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Dynamic Chiropractic – November 20, 1995, Vol. 13, Issue 24

The Nature of Evidence and Process

By Robert Mootz, DC
Over the past several decades, a number of problems in the health care system have caused the system to react, in many ways against the providers. I'm happy to report that most of the problems were not caused by chiropractors. I'm sad to report that much of the upheaval that has resulted affects all providers, including chiropractors.

Surgery cost too much and was done too frequently, and reimbursement levels weren't very fair. For instance, a bunionectomy (involving a resection of a tarsal bone) typically takes a competent surgeon less than an hour to perform. Trying to remove a needle that someone stepped on from within the layers of plantar fascia could take several hours. Yet the former was typically reimbursed at 2-3 times the rate of the later. So people with painful bunions were often encouraged to have them surgically removed, and people with needles in the soles of their feet were often encouraged not to worry about it unless it really started to bother them. When compared to an hour of patient evaluation and management, the bunion removal was reimbursed at a rate 10-20 times greater. As a result of these kinds of incentives, we have seen a proliferation of tertiary specialists in the United States, with a severely inadequate number of patient-centered primary care providers.

When conservative care providers and patients complained loud enough, the system gradually creaked over toward a reimbursement strategy more closely based on the actual cost of resources it takes to deliver a service. This approach, called resource-based relative value scales (or RBRVS), involves detailed evaluation and documentation of the physician work entailed in delivering each and every medical procedure, from an injection or suturing a wound, to doing a physical exam or taking an x-ray. To really understand the mathematics and research design in the process, one practically needs a PhD in economics or statistics. For the past 12 years, research grants have been obtained by various provider and specialty groups to develop the evidence to determine fairer levels of reimbursement based on the actual work involved.

This year, chiropractors finally attempted to gather some of this kind of evidence on services they provide. Research studies and formalized consensus panels (funded by the Foundation for Chiropractic Education and Research, state of Washington Department of Labor and Industries, the American Chiropractic Association, and with great assistance from the Washington State Chiropractic Association, the University of Washington and others) have finally started to document some evidence about the relative amount of work chiropractors do. Information about these research efforts and some of the preliminary evidence were provided to key individuals on committees with the Health Care Financing Administration and the American Medical Association. In addition, pressure was placed on appropriate individuals within the federal government, who in turn encouraged the AMA to involve chiropractic representatives on the committee.

As a result of the right mix of solid evidence and reasoned political effort (or maybe just because they're still a little testy about that law suit), chiropractors now have representatives in the "inner sanctums" of the AMA's current procedural terminology (CPT) committee, its RBRVS Update Committee (RUC), and its Health Care Professionals Advisory Committee (HCPAC), the centers for development of CPT codes and RVUs (relative value units) for clinical procedures. Although this will not ensure equal reimbursement to medical personnel, it does set the stage to develop and present our evidence for fair reimbursement. It is encouraging to see the power of research and the finesse of subtle politics work together to achieve a legitimate position for the chiropractic profession. Something like this would be unheard of 10 years ago, wouldn't it?

Could it be that the evidence synthesis by chiropractors like John Triano and Scott Haldeman within the Agency for Health Care Policy and Research (AHCPR) guidelines committees, the work of chiropractors like Alan Adams and Eric Hurwitz to facilitate evidence development and synthesis at RAND, and the landmark clinical trials research by chiropractors such as Pat Boline (NWCC's headache study) and Alan Breen (the "Meade" study) have placed the chiropractic profession on society's radar screens as a force to reckoned with?

Evidence and process can go a long way toward putting chiropractic into the social mainstream. They can also go a long way towards planting the seeds of change within the social mainstream. But evidence is a double-edged sword. What if the legitimately collected evidence reveals something that we don't like? What if chart extraction studies show that only 1/3 of chiropractors routinely check blood pressure on new patients? Are we willing to abandon any notion that we deliver "primary care" and should not be paid for evaluation and management services? Or would we use that information to drive continuing education efforts by our licensing boards and state associations?

