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Dynamic Chiropractic – April 22, 2008, Vol. 26, Issue 09

Looking Back: 1991

By Editorial Staff

As we celebrate our 25th anniversary as the definitive news and information source for the chiropractic profession, we look back at the important events as reported in DC since 1983, while also looking forward to the future.

Throughout 2008, we will feature a review of the top headlines in chiropractic for a given year, along with an article on the future of chiropractic authored by an influential member of the profession.

February 1991: CCA Awarded $2.2 Million in Bad-Faith Suit

Years ago, the California Chiropractic Association (CCA) purchased general liability insurance designed to safeguard its peer review program. The CCA purchased the insurance to the tune of $3 million from MGIC Indemnity Corporation. When five chiropractors filed individual lawsuits against the CCA, challenging the results of peer reviews, the association notified MGIC of these claims.

At that time, MGIC took the position that it had assigned the policy to CNA Insurance Company, a subsidiary of American Casualty. This assignment was pursuant to a secret agreement of which CCA had never been informed. When the CCA notified CNA of the claims, CNA would neither deny nor confirm coverage, thus effectively choosing not to cover the claims or pay expenses as they occurred. Additionally, CNA cancelled the CCA policy prior to completion of the term. This left the CCA with the burden of carrying all costs associated with the lawsuits. Even though the CCA won all five cases, they were not awarded legal fees, causing the association to divert funds from member services.

In response to these developments, the CCA sued MGIC and CNA in 1985, relying on financial support from U.S. Fidelity & Guarantee and National Chiropractic Mutual Insurance Company (NCMIC), both of whom provided insurance to the CCA (premises liability insurance and malpractice insurance of association peer-reviewers, respectively). Four years later, the court heard a motion for summary adjudication and ruled in favor of the CCA on all counts.

In July 1990, CNA offered $44,000 to settle. In September, they offered $100,000. Then, one week before the trial, CNA settled with CCA for the sum of $2.1 million and an agreement to testify against MGIC. On Jan. 18, 1991, a jury found MGIC guilty of breaching its insurance contract with the CCA and committing statutory bad faith. MGIC then presented the CCA an offer of $110,000 in cash. The CCA accepted the offer, recognizing that it had already won $2.1 million from CNA and gained a guilty verdict from MGIC. The $2.1 million settlement is likely the largest ever received by a chiropractic state association.

June 1991: First World Chiropractic Congress Meets in Toronto

National associations from 32 countries became the first members of the World Federation of Chiropractic (WFC) Assembly at the inaugural World Chiropractic Congress, held the week of April 29, 1991, in Toronto. More than 60 delegates and 11 observers representing 32 countries attended the two-day assembly.

In total, 42 countries submitted reports on the status of chiropractic during the historic event. The assembly also established world chiropractic policy in a number of different areas including diagnostic X-rays, international interference and vehicle restraints. Highlights from the country reports are summarized as follows:

  • New legislation recognizes the practice of chiropractic in three countries: Mexico (1989), Iceland (1990) and Cyprus (1991).
  • Government-funded education programs are now established in Australia and South Africa, and are imminent in Canada and Denmark. In the U.S., the University of Bridgeport will open a chiropractic college in September 1991, and there are current negotiations for university programs in Mexico and New Zealand.
  • Public funding of chiropractic research is growing, particularly in North America, Australia and Europe.
  • South Korea has three new Palmer graduates in full-time practice, while in the Middle East, successful practices have been established in Iran, Qatar and the United Arab Emirates.
  • The Venezuelan Chiropractic Association now has 14 members and has solidified a strong, secure presence in the country. Sira Borges, DC, MD, a 1990 Palmer graduate, has returned to Brazil and is working with local chiropractors and the government to legalize the practice of chiropractic.

July 1991: California's Sweeping Victory Regarding Scope of Practice

In November 1983, the CCA determined that it was imperative to end the 60-year battle over the proper legal scope of chiropractic practice in California. The CCA board directed its legal counsel, Michael Schroeder, Esq., to undertake the necessary legal and historical research to draft a complete, accurate definition of the legal scope of chiropractic practice under the California Chiropractic Act, and to recommend the most effective means to make this definition the law.

In July 1985, Schroeder presented the proposed definition to the CCA board of directors and suggested the best way to enact this definition into law would be to petition the California Board of Chiropractic Examiners (CBCE). The CBCE held two years of regulatory hearings and the definition was accepted as law in August 1987.

That's when the trouble started, in the form of lawsuits from the California Medical Association, the California Board of Medical Quality Assurance, the California chapter of the American Physical Therapy Association, the California Physical Therapy Examining Committee, 10 medical doctors and 10 physical therapists. These suits claimed, among other things, that chiropractors could not diagnose, perform physical therapy, or use ultrasound, X-ray or thermography.

Four years of protracted and bitter litigation followed, with Schroeder representing the CBCE. Finally, organized medicine agreed to accept a virtually identical definition of the legal scope of chiropractic - one that retained diagnosis, ultrasound, thermography, X-ray and physical therapy. A final judgment reflective of this agreement was entered by the Sacramento County Superior Court on May 29, 1991.

August 1991: Chiropractic in the Papers, on TV

In the past, chiropractic often has been met with little more than contempt from the media. All that may be changing. Witness two recent examples: an article in the New York Times that praises chiropractic and an appearance by Louis Sportelli, DC, on "CBS This Morning."

