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January 2005, Vol. 15, No. 1
Table of Contents
ACA's New CCGPP Guidelines • An Opinion of Shortcomings CBP® • ASHN: Chiropractic Enemy • CBP® fosters international Research Collaboration • CBP® Research Corner • Contraction/Expansion Mentally • COX Inhibitors and the FDA • Counter Point • Do You Practice CBP®? • Don's Opinion • European Spine Accepts CBP® Clinical Control Trial • Regarding the Use of Body Weighting • SAC Reaffirms Life University's Accreditation • Spine Accepts CBP® Research • The Diminishing Return Triangle • Traction Details • Validity of PosturePrint™
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ASHN: Chiropractic Enemy
By Jason O. Jaeger, DC
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Dr. Jaeger has been a local Chiropractor in Las Vegas since 2001 where he has brought his passion for health and wellness to the community that he and his family have called home since the late 1940’s. He is a husband to his lovely wife Carrie and father of two boys, Aden and Sebastian. Dr. Jaeger attended UNLV during his undergraduate program and graduate school at the Southern California University of Health Sciences 95’-00’. As class representative and Student American Chiropractic Association Vice President SCUHS chapter, he successfully lobbied in Washington DC for such issues as Medicare and HMO reform. Dr. Jaeger participated in a rotation through Cal State Northridge’s prestigious Physical Therapy program were he successfully integrated neuromusculoskelatal therapies on paralysis and stroke victims. He is a certified fellow in the CBP® technique. Dr. Jaeger is licensed to practice Chiropractic in Nevada, Arizona and California. Dr. Jaeger is proud to bring his experience and enthusiasm to the Southern Nevada community.
Many of us have had our patients’ claims cut, reduced, and/or restricted by American Chiropractic Network (ACN) or American Specialty Health Networks (ASHN). I laughed recently when I saw an article published by authors with some apparent ASHN financial conflict of interest (Legorreta AP et al. Arch Intern Med 2004; 164: 1985-92), in which they claimed superiority of Chiropractic care over medical care alone (by comparing health plans with and without chiropractic coverage). On the surface, this article appears to praise chiropractic care when included in health plans, but to me, it appears to be an advertisement for ASHN. When I read the frequency of chiropractic care visits listed in the article, I wondered what state that data was compiled from? I note that ASHN allows no such benefits in California or Nevada. In fact, in a recent newsletter, the California Chiropractic Association (CCA) stated that its June 2001 landmark lawsuit against ASHN is still progressing. I wondered if this Legorreta et al 2004 article was an advertisement for ASHN to other Insurance companies to come running to ASHN for administering their chiropractic coverages?
Recently, I was rejected from ASHN as a provider (see my letter at the end of this article).
Additionally, I was very disappointed in ASHN’s use of opinion articles (as compared to facts) on x-ray usage and x-ray exposure. ASHN’s opinion comes from a chapter by Reed Phillips, DC, PhD, DACBR in Haldeman S et al. Guidelines for Chiropractic Assurance and Practice Parameters. Aspen, 1993. As an LACC graduate, I respect Dr. Phillips, but I wonder why he would write an opinion that would restrict chiropractic care, not only hurting LACC graduates but also hundreds of field practitioners. Dr. Phillips’ opinion on x-ray usage and x-ray exposure is not supported by facts. For example, “It is about 100 times more likely that cancer will be produced in the average individual by some other cause than by radiation.”1 In fact, Kauffman4 stated that there is evidence that medical radiography has health benefits rather than health risks! For other examples, I refer the reader to four articles:
1) International Atomic Energy Agency, “Facts About Low-Level Radiation,” American Nuclear Society, 1982.
2) Maurer EL. Risk perspective. Dynamic Chiropractic 1990;8: (http://www.chiroweb.com/archives/08-14/11.html).
3) Cohen, BL, Lee, IS. A Catalog of Risks. Health Physics 1979; 36: 707-22.
4) Kauffman JM. Diagnostic Radiation: Are the Risks Exaggerated? J Amer Physicians Surg 2003; 8(2): 54-55.
I thought that AJCC readers might be interested in my “low risk” evidence for plain film radiography and my letter to ASHN, reprinted below. I hope you might get some ideas from my letter when dealing with ASHN.