I don't know if chiropractors are quite ready to let evidence change the way they practice before it has already changed society. We tend to wait until the world around us has changed so dramatically that we are forced to react by either fighting or to acquiesce. For example, last month, chiropractic saw another rash of decent and fair publicity on CNN and other news reports from the results of a study published by Tim Carey, MD, MPH and his co-workers out of Chapel Hill, North Carolina. His preliminary report (which was previewed as front page news in "DC" several months ago) was fully published in the New England Journal of Medicine. It was a prospective multisite trial enrolling consecutive patients into a study which tracked outcomes of acute low back care provided by 208 randomly selected practitioners, among them urban and rural primary care physicians, urban and rural chiropractors, orthopedists and HMO doctors. The good news? Over a six month period, patients were most satisfied with chiropractic care. The mediocre news? Outcomes relative to self-reported "complete recovery" and return to functional status were equal in all groups. The bad news? Chiropractic care was the most expensive. In fact, the care provided by urban chiropractors was three times as expensive as that provided by urban primary care physicians. Chiropractic care in rural settings was almost twice as expensive as primary care. Yet, self-reported recovery and function were the same. All costs including medication, physical therapy, referral to other providers were included. This was a reasonable, fairly well done study.

This kind of evidence poses some fundamental questions chiropractors will have to confront. Will we be able to convince health care consumers and purchasers that it is worth 2-3 times more money to use chiropractors for the same results, because our patients prefer the way we do things? This evidence will change the way medical doctors practice. I predict that primary care doctors are going to start learning manipulation and our patient management skills to increase their patient satisfaction outcomes and still keep their economic edge. I can hear it now: "Why go to the chiropractor when it is cheaper and just as satisfying to go to a primary care MD?" Good question.

What I wonder is whether chiropractic trade associations and individual practitioners will learn to use evidence and process for something more than short term PR advantages. Health care is now competitive in ways never before seen. MDs are reading the literature, managed care organizations are reading the literature, and they are struggling to deliver health care products to the market place that are more efficient, more palatable, more effective and cheaper than the way they used to do things. Can chiropractors do this too? Is it possible for established "IBM-styled" DCs to start learning to turn their practices into lean mean fighting competitive machines that can deal with the "Microsoft-style" innovations of medicine's new managed care approaches?

We have come a long way. We have respect like never before. Evidence is bringing us to the table like never before. Physicians are beginning to refer us patients like never before. And consumers are beginning to want our services like never before. But now we are going to have to learn to compete on a level playing field in a competitive health care market like never before. Will we learn to engage in process and incorporate strategies that include refining our practices based on the evidence? Or will we as profession succumb to the disease that got IBM: Mural dyslexia (failure to correctly read the handwriting on the wall)?

This is not a medical versus chiropractic philosophy issue. This is not a case of medical ostracism toward chiropractic. It is not a matter of wellness-centered, subluxation-based chiropractic against the allopathic medical model of disease. Quite simply this a straightforward case of consumer driven, market-centered economics. Chiropractors saw incredible success and flourished against incredible odds because we had the consumers, our satisfied patients, behind us.

Let's not make the mistake that the American auto makers and IBM made by assuming that our loyal customer base will persist come hell or high water. Ask yourself if you have ever lost a patient because their "plan" didn't cover you, and if that patient was willing to get care from someone else that they didn't like as well as you because they could not afford the increased out-of-pocket cost to stay with you. Ask your malpractice carrier if any good, loyal patients have sued a chiropractor because something went wrong somewhere along the line, or because the chiropractor pushed the patient to pay a bill that was denied by an insurance company. Today, health care consumers are becoming just as fickle as a car buyer or computer shopper. They are smarter, more value-oriented, and they are beginning to have more choices in health coverage plans, practice styles, and provider types.

It's still not too late to look at the evidence and start incorporating efficient care strategies and outcomes monitoring into your practice. Subscribe to journals like Topics in Clinical Chiropractic and Chiropractic Technique to stay current on efficient practice strategies. Within your associations, form grand rounds groups to teach and learn the ways to get the most results in the shortest time at the least cost. Reduce overhead cost through group practices, efficient use of critical care pathways and algorithms, and through lean internal business analysis. Yes, the market place will impact your practices, one way or another. For me, I want to figure out ways to give patients and health care purchasers the most value for their health care dollar. Perhaps I'm biased, but I think competent and reasonable chiropractic care is an integral part of that value.

Robert Mootz, DC, DABCO, FICC
Olympia, Washington

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