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Dynamic Chiropractic – March 27, 1995, Vol. 13, Issue 07

Spinal RounHealth Care Policy: What Is the Role of the Field Practitioner?

By Arthur Croft, DC, MS, MPH, FACO
If an infant is born with anencephaly and other gross malformations, should a society bear the burden of keeping that infant alive -- an infant with virtually no hope for survival; who will never experience a sentient moment -- at a cost of thousands of dollars a day? There was such a case last year in the midwest. The parents were frozen in their grief and neither the doctors nor the hospital administrators were willing to take a potentially controversial step and pull the plug. Still, most of us would have little difficulty with decisions such as that one. But suppose we create a hypothetical closed system with one million inhabitants and a fixed limit on available health care spending, which turns out to be substantially less than that required for the optimal care of these inhabitants. How do we decide who gets care and who does not?

Let's suppose that in our hypothetical community the wealthiest citizens can afford blue ribbon health insurance. The elderly are on fixed incomes and most are covered by a medicare-like fund which many supplement with private insurance. The poor have no health insurance but many are covered to some degree by state run medicaid-like programs. And when we recheck our community's demographics, we find that 100,000 people (mostly uninsured) have snuck into the system -- straining the already tight health care dollar.

Now consider some potential problems from a bioethical standpoint. Mr. Donald Jones, a 34-year-old father of two small children who is unemployed and uninsured, has a life threatening heart condition and badly needs a donor heart and surgery. Mr. Carl Smith, a 78-year-old retiree covered by the medicare-like program and supplemental insurance, is a widower with grown children. He also needs a heart transplant, but here's the dilemma: There is only one available heart. Who should get the heart? Who should decide?

Take another example. Gladys Murphy, 87-years-old, lies in a hospital bed in severe unremitting pain, dying of cancer. Her family watches in silent agony as she slowly dies. Although Gladys has enjoyed a relatively healthy life, rarely seeking the aid of doctors, the terminal intensive care given to her by doctors and nurses (whose logic is steeped in the methods of heroic medicine where death is perceived as the ultimate failure of medicine) is costing thousands of dollars every day. In her last, perhaps marginally extended, time on earth there is no real quality in her life. At least we might ask her if there is. Meanwhile, across town a young mother struggling in abject poverty watches helplessly as her infant daughter dies of a treatable disease -- the system doesn't always work for the huddled masses. The questions from these scenarios are: Should we limit the availability of donor organs to those most deserving? How do we make those decisions? What if Mr. Jones is a drug addict and convicted felon and Mr. Smith is active in large charity organizations? Would money spent in futile heroic medical care of terminal patients be better spent on the care of younger people who can't afford treatment? Such are the agonizing issues facing today's bioethicists and health care providers.

Even when patients are "fully insured" how much care is enough? We might employ statistics to help us with some of these issues. Assuming a normal distribution, suppose that 95 percent of patients treated for disease x will recover in 12-21 days. Half of the other five percent will, for various reasons, require longer than 21 days to heal. Can bioethicists decree that that 2.5 percent be denied coverage beyond 21 days based on a statistic? Can the insurers themselves make such decisions? They do -- and rarely after consulting bioethicists or expert physician panels.

We're all under the same microscope today. How much chiropractic care is enough? What is really necessary? How much should these services cost? These are difficult questions which we as a profession have not adequately answered. Yet most insurers have already adopted guidelines for chiropractic coverage that DCs would consider inadequate in many cases.

Simply complaining about our predicament is not likely to bear any fruit -- it hasn't so far. We should develop our own guidelines first and then work toward having the insurers accept them. Such acceptance will not come easily or without tangible scientific evidence to support it. As my friend William Meeker, DC, MPH, mentioned in his editorial in a past issue of Dynamic Chiropractic (13 Feb. 1995 "Research for Chiropractic and Research for Chiropractic Patients: Is There a Distinction?"), we have already cleared several major hurtles in proving the importance of spinal manipulation for certain low back disorders and in winning some degree of acceptance as exemplified in the recently released AHCPR guideline and the UK version, CSAG. Sweden has a similar guideline.

The RAND Corporation has helped greatly in that regard. Rather than looking at these guidelines as limitations as some have done, we should view them as a beginning. We have started the process at RAND -- this time looking at the cervical spine. Look for that study to be released soon. On the issue of utilization, RAND has been conducting another research project important in answering questions about the utilization of chiropractic services by Americans. However, the level of cooperation of field practitioners has disappointed me. Some doctors I spoke to were afraid the results would somehow be used against us. But they would no doubt be less agreeable to guidelines adopted without chiropractic input. Fortunately such head in the sand attitudes are not prevalent among chiropractors with vision.

The Spine Research Institute of San Diego will be sending out surveys to nearly all DCs in the coming months. We will be looking at several issues including manipulation of cervical disk herniations and the frequency, duration, and style of manipulation used in various other conditions. Scott Haldeman, DC, MD, PhD, is working on a very important manipulation/stroke project. You may receive a survey or questionnaire from him in the near future as well; RAND may also visit your community.

In each case please remember one thing about research: When a group of doctors is randomly selected to participate in research, the strength of the study (i.e., the power of the conclusions drawn) is dependent on participation. If only half the selected doctors agree to participate, the study will have little if any validity. Most journals will not publish results with less than 70 percent participation. Once the original group has been randomly selected, we can't add doctors to help reach the participation goal -- that would completely invalidate the research. We are dependent on the originally selected group. To refuse the few minutes or hours requested by the researchers because you are too busy or not interested is not simply a matter of not helping, but a matter of doing some damage to the effort.

Arthur Croft, DC, MS, FACO
San Diego, California

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