Where Is the Wisdom Lost?

By Arthur Croft, DC, MS, MPH, FACO
This year our profession mourns the loss of Martin Jacobs, DC. In an article which appeared in the January ACA Journal ("Let's face the facts") Dr. Jacobs provided us with a sober look into an imbroglio which has frustrated and aggravated many physicians: medical claims reviews. Originally I wrote this article as a letter to the editor of that journal but, because of the passing of Dr. Jacobs, they felt it might have been in poor taste to publish it. My comments, however, are not deprecatory in any way but merely add another opinion to dr. Jacobs'. Dr. Jacobs selflessly assisted my private group in setting up a very large industrial contract and I had only the highest respect for his devotion and knowledge.

Industry pundits, such as Dr. Jacobs, assure us that as the final denouement approaches (regarding the future of medical care), more and more of us will find our cases analyzed and scrutinized by utilization review personnel. Unfortunately it has become an immutable fact that paper reviews are on the rise, ostensibly to weed out the "five percenters" Dr. Jacobs refers to who tarnish the good name of chiropractic by over-utilizing and generally abusing the insurance industry. Clearly, however, this system has evolved without any countervailing control. For example, insurance companies mail copies of partially completed examination forms, medical bills, and perhaps scant other records to physicians, sometimes in other states, who then rather miraculously manage to arrive at a reasonable treatment schedule, diagnosis, and list of acceptable diagnostic procedures which they deem "allowable" -- and this without ever seeing the patient or x-rays. The insurer then feels obligated to pay for only these allowances.

In my studied opinion as an orthopedist, educator, and researcher, this practice has only limited validity. Peer review has been in place in the medical profession for a long time and has been grudgingly accepted for the most part. We are only now beginning to catch up to the medical profession when it comes to protocols and guidelines. Many of their procedures are relatively straightforward. Consider some examples: reducing and casting a simple fracture; an appendectomy; lancing a boil; a total hip replacement; suturing a superficial wound. Many procedures like these have a clear definition, a clear need, and a clear beginning and ending point. Patients don't commonly develop chronic appendicitis for example. As a result, it is easier to say that the average cost for the management of a fractured forearm is $942.39. Conditions such as myofascitis, fibromyalgia syndrome, mechanical low back disorders, whiplash injuries, carpal tunnel syndrome, and thoracic diagnostic and descriptive acumen. Surely even an astute diagnostician would consider it quite a challenge to prognosticate based only on limited records. Many of these reviewers are not content merely grappling with the issues of frequency, duration, and cost of care. They often challenge the diagnosis itself. Yet, I've often been uncertain as to my patient's precise condition even with the patient and all records sitting right in front of me. I sometimes wonder how anyone can do it long distance.

Perhaps the biggest problem of all is that there are no real established guidelines for many of these conditions. So rather than training a force of chiropractic police to enforce arbitrary guidelines (which are often devised by individual reviewers) perhaps we should concentrate on studying the condition: just what does it take to treat a certain type of myofascitis?

As one who speaks to thousands of other doctors yearly in my lecturing and teaching, I am fairly confident that my contemporaries in chiropractic echo these concerns. "File review" has become a metaphor for abnegation of medical bills. Few physicians view them as highly objective or reasonable. Dr. Jacobs suggests that it is preferable to accept the inevitablity of a claims review system and make every effort to specially train chiropractors for that purpose. Perhaps he is correct. Perhaps a more equitable system will emerge. However, in view of a number of studies which have recently shown chiropractic care to be the most efficacious and cost effective management paradigm for low back pain (e.g., most studies have shown that chiropractic patients use only a fraction of compensation costs compared to medical patients in industrial injuries) and in view of the fact that, in industry alone, low back pain is the leading cause of morbidity and absenteeism, I believe we should also make every effort to educate the public and the insurance industry to these findings, especially since we hold the key to saving the insurance industry literally hundreds of millions of dollars yearly.

And if insurers truly want to save money their time would be well spent reading the spate of recent literature comparing the cost of chiropractic care to medical care, with special attention paid to the overall cost which includes compensation costs, physician reimbursement, and disability payments. Since the effectiveness of most forms of conservative medical management have now been seriously challenged, I should think insurers would be well advised to reassess their management of these low back claims. Five percent chiropractic abuse notwithstanding, hundreds of millions of dollars could be saved annually by simply eliminating unnecessary, ineffective forms of health care management in low back pain disorders, the majority of which, frankly, is medical. Perhaps all cases of acute or chronic low back pain should first be seen by DCs and only by direct referral by the DC should patients be subsequently seen by MDs. Such revolutionary changes are not unreasonable in today's turbulent and demanding marketplace which is driven, after all, by the dollar.

The Mercy guidelines are a start at outlining what reasonable protocols should be. A consensus of experts may be repudiated by some, but in the end, is perferable to the surreptitious and perhaps arbitrary pen stroke of anonymous file reviewers who are, after all, not entirely independent. I believe reviews like these can be made reasonable but when resorted to they should be limited to addressing only those issues which can reasonably be considered by the reviewer based on established protocols or guidelines and that reviewer should be required to review a minimum number of pertinent records before commenting on the case. This means the insurance company would have a duty to collect the appropriate records from the treating doctor. And then, with a desk full of papers in front of him, that review doctor might ask the same question T.S. Eliot asked, "Where is the wisdom we have lost in knowledge, and where is the knowledge we have lost in information?" What do you think?

Arthur C. Croft, DC,MS, FACO
Coronado, California

Editor's Note: For more on personal injury, consult Dr. Croft's video, "Advances in Personal Injury Practice, #V-435, on the Preferred Reading and Viewing List, Pages XX.

Click here for previous articles by Arthur Croft, DC, MS, MPH, FACO.

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