My confidence in the U.S. federal government has been completely shaken with the recent defeat of the Rep. Crane's chiropractic amendment to the Medicare bill (H.R.2425). If I understand what happened correctly, the revised Crane amendment, which would allow DCs to refer out for diagnostic tests, passed almost unanimously out of the House Ways and Means Committee. This was a clear indication that members of the committee and voters from their home districts thought the Crane amendment was a popular bill. It would be a small step forward in the recognition of doctors of chiropractic by the federal government.
What happened next is still a mystery, but it is believed a late congressional budget office report stated the revised Crane amendment would cost tax payers an additional $1.7 billion over seven years to implement. Speaker Gingrich then pulled the bill from the Medicare reform bill in a parliamentary procedure in the House Rules Committee less than 24 hours before the Medicare bill was voted on. This is the foundation of my shaken confidence in our government.
Every chiropractor on the face of the earth realizes that there is significant cost savings when comparing chiropractic care vs. medical care for many of the most common conditions we treat. How the congressional budget office could possibly state the revised Crane amendment would cost an additional $1.7 billion is beyond comprehension. This bill also had a budget neutral provision in it that would keep the bill from adding any additional cost to the federal government.
The congressional budget office is made up of economists, accountants, and actuaries who calculate costs of federal programs. They are supposed to be nonpartisan and removed from the political forces in Washington. After reviewing their figures on the Crane amendment, it is apparent to me that they are very politically motivated. Republican House leaders met with leaders of the AMA one week before the Crane vote in an attempt to have the AMA endorse the GOP's Medicare plan. The AMA did endorse the plan. And while I have no proof, I believe the speaker of the house struck a deal on behalf of the AMA to kill the chiropractic bill.
Eliminating expanded recognition of chiropractic services under Medicare will not hurt our profession. However there is a deeper meaning which disturbs me greatly. If the congressional budget office can not get financial figures correct on chiropractic health care, what other projects are they blundering? What defense projects have slid through because they were the pet project of a powerful congressman, and what impact did they have on the soldier in the field. What social/welfare programs have been greased by the congressional budget office because of its powerful allies in congress, and how does that affect a welfare mother's ability to get off public assistance and find a job? The chiropractic experience points to the possibility of much more severe problems with our government.
I hope chiropractors will still continue to get involved in the political process for chiropractic and other issues they strongly believe in. I still believe the elderly of this country do not need more prescription medications. What they need is more safe, effective, cost efficient chiropractic care.
Craig Benton, DC
In the October 23, 1995 edition of "DC" on page 40, Christopher Mertz, DC, made the following statement and I quote, "Tell people subluxation is devastating because it robs the body of focus to think, organization to metabolize and power to heal -- that's hot! It's not only true, it's unique."
This statement is a pathetically embarrassing joke. The sad part is that it is exactly the kind of ammunition our detractors love. For someone who is supposedly concerned about the profession, I am flabbergasted that he continues to make such statements. I am also disappointed that "DC" would provide a format for such nonsense.
G. Douglas Andersen, DC
D.D. Knows Best
I suppose for some doctors it's like the old lyric, "You say tomato, I say tomato," but there are many of us that understand that there is a major difference in the interpretation of the terms "manipulation" and "adjust."
I would suggest that the basic problem is not with what we as doctors choose to call it, rather it is what the average person perceives it to mean. Looking at the common definition in any source such as the American Heritage Dictionary, you will soon see why those doctors you call "fundamentalists" (many associate that with religious zealousness -- can you see the power of the words you choose?) have a difficult time with its usage.
If the only definition of manipulation was "to operate or control by skilled use of the hands," then I think you would be somewhat correct. Yet even that definition does little to integrate the mechanical application of the hands with the intent of chiropractic which is to assist in the restoration of homeostasis. Now look at the remaining description of the term; 2. To influence or manage shrewdly or deviously, and 3. To tamper with or falsify. Wow!
Now consider the definition of "adjust." 1. To change so as to match or fit; cause to correspond, 2. To bring into proper relationship, and 3. To correct.
If D.D. Palmer, whom you correctly stated used the term "manipulate" until he changed it to "adjust" saw the need for refinement so as to clarify the intent, why then don't you?
Michael Willis, DC
Simi Valley, California
Managed Care -- A Ravenous Beast
I understand, although do not agree, with some of Dr. Cataldo's comments in the "We Get Letters" section of Dynamic Chiropractic's October 9 issue.
Yes, he owns two managed care companies, and as my article stated, "show me a doctor who likes one, and I'll show you a doctor who is profiting heavily from one -- and not as a provider only." To his credit I acknowledge that his are certainly not the worst managed care companies doing business in California. I know, because I was for a time a provider in one of them: its costs outweighed its benefits and I reasoned that I should not subsidize its ongoing development and evolving system refinements without a more immediate equitable return for myself and/or my patients.