MOUNTAIN WEST CHIROPRACTIC
Chiropractic Certification in Spinal Trauma Member: International Chiropractic Association
Dr. Albert G. Simoncelli, DC, CCST
Dr. Kenneth M. Bahoora, DC, PC
Jason O. Jaeger, DC, PC 1050246
August 08, 2004
American Specialty Health Networks
Attn: Appeals Committee/ Clinical
Quality Management Department
PO Box 509001
San Diego, CA 92150-9001
RE: Non-Approval Appeal
Dear Sirs or Madams:
The purpose of this letter is to initiate the appeals process for review of denial for participation in American Specialty Health Networks or ASHN. This letter is being written on behalf of Dr. Kenneth M. Bahoora and Dr. Jason O. Jaeger. We currently practice at:
321 North Pecos Road, Suite 200
Henderson, NV 89074
Please note that our third location in North Las Vegas will be opening fourth quarter 2004. The address of that location is:
5575 Simmons Street suite 12
North Las Vegas, NV 89031
In response to your three bullet points used as basis for your denial, you wrote:
• “The practitioners multiple sectional full spine x-ray protocol, as described on the submitted application, has not been proven or supported by established scientific rational and/ or the frequency of obtaining radiographs as described appears to indicate the use of x-ray as a screening procedure. Radiography of patients as a screening procedure is not appropriate. (Haldeman S etal. Guidelines for Chiropractic Assurance and Practice Parameters. Aspen1993). The potential diagnostic benefits of performing x-rays must be weighed against the risk of ionizing radiation.
In response:
We do not take full spine radiograph in our office. Our x-ray bucky is capable of holding a maximum film size of 14”x17” film. The word “Screening” as defined by 1) McDonough, J.T.,Jr. Ph.D, Stedman’s Concise Medical Dictionary, second edition is “Examination of a group of usually asymptomatic individuals to detect those with a high probability of having a given disease, typically by means of an inexpensive diagnostic test.” Our office does not radiograph patients who are asymptomatic, in fact it is typically the symptomatic individual who seeks care at our office. After a proper History and examination is conducted, we determine whether a radiograph is warranted.
If your panel is considering the Nasium view to be a “Sectional Full spine,” I would point out to the review board an article by, Harrison, DE et al. Reliability of Spinal displacement Analysis on Plain X-ray: A Review of the Commonly Accepted Facts and Fallacies with Implications for Chiropractic Education and Technique. JMPT vol. 21,Number 4 May 1998, and Harrison, DE. Letter to the editor, JMPT vol.22, Number 9, Nov/Dec 1998 in response to a Dr. John Hart, in regards to the aforementioned paper. In general, the article discusses the reliability of line drawing analysis in measuring spinal displacement, but more importantly in the follow up letter Dr. Harrison goes on to expound that the Nasium view is the only view that demonstrates validity in biomechanical assessment. Haldeman S etal. Guidelines for Chiropractic Assurance and Practice Parameters. Aspen1993 states in Chapter 2 pg. 14 section 3 line C that “acquired postural, kinematic and biomechanical information” is one of “The purposes for radiographic examination.”
Furthermore in regards to exposure to ionizing radiation, I will include the following article in its entirety. The article summarizes that soda, cigarettes and overeating are more dangerous than diagnostic x-ray from Dynamic Chiropractic:
“Risk Perspective”
by Edward L. Maurer, D.C., D.A.C.B.R.
Kalamazoo, Michigan
Environmental pollution, cholesterol, steroids, drugs, iatrogenic disease, radiation effects, and others, have all been highly visible in the media over the past few years. Near daily announcements are made of items which are purported to be carcinogenic. One begins to wonder if it would be easier to list the things that do not cause cancer.
Radiation health and safety are being discussed at social gatherings, and people are generally more aware of associated risks. Many still have visions of Nagasaki, Hiroshima, Chernobyl, and Three Mile Island whenever radiation is mentioned. Little wonder then that patients frequently ask questions related to the necessity and safety of radiographic procedures. At times simple reassurance will suffice, but often we must attempt to help put things in perspective.
Science and technology have combined to provide some of the most in-depth studies of ionizing radiation known to man. The International Atomic Energy Agency (IAEA) states that “radiation and its effects have been studied by expert bodies for over half a century and more is known today about radiation risks than about those of practically any other physical or chemical agent in our environment.”
Authorities agree that while no radiation dose level is risk-free, the level used in diagnostic radiology provides low-dose risk and is considered as acceptable to the average individual. According to the 1949 National Council on Radiation Protection and Measurements (NCRP), the definition of permissible dose is: “Permissible dose may then be defined as the dose of ionizing radiation that, in light of present knowledge, is not expected to cause appreciable bodily injury to a person at any time during his lifetime.” Since this NCRP statement, the trend in science has been away from the “permissible or acceptable” dose concept to the current “risk” concept. In either approach, the end result is similar, e.g., for the information gained with diagnostic radiology, the radiation risk is minimal.
The IAEA states that “one should not disregard the risks posed by radiation as a health hazard, but it does not pose a unique set of health affects.” Other agents pose a much greater health risk. “It is about 100 times more likely that cancer will be produced in the average individual by some other cause than by radiation.”
