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July 2006, Vol. 16, No. 3
Table of Contents
Autism and Glutathione • CBP® Nonprofit has 24 publications in 12 months • CBP® Research Presented at the International Spine Conference in Norway • CBP® to File Lawsuit Against Quackwatch • CCE Weathers the Storm • Chiropractic Culture • Dr Don Harrison is ICA's Chiropractor of the Year • Dr Jim Gudgel to Co-Instruct With Neuromechanical Innovations • Dr Deed Harrison Speaks at Palmer West • Experimental or Medical Necessity • Fine Tune Patient Communication • From Screening to the Value of Proper Posture • ICA at the Table • ICA's Newly Elected Board Members • Instrument Adjusting's Mechanical Advantage • It's Don's Opinion • Letters to the Editor • My New Whiplash Text is Available • Patient Expectation and Retention • Principles, Ethics and Other Bygone Ideals • Problematic Decision Spectrum • Research Corner • Triano and CCGPP's Will Give You Six Visits
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Triano and CCGPP's Wil Give You Six Visits
by Joseph Betz, DC
After graduating from the University of Pittsburgh with a B.S. in Biological Sciences in 1995, Joe Betz attended Life University where he graduated Magna Cum Laude in 2001. He received the CBP® Outstanding Achievement Award in the year 2000 for his service as the CBP® club president while at Life University. He was also presented with the CBP® Researcher of the Year award in 2003. He is currently in private practice in Boise, Idaho. He serves as the ICA Representative for the State of Idaho. He has co-authored several research papers with CBP® Nonprofit and is currently working on several chapters in a text on CBP® Structural Rehabilitation of the Thoracic Spine.
In a recent talk (June 10, 2006) at the Arizona State Chiropractic Convention meeting, Dr. John Triano (sponsored by NCMIC, who pays Triano’s way and gives DCs five percent discounted premium for attending) told the crowd that the future of chiropractic was a 6-8 visit limit. We believe him since he is the leader of COCSA/FCLB/ACA/WFC’s new CCGPP Guidelines. We discovered this fact when we went to CCGPP’s web site and noted that they stated “their” Guidelines would be published on the Official Disability Guidelines 11th edition web site. We went to that web site and noted that there already was a frequency and duration listed as:
“Chiropractic Guidelines: Therapeutic care —
Mild: 6 visits over 2 weeks
Severe: Trial of 6 visits over 2 weeks, and with evidence of objective functional improvement, total of up to 18 visits (12 additional) over 6-8 weeks, avoid chronicity of care
Elective care: As needed”
Thus, we believe that 6-12 visits with a 2 block trial of care (24 visits) will be a Mercy Center thing of the past; the new CCGPP “Guidelines” will result in only 6 visits unless there is pain rated at NRS = 7, 8, or 9, which seldom occurs clinically.
These SEVERELY restrictive Guidelines will put the majority of DCs out of practice. These six visits (in the past: 6-12 visits, etc.) come from IMEs, who work for 3rd party payers and who want to cut costs and maximize profits without regard to individual patients.
Triano was absolutely incorrect when he stated that the evidence shows that patients will be symptom free within 6 visits. We discovered that we were lied to by most Guideline developers about the frequency and duration “shown” by Randomized Control Trials (RCTs). We did an analysis of neck and low back trials in a recent publication (Oakley et al., J Canadia Chirop Assoc, Dec 2005).1 We read all the RCTs’ methods, and discovered that the “results” of these neck and back pain RCTs were Not as we were led to believe. The incoming Numerical Rating Scale (NRS: 0,....,10) averaged 4.6 and the ending NRS was 2.6. This is a 2.0/4.6 = 44% improvement in pain only!
Next we took all the studies that reported both pain (NRS) and number of visits, and then we performed some ratio predictions: we have RCTs with 9.9 visits averaged at 44% improved, which provides an average of 22.5 visits (x = [9.9]100/44) estimated to be needed to achieve pain free subjects from this “Selective” data.
Thus Triano’s and his CCGPP’s Frequency & Duration of 6 visits will never get patients out of pain, but will cut costs and maximize profits for insurance companies and Managed Care Organizations, such as ACN and ASHN. We note that ACN and ASHN are ironically owned/run by chiropractors or were. I was one of three ICA members, who wrote a critique of these very restrictive CCGPP Guidelines. (If you want a copy contact me at drbetz@idealspine.com )
The Council on Clinical Guidelines and Practice Parameters (CCGPP) was formed in 1995 at the request of the Congress of Chiropractic State Associations (COCSA). The website of the CCGPP states, “CCGPP is also taking significant measures to not revisit any problems presented by any previous document.” We assume that they are referring to the “Mercy” document that was a curse to practicing chiropractors for a decade and a blessing to the insurance industry who utilized the document to cut legitimate chiropractic claims. The steering committee of the CCGPP wanted to avoid this problem so the group decided to release a chiropractic “Best Practice” document that does not specify duration and frequency.