I, and the dictionary, define a contract as an agreement reached between two or more parties, and usually implying some negotiation, some give-and-take exchange. But the managed care contracts are incredibly one sided, and presented to the providers as "take it or leave it ... but if you don't take it you can expect to be put out of business because we are signing more contracts with larger groups on a daily basis." How free is a choice made with that type of economic gun at your head?
Federal regulations for HMOs are much laxer than state legislation and state insurance commissioner rulings: the Department of Corporations (DOC) is very broad-based and its grievance provisions are thus much less specific, and more cumbersome, and much less consumer-oriented than those of the insurance commissioner. This is precisely why large insurance companies have re-incorporated as HMOs in California: looser regulations and higher profits.
Some readings to clarify the real meaning of laissez faire system, free marketplace, capitalism, economic theory, etc., follow in a reference list. The current best-selling book, The Rainmaker, by John Grisham is also revealing reading, depicting in a novel what many believe are not uncommon insurance industry and managed care industry practices. Dr. Lowry Morton, chairman of the ACA board of governors, recently said, " ... In the ACA's view, managed care companies are trying to consume the entire health care system, call all the shots, and shove providers and patients around whenever and however they choose."
Lastly, Dr. Cataldo makes a rather deceptive analogy when comparing managed care to a vehicle that can be driven by its participants. Wrong! The participants aren't driving the vehicle, they are passengers who are paying a high fare ... back seat drivers at best, traveling a route chosen by the driver (company owners) with no proof (no unequivocal studies) that the destination lies anywhere in the direction they are being driven, and wearing handcuffs instead of seatbelts!
I'm somewhat sorry I wrote that article. For a week after it came out my office was deluged with so many phone calls from chiropractors thanking me that I barely had time left to treat patients and fill out my usual managed care treatment request forms. Maybe this tells us something about provider satisfaction in many of these managed care plans.
Jane Orient, MD. Your Doctor Is Not In. Crown Publishers, Inc., New York, 1994.
Leonard Peikoff, PhD. Medicine: the death of a profession. The Objectivist Forum, New York, April & June, 1985.
Ayn Rand. The age of envy. The Objectivist, July 1971.
Ayn Rand & Leonard Peikoff, PhD. The forgotten man of socialized medicine: the doctor. The Objectivist Newsletter, 1957, 1962.
George Reisman, PhD. The real right to medical care versus socialized medicine. The Jefferson School of Philosophy, Economics, and Psychology, 1994.
Greg Stanley. HMO's -- a deal with the devil. The Whitehall Report, Summer, 1995
Rand Baird, DC, MPH, FICA, FICC
Once Again I Have Struck a Nerve
In reading the November 6, 1995 issue of Dynamic Chiropractic, I found a letter written by Dr. Bruce Haggart concerning my editorial on spinal diagnostic ultrasound (let's call it SDU ). In the same issue is an editorial by Dr. Robert Dishman, "Diagnostic Ultrasound: the Wave of the Future." So, apparently, once again I have struck a nerve! And I applaud both of them for speaking their minds on this controversial subject. In fact, those of us who write articles often wonder if anyone reads them, so I am quite pleased.
However, I did take the time to write because I'm afraid the undertone of my editorial may have been lost on some readers. In capsulation, one of my criticisms was the poor state of the literature available to support the claims made by some advocates of SDU (claims that range from the plausible to the fatuous); that is to say, the near lack of this literature. I cited four papers that actually concerned themselves with what we were talking about -- diagnostic spinal ultrasound. The concern that I voiced was that some practitioners are using the procedure rather uncritically and with inadequate training (the latter I didn't mention it earlier, but it is also a problem in my opinion). By uncritically, I mean that they are willing to take the machine into their clinics and, presumably, use the results in making judgments about how they treat patients without first satisfying themselves that anyone has actually done any kind of research to see whether the thing has any diagnostic or clinical merit.
For instance, are the results repeatable? Is there any intrarater reliability? That is, if the same doctor, blinded to the study in question, were to look at the same scans on 10 different occasions, would he reliably agree with his other readings? How about interrater reliability? Would a group of doctors agree with each other? How do we know what we're looking at? They say capsular inflammation, for example, but how do they know? Has anyone ever tested that? Well, I can tell you. In a word, no.
Dr. Haggart, in his letter, wants to reassure the readers that SDU is a great modality, and OK to use, so long as you have adequate training. I'm not saying whether it is or not. I'm merely saying that I don't think things are going to pan out in the direction predicted by Dr. Haggart. Unfortunately, in his earnest enthusiasm to bolster SDU, Dr. Haggard is recruiting literature that really doesn't support SDU at all. He references, for instance, the prenatal application of ultrasound, and texts on ultrasound that do not support nearly any of the claims made by some practitioners and by the distributors of SDU equipment. Indeed, of all of the references listed, only one was a paper about spinal ultrasound, and that was only an editorial. So what has been proved? Nothing, unfortunately. None of this literature validates SDU.
