communicate through email.
9. Automated medication entry-order systems reduce errors in prescribing and dosing drugs

10.  Computerized reminders help patients and clinicians identify needed services.

If the IOM wants “best practices” to promote, I suggest they look seriously at comprehensive chiropractic care as the solution to the epidemic of back pain. Not only will 9 out of 10 adults suffer from an episode of LBP, costing upwards of $50 to 75 billion annually in the US alone, now the National Academy of Sciences admits this back crisis is worsening. In The Back Letter (vol. 16, # 3, 2001), the NAS reports that “musculoskeletal disorders (MSDs) represent the most common cause for disability among workers in their 50s and 60s… and projections suggest that these figures are rising.”

According to the recent NAS report, MSDs are the most common reason for seeking health care after respiratory conditions, and back pain is the most common musculoskeletal reason for a health care visit. “For 1989, it was estimated that there were 19.9 million visits for back pain, 8.1 million for neck pain, and 5.2 and 5.7 million for hand and writs pain, respectively,” according to the NAS report.

This report also notes that MSDs account for nearly 70 million physician office visits in the US every year and an estimated 130 million total health care encounters, including outpatient, hospital, and emergency room visits. In addition, nearly one million US residents took time off from work because of a MSD in 1999.

No one doubts back problems are huge and costly in the US, yet the powers-to-be have constantly ignored the evidence-based reports recommending SMT for patients with back pain. Here’s just a short list of major reports that support SMT as reported by David Chapman-Smith in his Chiropractic Report:

1. RAND in 1991
2. Mercy Center in 1993
3. Manga in 1993
4. Glenerin (Canadian Chiropractic Association) in 1994
5. AHCPR in 1994
6. Clinical Standards Advisory Group (UK govt) in 1994
7. Royal College of General Practitioners in 1996

You can also include other governmental studies from Denmark, Sweden, Australia, New Zealand, and Scotland to name a few of the many industrialized countries where back problems are epidemic and whose studies all showed that SMT is the preferred choice of treatment for LBP.

Although this article was well intentioned, probably the most difficult statement to understand in The Back Letter article was its conclusion, sub-titled “Truth Likely to be Complex.”

“The ultimate truth about the causes of low back pain and LBP disability is likely to be more complex than the discussion in this report indicate. It is worth noting that scientific studies have not yet even determined the anatomic sources of most low back pain. The etiology of LBP remains obscure, despite the best guesses and inferences of prominent researchers. Bearing these facts in mind, it is important not to leap to conclusions until better evidence becomes available.”

Uh? Just under what rock has this editor been hiding? How can anyone dispute the above-cited major evidence-based reports and governmental studies and still ask us, “not to leap to conclusions until better evidence becomes available”? Just what is this editor waiting to hear? Even if God Almighty spoke from on high recommending chiropractic care, these medical folks would still turn a deaf ear.

This unenlightened conclusion simply illustrates the blind eye the medical profession has taken when it comes to research supporting their chiropractic nemesis. They simply cannot give credit where credit is due when it might take money out of the medical pockets, no matter what expert panel or researchers have to say.

For example, Richard Deyo and his co-author, James N. Weinstein, published an article a few months ago in The New England Journal of Medicine about Primary Care and LBP. While they were willing to admit the excesses of the medical interventions for LBP, such as surgery based on the fallacy of a diagnosis made solely from imaging scans of abnormal disks, they also seemed to have great difficulty admitting the actual causes and best treatments for this epidemic.

In their Table 1: “Differential Diagnosis of Low Back Pain,” they did show that “Mechanical Low Back or Leg Pain” constituted 97% of these cases, of which “lumbar strain, sprain” accounted for 70% of these cases; “Nonmechanical Spinal Conditions accounted for “about 1%”; “Visceral Disease” accounted for 2%. While Deyo admits that most LBP stems from mechanical problems, he just cannot bring himself to suggest that perhaps the chiropractors have been right all along with their vertebral subluxations / joint dysfunction concepts.

Dr. Deyo published another article in 1998 in the Scientific American titled “Low-Back Pain.”[1] He mentions, “Calling a physician a back-pain expert, therefore, is perhaps faint praise–medicine has at best a limited understanding of the condition. In fact, medicines’ reliance on outdated ideas may have actually contributed to the problem.”

Despite his willingness to reject MDs as experts in LBP as he debunks the “slipped disk” theory as the main cause of back pain, he has great difficulty to admit that the human spine, consisting of 137 joints, is very susceptible to joint dysfunction as the cause of pain. Even his recommendation of SMT is laughable at best, and downright insulting to DCs, and even smacks of malpractice at its worst.

“Spinal manipulation and physical therapy are alternative treatments for symptomatic relief among patients with acute or subacute low back pain, but their effects are limited. In general, we recommend delaying referral for manipulation or physical therapy until an episode of pain has persisted for three weeks, because half of the patients spontaneously improve within this period.”

So, according to Deyo, 70% of LBP is of “idiopathic,” unknown origin and “spontaneously improves within this period” of three weeks. Of course, the root word here, “idio,” is actually short for “idiot.” While the cause of LBP may be unknown to biased MDs who are mostly idiots when it comes to the management of these cases (their unfounded reliance on “slipped disks, pulled muscles, drugs and surgery are testament to that claim), we DCs know the real cause rests in dysfunctional joint play. And his suggestion to withhold SMT for 3 weeks borders on cruelty, if not sheer malpractice. (I wonder if he would recommend a patient with chest pains to wait 3 weeks too?)

