Monday, June 27, 2005

The can of worms is open......

I know I'm getting ready to step into a big pile of stinky fecal matter, but the whole idea of spending public dollars earmarked for health care on chiropractic services is something that has always bothered me. As I noted in my previous post, a new report from the Office of the Inspector General at the Dept of HHS reveals that there have been significant Medicare overpayments to chiropractors due to fraudulent billing. All physicians understand how difficult it is to bill Medicare within ever-changing guidelines; indeed, there is a whole industry built around helping physicians and hospitals appropriately bill Medicare. However, the report is fairly straightforward, and did not look at minor billing discrepancies. Nearly all of the overpayments were due to "maintenance" therapy, something specifically excluded from payment by federal law.

Looking at the report itself, a few things stand out:

  1. The Medicare Carriers Manual states that "ongoing maintenance therapy is not considered to be medically necessary under the Medicare program." I think that is a pretty simple-to-understand statement.
  2. Medicare outlays for chiropractic care have increased from $255 million in 1994 to $683 million in 2004.
  3. This review was done by performing a random sample of 400 Medicare services submitted by chiropractors and allowed by Medicare in 2001; the reviewers were practicing chiropractors.
  4. Nearly 94% of chiropractic services reviewed lacked at least one of the supporting documentation elements listed in the Carriers Manual; this included many that were completely undocumented.
  5. Upcoding resulted in $15 million in overpayment.
One of the major criticisms of chiropractic care is the idea that patients need "maintenance" therapy. This leads to overbilling and what Medicare says is unnecessary treatment:
As chiropractic care extends beyond 12 treatments a year, it becomes increasingly likely that individual services are medically unnecessary. The likelihood of a service being medically unnecessary increases even more significantly after 24 treatments.
OK, so what? As the report itself states, chiropractic services accounted for only 0.26% of Medicare fee-for-service claims in 2001 ($500 million out of $191 billion paid to hospitals, physicians, outpatient care delivery services, etc.) For me, the "so what" part of things comes down to the way that CMS has decreased payment for medically necessary treatments, sometimes drastically, while continuing to pay for care that has no scientific basis. We are in an era that is demanding ever more scrutiny on outcomes, compliance with "evidence-based medicine," grading hospitals on meeting certain care delivery guidelines, etc. Why are those standards not being applied to chiropractic care?

What is more concerning to me at a time that health care expenditures are going ever higher is the fact that most of us with health insurance are required to pay for coverage for this type of unsubstantiated care. While Medicare has very strict guidelines for what they will pay for, other insurers are often required by state insurance commissioners to cover all sorts of chiropractic services. Our new plan includes coverage for "spinal manipulations, adjustments modalities; limited to 20 visits per calendar year." Hell, this is a plan without dental coverage! I suspect that if each person that reads this reviews his or her own insurance coverage in detail, they would find medically necessary and scientifically validated therapies that are not covered as those services are too expensive --- transplants, aggressive chemotherapy regimens, etc. We are slowly heading towards an era of care rationing (how do you think they keep costs lower in England), and need to look at where each dollar is spent.

In our community, there are some chiropractors who see their role as basically providing good massage treatment and instruction on muscle strengthening, posture, etc. I think that's great, and arguably something to pay for; there may be a good role for this type of therapy for acute low back pain. Unfortunately, there are many more who have taken too big a swig of the chiropractic Kool Aid and advertise that they provide "wellness care," "family practice," naturopathic endocrinology," natural health care," "pediatric care," and even "pregnancy care." All of these are direct quotes from Yellow Pages ads in my community.

What the......? Pregnancy care? Endocrinology? Wellness? Where does this kind of stuff come from? It all stems from the fact that chiropractic care was invented out of whole cloth, with ridiculously unsubstantiated claims that most health problems stem from spinal problems --- in particular, "subluxation". This is a standard medical term which has been adopted and completely bastardized by the chiropractic community, and one which chiropractors cannot even adequately define:
Chiropractors also disagree on whether their "subluxations" are visible on x-ray films. "Straight" chiropractors tend to believe that they cause nerve interference, are readily visible, and that virtually everyone gets them. Most other chiropractors (commonly referred to as "mixers") define subluxations loosely and see them when it suits their convenience. Chiropractors who reject subluxation theory consider them invisible but have been forced to acknowledge them to get paid by Medicare.
If one peruses one of the multitude of chiropractic web sites, you will discover repeatedly that "subluxations are epidemic in our society."

Epidemic!!

Why, it seems that even children are in need of regular "correction" of their subluxations, as they are not immune to this terrible epidemic. And what about the littlest members of our subluxation-prone community, newborns? Sure enough, they need adjustment because of "traumatic birth syndrome" (Google it yourself):
All children should be examined by a Chiropractor immediately after birth. Take this critical step to ensure that your children are as healthy as they are designed to be.
With this subluxation problem of epidemic proportions, how does one know what's wrong with oneself in the chiropractic view of things? Rather than link to any particular web site, this chart produced by a designer of chiropractor web sites gives one an idea of the kind of things chiropractors preach: all of the organ systems of the body are directly affected by the spine. Detailed descriptions are found on many web sites; this exact quote can be found on a total of 145 web sites in a Google search (emphasis is mine):
The internal organs supplied by nerves from the thoracic spine include much of the body parts supplied by the sympathetic nervous system. This portion of the nervous system innervates many of the organs in the chest and abdomen including, the heart, lungs, bronchial tubes, gallbladder, liver, stomach, pancreas, spleen, adrenal glands, kidneys, and small intestines. Subluxations affecting these organs can lead to a large list of functional and systemic problems including, asthma, certain heart problems, bronchitis, blood pressure problems, ulcers, allergies, kidney trouble, and digestive problems, to name only a few. Most subluxations affecting these areas go undetected for a long time before a health problem is ever noticed.
And that's just the thoracic spine!

So, if I get this right, almost every health problem imaginable is caused by spinal problems, specifically subluxations; all of us, including newborns and children, need regular "adjustments;" and we should be increasingly utilizing chiropractic care because " Chiropractic restores health, relieves pain and restores life with drugless, knifeless, natural, holistic methods" (from Parker College of Chiropractic). If you think chiropractic care is appropriate for your medical needs, we are fortunate enough to live in a society that allows you to seek out that care. It is worrisome to me, however, that we are being forced to pay for this type of unsubstantiated care through our tax dollars --- even now with the knowledge that much of those funds are being disbursed due to fraudulent billing. Our health care resources are limited, and are now being stretched to their limit; if we need to look hard at evidence-based medicine and have report cards for hospitals in order to ensure appropriate use of those funds, we need to critically look at expenditure of those limited resources on chiropractic care.

There are many more eloquent evaluations of chiropractic care to be found on the internet, and I'd encourage anyone with curiosity to check them out.

Improper Claims on Chiropractic College Web Sites at Chirobase

Chirowatch

Nat'l. Council Against Health Care Fraud - Position Paper on Chiropractic

What are the warning signs of a bad chiropractor?

Chiropractic's Elusive Subluxation


Pharyngula::Chiroquackery