Dr. Dishman, who also is one of SDU's advocates, believes that research would be difficult, invasive, expensive, and improbable. He concludes his editorial by saying that, "One may choose the egghead/ivory tower approach and struggle with the historic delays of grantsmanship/funding and unending rhetoric." "My approach," he says, "would be to get on the road and start the journey one foot in front of the other and observe everything along the way." Although it sounds like the kind of quaint advice you'd hear from Will Rogers or Mark Twain, we simply can't get away with justifying our use of diagnostic measures -- especially expensive ones -- with colorful metaphors. Imagine if surgeons followed that logic.
My point is simply this: We must be critical of new tests and new tools. The health of our patients depends on our application of the science and our art we were taught. If we wish to think of ourselves as scientific, we must learn about science philosophy. We must respect the rigors of the scientific methods. We must first make hypotheses and then test them. Dr. Haggart cautions his readers not to be lulled into imagining that SDU will go the way of thermography, as I predicted. Maybe not, but it is surely headed in that direction.
Arthur C. Croft, DC, MS, FACO
San Diego, California
Diagnostics spinal ultrasound: not interchangeable with diagnostics ultrasound
I am writing in response to Dr. Haggart's letter and Dr. Dishman's article concerning spinal ultrasound, both in the 11-6-95 issue.
I think that an uncritical acceptance of diagnostic spinal ultrasound will lead to its downfall and damage the credibility of the profession using it incorrectly. While there is abundant literature available on diagnostic ultrasound, it refers to its use in more established application, such as intra-abdominal ultrasound, extremities pathology (rotator cuff tears, tenosynovitis) and spinal muscle assessment (lipomatosis, myositis ossificans).
In a press release from the American Chiropractic College of Radiologists, the consensus of the radiologists is that diagnostic ultrasound is well established in obstetrics, in fetal and infant spine, and in accessing superficial musculoskeletal structures such as rotator cuffs and ankle tendons. There is no established use for this technique in accessing nerve root or facet inflammation. Its use in spinal stenosis and disc herniation has not been established. I have yet to see a report from the diagnostic companies that did not include nerve root signs, facet joint or costovertebral joint signs. To refute another claim by these companies, diagnostics spinal ultrasound was never reviewed in the Mercy Guidelines.
In the 30 references of Dr. Haggart's, 12 were from peer-reviewed periodicals. From those 12 articles, five articles were unrelated to diagnostics spinal ultrasound. I have not seen the hundreds of references for diagnostics spinal ultrasound. Diagnostics spinal ultrasound and diagnostics ultrasound are not interchangeable. If we are going to be intellectually honest there is a limited amount of literature that supports diagnostics spinal ultrasound.
I have seen this equipment in use in a clinical setting. As Dr. Haggart stated, it requires "diligent practice and is very time intensive." It is also highly operator dependent. The interpretation of findings are dependent on the orientation and size of the muscle fibers whose appearance is dependent on the angle of the transducer. This technique is not something that can be learned in a few hour seminar. It has to be practiced and honed.
I agree with Dr. Haggart if we do not learn from our past mistakes we will lose sonography. If we do not use new technology properly it will be taken away from us and we will tarnish credibility as the musculoskeletal experts
Harry J. Morgan , DC
Woodbury, New Jersey
Chiropractic is marvelous. In my situation, chiropractic is miraculous. It has given me a second lease on life. I am the result of that miracle, although not yet complete as of this writing.
Early on in my childhood, as a pedestrian, I was hit by a car, thrown through the air, and rendered unconscious. Afterwards I could barely walk and had so much pain. For five or six winters early on in my 20s, I was expelling unmentionable matter from my lungs. For two years I had an uncontrollable swing in my left arm when I walked, and also migraine headaches. I was tested medically for a few things, with negative results.
By the age of 25 the pain was such that to climb stairs I had to at times do so on hands and knees. There was a time I couldn't laugh because of such severe pain in my full spine. Quite by chance I became introduced to chiropractic in 1969 after having found no solutions to my health dilemma through the medical field. I had severe full spine spasms over the years, lasting for weeks at a time.
These conditions have mostly disappeared, with the help of chiropractic and the grace of God. I walk with little or no discomfort. My lung problem is nonexistent. There is no more arm swinging, migraine headaches or full spinal spasms (just an occasional minute one). The strict rigidity of neck and full spine of so many years has become much more flexible. I also regained some hearing, an impairment I was unaware of before chiropractic. The support and dedication of the chiropractic physicians in and around my community have been extraordinary. Again I say, chiropractic has truly been miraculous in my life.
Mrs. Janet Carroll