If you follow U.S. health care policy-making at all, it's easy to get distracted by the unknown fate of the Affordable Care Act right now. However, while this battle is carried out among our elected officials, the marketplace continues to move toward rapid change in health care delivery. One of these changes involves a new emphasis on patient outcomes and physician adherence to established best practices, such as process and outcome measures associated with high-quality patient care.
The Opportunity
Exactly what does this mean for practicing doctors of chiropractic? First and foremost, it means the profession has an unprecedented opportunity to expand the reach of chiropractic care to help solve a critical public health problem. Second, it means we may want to consider steps each of us should take if we choose to leverage this opportunity through better integration into mainstream health care.
The nation is struggling for solutions to somehow mitigate the impact of spine-related disorders, which are now the No. 1 cause of morbidity worldwide. There is increasing awareness that current widely used medical treatments don't work very well for many people, and have side effects that can be dangerous.
We are all well-aware of the opioid crisis. But opioids are not the only medication of concern. Recent studies have shown that NSAIDS are often ineffective, and even one week of use is correlated with a higher incidence of acute myocardial infarction. On the flip side, recent systematic reviews show that spinal manipulation can have a positive impact on back pain.
These findings, combined with the low-risk profile associated with conservative spine care such as chiropractic, has caught the interest of providers and payers. For example, this past February, the American College of Physicians published a guideline for low back pain which recommends that many conservative treatments, including spinal manipulation, be considered before initiating drug therapy. This guideline was followed by editorials and blog posts encouraging medical doctors to consider the possibility of chiropractic care for their patients.
This positive momentum creates a unique opportunity for increased patient access to chiropractic care through referrals from medical doctors, patient self-selection, DC inclusion within integrated health care systems and improved payment policy.
The Challenges
However, there are barriers to actualizing the full potential of these opportunities. Conversations with payers, purchasers and other stakeholders over the past year have led me to believe that many of those who have decision-making power regarding access to chiropractic services remain cautious.
Based upon the scientific literature, they are beginning to think about chiropractic care as an option, but have concerns regarding the consistency and quality of chiropractic care delivery, and/or are unsure about how to find a well-qualified doctor of chiropractic.
In other words, they believe chiropractic might have something to offer, but are somewhat leery of some individual chiropractors.
The Solution
I strongly believe this barrier can be overcome using a fairly straightforward strategy – clinical data registries. Clinical data registries are computer-based networks that collect data from clinicians in order to describe the natural history of disease, determine the clinical effectiveness, cost-effectiveness of health care services, and measure and monitor safety and quality.
Registries are increasingly used by health care professions to establish the value of the care they provide, and will become even more important as the world moves toward performance-based payment systems.
Currently the Centers for Medicare and Medicaid Services (CMS) is leading the way in the development of registry-based performance measurement through the Merit-Based Incentive Payment System (MIPS) program, which places a heavy emphasis on CMS-approved Qualified Clinical Data Registries (QCDRs). Examples of the approximately 25 CMS-recognized performance measures that fall within the chiropractic scope of practice include:
Clinical data registries provide an unprecedented opportunity for doctors of chiropractic to collectively define what quality means in the context of spine care delivery, to demonstrate the value of the services we provide, and to build trust not only with our patients, but also with other providers, payers, purchasers and other stakeholders. They are an excellent way for DCs to alleviate the concerns mentioned above because they can be used to demonstrate the quality of the care we provide via data – what I like to call “the great leveler” – that comes directly from the patient care experience.
Action Steps: Getting Started
For more information on clinical data registries, take the following action steps:
1. Learn more about the how and why of clinical data registries by reading the Agency for Healthcare Quality and Research User's Guide to Registries Evaluating Patient Outcomes: https://effectivehealthcare.ahrq.gov/ehc/products/21/12/PatOutExecSumm.pdf.
2. Check out the list of CMS-approved Qualified Clinical Data Registries for 2017 at https://qpp.cms.gov/docs/QPP_MIPS_2017_Qualified_Registries.pdf. Examples of clinical data registries used by clinicians treating spine-related disorders include:
4. Find out if you are eligible for the CMS MIPS program for 2017 by entering your National Provider Identifier (NPI) number here. The threshold for eligibility is 100 or more Medicare patients and $30,000 in annual Medicare services per year.
5. Ask your electronic health record (EHR) vendor if it is integrated with a clinical data registry.
Many relevant diagnostic signs are not performed deliberately by the examiner or by the patient at the examiner’s direction. They are observed as the patient reacts to their condition. Fortin’s finger sign, Minor’s sign, and Vanzetti’s sign are three examples of this principle.
Spearheaded by burgeoning scientific and clinical research literature, psychedelics have reached a level of media coverage and popular interest that has not been seen for over half a century. By “psychedelics,” we are referring to the unique class of substances that includes psilocybin (the active compound found in so-called “magic mushrooms”), LSD, dimethyltryptamine (DMT), ayahuasca, 5-MeO-DMT, and mescaline – each of which occurs in the natural world (except for LSD, which is a semi-synthetic compound).
While working at the Lovelace Medical Center in Albuquerque, N.M., one of the primary care physicians stated that imaging every patient prior to receiving chiropractic was not medically necessary. It was at that point I reconsidered the need for the imaging of every patient to avoid malpractice.