Just as the medical profession ignored the AHCPR guideline on LBP, medical researchers seem to live on a merry-go-round where they examine the problem, research the best solutions, and then ignore their findings if they conflict with the status quo methods, only to suggest they don’t have any answers, and then warn us to “not to leap to conclusions until better evidence becomes available.” So, we’re right back at the start.

Not only do medical researchers suffer from myopia and work with biased blinkers on, they also must fear the wrath of their own colleagues as Deyo experienced after the AHCPR guideline on LBP was released in December of 1994. Shortly thereafter, these researchers were sued by their own orthopedic society! In an article published in the NEJM, these two confessed their frustration of doing research that conflicts with orthodoxy. As they concluded, the only research that will see the light of day must conform to the wishes of the status quo or else it gets buried in file 13.

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.  As a former member of the AHCPR panel, Dr. Deyo, also co-authored an article in The New England Journal of Medicine, “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.”[2] Ironically, the special interest group he is referring to is his own orthopedic society.

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. Apparently offering a better service at a lower price not only is disadvantageous, but it creates a backlash from the powers-to-be. Considering back problems is the number three reason for hospital admissions, if chiropractic care was in every hospital, there would be a lot of disgruntled orthopedists and hospital administrators losing a lot of money.

Until the medical researchers begin to look outside their own box for solutions to the many chronic health problems, we will continue to be stymied by their inability to tell the truth about this epidemic of LBP. As mentioned already, there are plenty of evidence-based reports recommending SMT for patients with LBP, but the leaders of SMT—DCs—still remain outside the loop because we’re too cheap and we’re not MDs. This medical merry-go-round, or should I say, run-around, will continue to spin off feeble excuses as they ignore the obvious facts in front of their faces.

If the IOM wants to re-invent the health care delivery system, they must circumvent the medical profession that has shown itself to be untrustworthy in this matter. Simply put: A monopoly is not interested in re-inventing itself, nor is it willing to offer consumers freedom of choice or competitors distributive justice. The only solution is to break up the AMA cartel just as Microsoft was so ordered by a federal court.

As Mr. Richardson mentioned, “the system is a maze for many patients, and as a result, many do not receive the services from which they would likely benefit.” Indeed, the medical mentality firmly believes the answer to all ailments rests with more drugs or more surgery, and nothing else. This medical dogma reminds me of AH Maslow’s famous saying, “If you’re only tool is a hammer, everything looks like a nail.”

As long as the AMA’s members control the hospitals, sit on the boards of major insurance companies, workers’ comp, and government agencies, we will never see this mess of a medical maze improve. Obviously self-preservation supercedes the Hippocratic oath in American healthcare. How else do you explain the ungodly amounts of unnecessary expensive surgeries, over-priced hospitalizations, and the billions of pills poured down patients’ throats daily? Despite the over-use of many medical services, the US still leads the world in every category of chronic degenerative diseases. So, what’s wrong with this medical formula?

Not only can the AMA not re-invent itself, they cannot even look out of the box for fear of retribution, litigation, and loss of income, as Deyo experienced. Indeed, thinking out of the medical box is not good for the AMA’s own health. We’re stuck in a medical rut that will not change itself from within and, as it showed during Clinton’s Health Care Reform Act, they will fight tooth-and-nail any attempt for reform from the outside.

While I applaud the IOM’s intent to improve patient care, the only health reform to come will occur from the restlessness and discontent of millions of Americans who finally have had enough paying huge premiums for ineffective and limited medical care. Until the public screams at their own legislators to demand changes, we all will suffer from the boxed-in thinking of a medial-pharmaceutical-hospital cartel.

But, as we’ve seen with the past failure of Congress to pass a Patients’ Bill of Rights, that day may never come as long as the medical/ insurance lobby remains as strong as it has been. Every attempt at health care reform, starting with President Harry Truman and every president since, the medical monopoly has been able to kill any legislation aimed at improving consumers’ rights. The AMA is definitely not letting go of this cash cow even in light of the rising costs and poor patient care.

During the NCLC, I asked Sen. Cleland’s health aide, Tamara Jones, PhD, whether or not we will ever have socialized medicine in the US. Of course, she flinched then asked me what I thought. Considering the average American baby boomer may have the routine heart surgeries, back surgeries, cancer surgeries, hysterectomy, gall bladder, drug therapy, hospitalization, long-term care, to name just a few major expenses, I wonder how the insurance companies can afford this huge sum of money?

With the current poor quality medical care and the on-going degeneration of the baby boomers, I envision increasing costs, not lowering expenses, in the future despite the guise of HMOs. The medical arsenal of drugs and surgeries can do nothing to prevent disease or to maintain health, consequently the onset of more diseases is inevitable. Obviously the medical profession will never embrace the “ounces of prevention” instead of the “pounds of cure.”

Indeed, health care costs will become the number one expense for all Americans—more so than home mortgages, car loans and even college tuitions. When the insurance companies see their lack of cash reserves to cover these huge costs, they will sell out their stock holdings and this mess will inevitably fall into the lap of the government to solve. Then we will have Medicare for everyone like Canada. Mark my word.