Evidence-based practice has many facets of utilization. The evidence is available as a tool in patient management, clinical decision-making and substantiation of care, and serves to professionally defend your care against unwarranted and inappropriate attacks.
Today, I would like to discuss one of the methods of how to utilize it to substantiate the care process and clinical decision-making to payers.
Although competitive and belligerent practitioners were more common 20 years ago, they are still prevalent today and are likely to return as the competition in health care heats up. All of us have experienced the occasional run-in with the local medical practitioner who provides false, misleading and biased information to your patient in order to scare them out of your office. In the early years, medical physicians used the evidence stick to downgrade and berate the chiropractic profession. Well, evidence-based practice can now work in both directions. I would like to share one instance in which it was beneficial in my health care community.
A patient presented to my office for complaints of severe intermittent low back pain of sudden and insidious onset and one-week duration. Upon knowledge of the patient's history and after examination, it was found that she was suffering from acute lumbar sprain/strain with associated facet-locked syndrome, along with chronic cervicodorsal joint dysfunction. However, she was 64 years old and had a history of osteopenia from an earlier bone-density study performed by Dr. MD. As a result of the age and history of possible decrease in bone density, I found it necessary to order standard screening X-rays of the lumbar spine (AP and lateral) to assess the type of manipulative procedures the patient could tolerate and to rule out progression of osteopenia. Due to her insurance policy requirements, she needed her primary care physician's referral for X-rays. Therefore, I forwarded my office notes and X-ray requisition form to Dr. MD.
Unfortunately for the patient, Dr. MD decided not to approve the referral. However, he gave no clinical reason for his decision. When the patient asked why the referral was denied, she was given a handwritten note telling her to find a physical therapist for a "cheaper alternative to chiropractic." This made it quite clear that Dr. MD was making uninformed diagnostic and treatment decisions based on his own philosophical and economic reasons as opposed to clinical rationale. Such biased decisions unnecessarily put his patient population at risk. In addition, the doctor failed to respond directly to my concerns and neglected to forward to me any previous bone-density studies.
I called and subsequently followed up in writing with the managed-care network regarding the fact that this doctor's decision resulted in care unnecessarily needing to be adapted to a less-optimal alternative, due to the unknown and unverifiable risk to the patient. This subsequently precluded the optimum outcome in the most cost-effective and expedient fashion. Insurer policies for oversight of referrals by a primary care provider (PCP) can only be effective if the PCP reviews the case and makes a rational clinical decision based on the literature, the documented evidence and the patient's values and needs, and then coordinates this with the clinical judgment of the chiropractor. When physicians such as Dr. MD ignore the clinical evidence from the chiropractor, the literature-based evidence for risk factors for high-velocity low-amplitude manipulation,1 and the needs of the patient by making a biased decision - they undermine the insurance product and intervene in the rendering of quality care to the managed-care networks' insured.
The payer was indeed interested in improper clinical decisions that compromised the quality and cost-effectiveness of the care. The issue was taken up by the medical director and Dr. MD was subsequently disciplined, with a copy of the letter sent to the patient and me. The clinical evidence in my documentation and the literature which substantiated my clinical rationale certainly overshadowed Dr. MD's unsubstantiated actions. Doesn't this look like role reversal?
As you become more familiar with the evidence, you begin to learn how often medical clinicians make unsubstantiated decisions. It has been a year since this situation occurred. Dr. MD continues to provide PCP services to a number of my patients. However, he no longer acts as an improper road block to my patients' care. In fact, he is less likely to challenge or second-guess my clinical decisions. He has never denied any request since this incident. His actions reflected poorly on him, lost the confidence of his patient and threatened his continued ability to service other patients in this network. The patient completed care at our office with a good outcome. Once the patient was able to change physicians, she immediately switched her PCP.
The moral here is that evidence-based practice can work in our favor with patients, payers and other providers. In fact, it is now exposing other types of practitioners for their bias against chiropractic. Wow, this evidence-based practice is getting cooler all the time!
- Haldeman S, Chapman-Smith D, Petersen DM Jr. Guidelines for Chiropractic Quality Assurance and Practice Parameters: Proceedings of the Mercy Center Consensus Conference. Gaithersburg, Md: Aspen Publishers, Inc., 1993.
Dr. David Taylor, a 1983 graduate of National University of Health Sciences, is a past secretary of the Massachusetts Licensing Board and a past FCLB representative to the CCGPP. He is currently director of the Multimed Center, Inc., in Greenfield, Mass., and president of Healthcare Review & Consulting, Inc. Contact Dr. Taylor with questions and comments at