The July 3, 1991 issue of the New York Times featured an article titled, "Back Manipulation Gains Respectability." The article discusses the benefits of manipulation and mentions the important findings from the RAND Corporation's recent research project. According to the article, "A panel of experts assembled by RAND to review the medical literature concluded that manipulation was appropriate for patients with certain types of low back pain. The best candidates were patients whose pain had lasted less than three weeks, who had no signs of spinal nerve damage and whose spines appeared to be normal on X-rays. In studies, patients in this group [experienced] significant relief after manipulation and were able to return to work sooner than similar patients treated with conventional methods."

The author quotes respected doctors of chiropractic Scott Haldeman, steering committee chairman for the upcoming 1992 Chiropractic Quality Assurance Conference; and Louis Sportelli, past board chair of the American Chiropractic Association. According to Dr. Haldeman, "Chiropractors, who used to be ostracized, are now invited into major hospitals, HMOs and practices," while Dr. Sportelli is quoted as saying, "Until a few years ago [medical doctors] were still buying into the AMA effort to eliminate chiropractors. Now there's no stigma attached to referring people to us."

A few weeks after the pro-chiropractic article appeared in print, Dr. Sportelli was interviewed on the nationally syndicated television show, "CBS This Morning." The interview was conducted during the "Health" segment of the program. Included were demonstrations of motion palpation and chiropractic manipulation (as conducted by Dr. Sportelli on patients in his office), as well as the discussion of the AMA attack on chiropractic and the subsequent Wilk decision. Perhaps the most significant part of the segment took place when Dr. Sportelli was able to present the results of some of the most recent research demonstrating chiropractic care to be twice as effective as conventional medical care for low back pain.

Between the New York Times article and the "CBS This Morning" show, the chiropractic profession can't buy this type of positive public relations. It is gratifying to see our investment in quality research by internationally recognized organizations pay off with positive PR and media exposure.

October 11, 1991: Dr. Shekelle Discusses RAND Findings at Conference

During the 1991 Conference on Research and Education, held in Monterey, Calif., Dr. Paul Shekelle presented a detailed report on the RAND project as one of the opening addresses. Dr. Shekelle, primary investigator for the project, began his presentation by explaining that RAND ("Research and Development") "is a nonprofit corporation performing research for the public good. RAND's research programs include classified defense research for the military, applied economics, education, sociology, civil justice and health sciences." He went on to discuss the methodology utilized to assess the appropriateness of spinal manipulation for low back pain. Key points are excerpted as follows:

  • "First, we performed a literature review. We searched the Index Medicus and Medline for relevant articles, then searched the bibliographies of these articles for additional sources, and lastly had our sources reviewed by experts to ensure that we hadn't left out any critical material. That netted 74 sources, which included 21 controlled trials of spinal manipulation as a treatment for low back pain. From these sources, a 32-page review was prepared, which summarized what is known about utilization, complications and efficacy."
  • "We then developed a detailed list of indications for patients who could potentially undergo spinal manipulation. ... We did this by observing clinicians in their offices and questioning them about their clinical reasoning. We [also] spoke with experts and reviewed the literature. We attempted to explicitly define key terms. The result was over 1,500 separate descriptions of patients with back pain."
  • "We then selected a panel of experts [consisting of] three chiropractors ... two orthopedists and one osteopath, all of whom are distinguished experts in low back pain; one internist, who is an expert in back pain and is the principal investigator on the back Pain Outcome Assessment Team; one family practitioner who is trained in manipulation; and one person with degrees in many disciplines, a past president of the North American Spine Society, who practices as a neurologist. We mailed the literature review, the definitions, and the 1,500 indications to the panelists. In private, they assigned an appropriateness rating, on a scale from one to nine, with one being highly inappropriate and nine being highly appropriate, to each of the 1,500 indications."
  • "All of the panelists met at RAND in Santa Monica. They were provided with [summaries of the] ratings, as well as a reminder of their own individual ratings. We then had an open discussion for each indication for appropriateness, concentrating on areas of disagreement. ... After each general class of indications was discussed, each panelist privately re-rated each indication for appropriateness. These second-round ratings constitute the final results of the process."
  • "In general, the appropriate conditions tended to be those patients with acute low back pain; none or minor neurologic findings; no evidence of sciatic nerve root irritation ... physical findings of joint dysfunction; unremarkable lumbosacral radiographs; and no adverse response to prior spinal manipulation, if any."
  • "To summarize, let me state that this conference was not the 'final word' on the appropriate use of spinal manipulation for low back pain. Rather, it is a first step, in that for the first time, orthopedists, chiropractors, and others assessed the appropriateness of spinal manipulation using a well-established method developed for such assessment."

October 1991: Chiropractic Costs Medical Care for Workers' Compensation Patients

A study titled "Cost Per Case Comparison of Back Injury Claims of Chiropractic Versus Medical Management for Conditions With Identical Diagnostic Codes" suggests medical care is 10 times more expensive than chiropractic care. The study was prompted by "the need for cost-containment due to spiraling premium costs in the Utah industrial setting."

Researchers analyzed data from nearly half of the 7,551 workers' compensation cases that occurred in Utah in 1986. The Workers' Compensation Fund of Utah provided the data including time-loss and non-time-loss injuries. Surgical cases were excluded from analysis.

Results showed that patients of medical doctors were compensated for almost 21 days, whereas chiropractic patients needed less than three days of compensation on average. Total average compensation was $668 for patients under medical care, compared with only $68 for patients receiving chiropractic care.

The study, results of which were published in the August 1991 issue of the Journal of Occupational Medicine, was conducted by Kelly Jarvis, DC, who practices in Herber City, Utah; Reed Phillips, DC, PhD, president of Los Angeles College of Chiropractic; and Elliot Morris, JD, MBA, claims director of the Workers' Compensation Fund of Utah.
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