They (CCGPP) are releasing several sections according to anatomical area. The Low Back section was released May 2006 for “stakeholder review.” Essentially this process leads to the development of a database of research suitable for interested parties to develop their own parameters of duration and frequency. So, instead of developing our own duration and frequency parameters, this group is leaving it up to the insurance industry to decide on it for themselves or to the above mentioned web site of the Official Disability Guidelines 11th edition.
The CCGPP Low Back document essentially includes only RCT’s on LBP and LB related leg pain. The average number of visits of these trials was 6-8 visits and this is how the restrictive use of RCTs translates into restricted care for DCs. There are a couple reasons why we believe a group of DC’s would decide to “eat their own” in the production of these guidelines:
Financial Conflict of Interest
One would assume that this group would be comprised of individuals who have a history of defending our profession. Unfortunately this couldn’t be further from the truth. We note that several of these “team members” either still are or have worked in State or Federal Government positions utilizing Guidelines, Hospital Administrators, and/or IMEs for insurance companies.2-5 They make a portion of their living being paid by the insurance companies for cutting chiropractic claims. It is in the best interest of their “bosses” to have guidelines that limit chiropractic care.
In addition, this document now becomes available to state boards whose function could become protection of the public from the practicing chiropractor who utilizes chiropractic care more than 6-8 visits for a typical LBP patient or for treating another patient for any condition other than low back pain, e.g. subluxation. In a press release from COCSA/CCGPP on October 26, 2005, titled, “CCGPP Responds to Questions on Conflict of Interest”, the organization provided a blanket denial that there is no conflict of interest with any of its members. I was dismayed after reading the press release in that one could easily pick up on the bias of the tone of the letter. They asserted that the individuals comprising the group represent the diverse nature of our profession. If “diverse” means those who practice part-time at multi-professional clinics, perform IME’s, train IME’s or consult with the insurance industry for determination of policy limitations, then perhaps this committee is indeed diverse.
Philosophical Conflict of Interest
The CCGPP website states, “CCGPP has purposely designed this document to appeal to all philosophies and, by the very nature of a best practices document, it should be useful for all types of practitioners. Our intent is that it will serve as a useful information source for all chiropractors as well as those who interact with the chiropractic profession.” Although they state that this document is for all chiropractors of different philosophies, after reading the document one would find the opposite. The document is designed to help destroy subluxation-based chiropractic and any DC who practices as such. Many of the authors are known to have opinions against subluxation-based chiropractic.7-11 Perhaps it is the intolerance of these individuals for subluxation-based chiropractors that directed the process of development of this document.
Some of you reading this may think that insurance companies already limit care to this type of frequency/duration, so what is new here? The biggest problem is that these “Best Practices” for chiropractic will be disseminated to State Boards as well. If a State Board would like to crack down on DC’s who correct subluxations (>6-8 adjustments), they have the firepower to do so. Just having a “cash practice” does not protect you. This is not an insurance guideline only, but rather a tool to be used by anyone and everyone.
References
1. Oakley PA, Harrison DD, Harrison DE, Haas JW. Evidence-based protocol for structural rehabilitation of the spine and posture: review of clinical biomechanics of posture (CBP®) publications. JCCA 2005;(49)4: 270-296.
2. Charles N. Cooper. My Opinion: Triano is a Chiropractic IME Pariah. Amer J Clinical Chiropr 2006;16(1). Available online at http://www.idealspine.com.
3. Washington lawsuit targets Mercy Guidelines: Says denial based on Triano’s opinions is ‘arbitrary and capricious’. The Chiropractic Journal. April 1996. Available online at http://www. worldchiropracticalliance.org/tcj/1996/apr/apr1996g.htm
4. Mittelstaedt B. Washington State Workers Comp Retrospective Review Part II: Audits decrease payments to DCs 36%, Increase payments to MDs 57% and PTs 150%. Amer J Clinical Chirop Oct 1998; 8(4): 1,4-5.
5. Mittelstaedt B. Washington State Workers Comp Retrospective Review Part III: Response to Dr. Mootz’s Double Talk. Amer J Clinical Chirop Jan 1999; 9(1): 1, 4, 6
6. Nelson CF, Lawrence D, Triano D, Bronfort G, Perle SM, Metz D, Hegetschweiler K, LaBrot T. Chiropractic as spine care: a model for the profession. Chiropractic & Osteopathy 2005;13(9): 1-17.
7. Keating JC Jr, Mootz RD. The influence of political medicine on chiropractic dogma: implications for scientific development. J Manipulative Physiol Ther. 1989 Oct;12(5):393-8.
8. Meeker WC, Haldeman S. Chiropractic: a profession at the crossroads of mainstream and alternative medicine. Ann Intern Med. 2002 Feb 5;136(3):216-27.
9. Cates JR, Young DN, Guerriero DJ, et al. An independent assessment of chiropractic practice guidelines. J Manipulative Physiol Ther. 2003 Jun;26(5):282-6.
10. Cates JR, Young DN, Guerriero DJ, et al. Evaluating the quality of clinical practice guidelines. J Manipulative Physiol Ther. 2001 Mar-Apr;24(3):170-6.
11. Keating JC, Green BN, Johnson CD. “Research” and “science” in the first half of the chiropractic century. J Manipulative Physiol Ther 1995;18:357-78
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