An interesting article by Cohen and Lee entitled, “A Catalog of Risks,” published in Health Physics, provides a look at radiation risk levels, along with other examples of risks associated with various activities and how they translate into loss of life expectancy. It provides the likely results of both general patterns of behavior and one-time occurrences. According to the study: The drinking of one diet soft drink per day reduces life expectancy by two days; ingesting 100 calories per day by drinking regular soft drinks increases body weight by 7 pounds and reduces life expectancy by 210 days. If you are 30 percent overweight you lose 1,300 days; 20 percent overweight 900 days. Unmarried males lose 3,500 days, smokers 2,250.
While accidents in an average job cause 74 days of life loss, a job with radiation exposure carries only a 40 day loss. An average person who receives a lifetime of medical (diagnostic) x-rays, results in a life expectancy loss of six days. Radiation to workers in the nuclear industry lose 0.02 days. Single, individual acts and their associated risks were also reviewed. Smoking one cigarette reduces life expectancy by 10 minutes, eating a calorie-rich dessert by 50 minutes; and the missing of an annual PAP test will cost the average woman 6,000 minutes. One millirem of radiation reduces life expectancy by 1.5 minutes.
This study and many others point out that risks are associated with nearly all activities of daily living. Some can be guarded against, for example, wearing a seat belt, losing weight, stopping smoking, etc., but even these measures will not eliminate all risk. Minimal risk in everything we do during the human experience is near-inherent. While we must constantly work towards the reduction of risk, in all endeavors, we must accept a minimal level as normal. Diagnostic radiology does present risk; but the radiation dose when compared to the benefits of useful information gained, necessary for appropriate treatment selection, is indeed an acceptable trade-off when put into perspective.”
References From Maurer
1. International Atomic Energy Agency, “Facts About Low-Level Radiation,” American Nuclear Society, 1982.
2. Cohen, B.L.; Lee, I.S. “A Catalog of Risks.” Health Physics June 1979; 36: 707-722.”
Are any on your panel DABCR’s or members of the American Nuclear society?
• “The practitioners regional x-ray protocol, as described on the submitted application, has not been proven or supported by established scientific rational and/ or the frequency of obtaining radiographs as described appears to indicate the use of x-ray as a screening procedure. Radiography of patients as a screening procedure is not appropriate. (Haldeman S etal. Guidelines for Chiropractic Assurance and Practice Parameters. Aspen1993). The potential diagnostic benefits of performing x-rays must be weighed against the risk of ionizing radiation.
In response:
We do regional AP and lateral x-ray of a region only if the history, exam and subjective complaints support and warrant it.
As stated above, radiograph is not used as screening in our office.
The rationale for regional radiograph when correlated with history, exam and subjective complaints is STRONGLY supported by scientific rationale and peer reviewed literature. Together, Don Harrison, PhD, DC, Rene Cailliet, MD, T Janik, PhD., S Troyanovich, DC, Deed Harrison, DC have over 60 papers published in index medicus, peer reviewed medical, chiropractic physical therapy and biomechanical journals supporting the correlation between symptomatology and abnormal biomechanics on radiograph. All of these citings are more recent and current than Haldeman S etal. Guidelines for Chiropractic Assurance and Practice Parameters. Aspen1993. I would be happy and am prepared to provide every article in its entirety upon written request.
Haldeman S etal. Guidelines for Chiropractic Assurance and Practice Parameters. Aspen1993 gives a rating to radiograph of established, Evidence class I, II, III and a consensus level of 1. Conversely, in an Article in by Troyanovich, S etal. Motion Palpation It’s Time to Accept the Evidence, JMPT, vol, 21,Number *, October 1998 pg. 570 second paragraph cites Haldeman S etal. Guidelines for Chiropractic Assurance and Practice Parameters. Aspen1993 and Mercy guidelines that, “There are few validity studies of joint palpation although the existing literature on reliability is disappointing.” Joint Palpation is rated as equivocal or promising, evidence Class II, III and consensus level 1. This rating is inferior to radiography.
Is palpation alone the alternative that your network would have us turn to? What if there is a grade III spondylolisthesis? This could not be determined without x-ray. What if there is an anterior body lumbar osteophyte pointing at an abdominal aneurysm? I have had these cases.
• The described use of Surface Electromyography to measure volitional response and examine superficial layer muscle recruitment and fatigue lacks sufficient documented clinical evidence and scientific rationale to be supported as an effective method of diagnosis or treatment.
In response:
Surface EMG technology is neither diagnostic nor can it serve as treatment. We do not use it in such a capacity. We use Myovision EMG at health screening events. We provide it as a free service to patrons.
In closing, it is our objective to be able to provide excellent, evidence based chiropractic care to our fellow southern Nevada residents. As I mentioned above, we are close to opening a third location in the Las Vegas area. A group such as ours adds credibility, ethics and value to your base of insured. It would be a great loss to ASHN to not have us on your panel.
Sincerely,
Jason O. Jaeger, D.C., P.C.
Mountain West Chiropractic of Green Valley
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