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October 2006, Vol. 16, No. 4
Table of Contents
Do 90% of Acute Low Back Pain Episodes Resolve Within Two Months Regardless of Treatment Rendered? • Blues Already Using CCGPP to Cut Claims! • CBP® Annual Awards • Chiropractic, Disease, Adjustments and Other Voodoo! • Effective Initial Exam • It's Don's Opinion • Letters to the Editor • Neurosurgeon Heralds Posture Pump® MRI Study • New PCCRP X-ray Guidelines Will Protect Your Rights • Association of NJ Chiropractors OPEN LETTER to the CCGPP • PosturePrint® Head Manuscript Accepted by JMPT • Research Corner • The Benefits of Short Duration Whole Body Vibration • Triano and CCGPPs Will Give You Six Visits Part II • PostureRay™: Digital X-ray Digitization and Analysis has Finally Arrived
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Triano and CCGPPs Will Give You Six Visits
Part II
by Joseph W 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 the previous issue of the AJCC, I discussed the likelihood of the new CCGPP Low Back Draft awarding chiropractors with a total of 6-8 visits for the typical low back pain patient presenting to the chiropractic office. I connected the “dots” from CCGPP to the Work Loss Data Institute (WLDI), which had the six visits in two weeks limit. I emphatically asserted that this document would not only affect those playing the insurance game, but also those in “cash” practices, through the “enforcement” of the “Best Practices” by renegade state boards against “over-utilizers”. I also discussed the potential financial and personal philosophical conflicts of interest of the leader of the Research Commission, Dr. John Triano and other Team Leads for the CCGPP.
Since writing this story in the last issue of this journal, much more information has come to light. While I was reading the website of the Work Loss Data Institute (WLDI), the private company “hired” by the CCGPP to disseminate the document to the insurance industry, I saw John Triano’s name listed as a member of its Editorial Advisory Board. I thought this was quite strange since Triano was the head of the CCGPP research Commission. I forwarded the link to colleagues and they forwarded it again, again, and so on. Suddenly though, an email from someone associated with CCGPP denied the connection of Triano with the WLDI, stating that his name was not on the list of advisors. Somewhat confused, I went to the WLDI website and indeed his name was suddenly now not there. Now I was mad. All of a sudden, his name was gone and the CEO of WLDI, Phil Denniston, MD, apparently denied Triano ever being an advisor!
Luckily, I tend to save the web pages of sites that have information on them that I want, JUST IN CASE that information disappears when the web pages are updated. So I forwarded my archived pages PROVING that WLDI had Triano listed as an Advisor from at least 2003 until the night that I saw his name on the website.
With this information in hand, next the CCGPP stated that it was a MISTAKE of the WLDI to list him on their website FOR THREE YEARS! Wow. This is like having the New England Journal of Medicine list me as an editorial board member, by mistake, for years. The way I see it, one of two things is happening here. Either the WLDI and the CCGPP are in cahoots of some sort, or the WLDI is so poorly run that they inadvertently list individuals on the Editorial Advisory Board. Regardless, this sounds like an organization with whom we, as a profession, should not be associated. Why would CCGPP publish and disseminate its “Best Practices” document on the WLDI’s web site and not ACA’s or COCSA’s anyway?
The WLDI website also describes their recommended dosage of chiropractic care as six (6) visits over two weeks for those with acute LBP (Pain < 7/10 on NRS pain scale). Another proposal of those defending Triano and the WLDI (the self-proclaimed leaders of our profession) is that they are trying to change those restricted limits posted by WLDI on their website for chiropractic care for acute LBP. I ask the profession if we should believe CCGPP on this one??.
Wow, think about it; CCGPP is going to convince the WLDI, who is paid by insurance industry for restrictive guidelines, to all of a sudden sell, say 18-20 visits, instead of 6-8 visits we now recommend. Would the insurance industry like this? Would they reference the WLDI (CCGPP) guidelines? Would WLDI be able to “sell” these guidelines to the insurance industry? My answers: no, no, no!
Another important point is that, although the majority of Randomized Clinical Trials (RCT’s) utilized 6-8 visits in their studies, this duration of care left patients with only an average of about 44 percent pain reduction (pain levels at 3/10, constant pain with affect on ADL’s). This is not MMI; it is just because this is the point (research design) at which these studies stopped. If other levels of evidence are considered, this average of 6-8 will rise significantly. As reported in the previous issue of this journal, if you extrapolate these RCT data, the number of visits to reach MMI would be 19 visits (8.4 visits X [100%/44%] = 19 visits on average). Of course, this is not the number the insurance industry will use because WLDI will not be able to “sell” it to them. So they will likely beef up their recommendation for six (6) visits over two (2) weeks with the new CCGPP guidelines. The insurance companies will be thrilled with this duration and frequency. Also, the CCGPP gave modalities grades of “C”, “D” or “I”. Other commonly used treatments have been deemed average or “failing” as well. Do you think they will reimburse for a treatment procedure receiving these “grades”? Neither do I.
The CCGPP’s document is a farce. Beneath the bull, lies the contention that too many people have worked too long to just discard the document. This is a point I find hard to believe after reading the document and discovering what they actually did and did not do. Unfortunately, I do not believe the document can be saved for the reasons following and there are many others that I will not have the space to include:
1. They used their own made up rating system when other systems are available and used in other professions (and approved by governmental and research groups);
2. They confuse their own rating system in their document (something that cannot be simply “switched”-This is a fatal flaw!);
3. They provide an inaccurate review on the natural history of LBP (see Dr. Murphy’s analysis of the unsupported Dixon study in this issue);
4. They do not include non-RCT studies (e.g., non-randomized clinical trials, case series, etc) in their document, when these categories are in their levels of evidence and were supposed to be reviewed;
5. They refuse to include 90% of all chiropractic research (the case report) as any type of level of evidence, but will rely upon Level 5 “Expert Opinion”;
6. The review of diagnostics was pitiful. The X-ray section was an embarrassment (see www.pccrp.org for a complete review- more than 1500 references!), as was the section on SEMG and others;
7. The vast majority of reviewed ‘evidence’ in the document comes from non-chiropractic sources and non-chiropractic authors;
8. The CCGPP refuses to consider “technique” research individually, despite the fact that at least 15 “techniques” are taught at chiropractic colleges;
9. Manipulation was reviewed as HVLA maneuvers...what about drop table, instrument and other “low force” adjusting methods?;
10. “Traction” lumps together ALL types of traction methods, as does “Electrical Modalities” and “Exercises”;
11. The financial and philosophical conflicts of interests, too numerous to describe here;
12. and lastly, the ICA has been screaming that these CCGPP “Guidelines will be used by Insurance companies and other 3rd party payers to cut claims, which has been denied by CCGPP; however in September 2006, a DC in Georgia already had his claims cut by the Blues (see Dr. Maltby’s front page article) using CCGPP; so much for CCGPP’s lies to the profession.
Over 90 percent of state associations have officially rejected the document at this point (see COCSA’s website www.cocsa.org for downloads of many state association opinions or email Russ Leonard at the Wisconsin Chiropractic Association rleonard @aol.com). The only national/international organization that I know of that has yet to reject the CCGPP document is the ACA. If the ACA does not reject CCGPP, they will lose members by the droves as more DCs get their claims cut.
I am happy to inform you that a different group of chiropractors will be developing new guidelines through the ICA by reviewing ALL of the available literature. We hypothesize that a complete guideline will actually protect the practicing chiropractor and patients and will not line the pockets of third party insurance industries.
Lastly, I submit the State by State Association vote as of September 20th as provided by Russ Leonard, Executive Director of the Wisconsin Chiropractic Association:
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