It’s Here: New Guides For Chiropractic That Doctors Are Ignoring

Friday, February 23rd, 2018

In this article, we are talking about acute and non-acute low back pain. What are current healthcare guidelines? Why does it matter to chiropractic patients and non-chiropractic patients and are those in the medical field getting (and implementing) the information?

To start off the discussion, I would say that one would be completely oblivious to not understand that Chiropractic is considered to be on the fringe of healthcare by many to most in the medical field. It’s just a fact and chiropractors deal with this daily.

In other articles, I have covered the Wilk vs. AMA case1,2. I’ve covered the Doctored film by Jeff Hayes that spotlights some of the mistreatment of chiropractors. I have also covered current attacks on Texas Chiropractors by the Texas Medical Association. It is all very well-documented at this point.

Chiropractic is currently undergoing an amazing renaissance. This is due to a couple of key factors. The first being the need to develop non-pharmacological treatment recommendations in the midst of a national opioid addiction crisis3. One that has killed thousands and thousands in the last several years. The second reason being the body of high-quality research that is consistently coming to light almost every month showing the effectiveness of Chiropractic and evidence-based chiropractors.

With all of the new information and new healthcare laws emerging, the questions going forward will be, “Is the medical field and is the insurance industry listening and implementing?” We shall see. So far, the answer is, “Absolutely not.” In fact, it’s almost defiant.

Let’s begin with the most glaring denial of Federal Law by the insurance companies right now. It has to do with Section 2706 of the Patient Protection and Affordable Care Act. Also commonly known as “Obamacare.” Section 2706 of the PPACA is entitled the nondiscrimination In Health Care section of the Federal Law and is intended to keep insurance companies and health plans from keeping chiropractors and the services they provide out of the system.

It reads as follows, “A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider’s license or certification under applicable State law. This section shall not require that a group health plan or health insurance issuer contract with any health care provider willing to abide by the terms and conditions for participation established by the plan or issuer. Nothing in this section shall be construed as preventing a group health plan, a health insurance issuer, or the Secretary from establishing varying reimbursement rates based on quality or performance measures.” 4

On the American Chiropractic Association’s FAQ site for 27064, they state, “It is important to understand that Section 2706 and its assurance of non-discrimination in terms of participation and coverage requires that doctors of chiropractic not be discriminated against in the provision of any “essential benefit” that is within their scope of practice.”

Here’s the rub on 2706: part of its purpose is to reimburse chiropractors performing the same services under their scope and license the same as any other professional that provides that service. For instance, under the PPACA Section 2706 Federal Law, chiropractors are to be paid the exact same for a 99203 exam code as a doctor of medicine or osteopathy is paid. Plain and simple. This is not happening. With so many chiropractors now integrating their practices with medical directors, physician assistants, nurse practitioners, and physical therapists, it is painfully clear that doctors of chiropractic are being discriminated against when it comes to reimbursements for the same codes performed. In fact, chiropractors are integrating with these other professions just so that they can finally GET the reimbursements that the other practitioners are allowed! It is madness and clearly violates Section 2706 of PPACA.

Also, there is violation of the law if an insurer does something such as applying caps on specific services provided by one healthcare provider whereas the cap does not apply to another type of provider. It is my understanding that United Healthcare has moved to a $65 visit cap on chiropractic care here in Texas.

It is the American Chiropractic Association’s opinion that a violation exists if the insurer or plan denies specific forms of care that are otherwise covered if it is a chiropractor providing the service and it is within their scope and licensing. I would suggest that a medical doctor likely gets services such as non-surgical decompression covered under insurance, but chiropractors are routinely denied coverage.

There is also a possible violation when doctors of Chiropractic are denied inclusion into a plan or group purely based on the profession. For example, it is my understanding that FirstCare won’t cover Chiropractic. There is a local insurance network that charges $200 per year for chiropractors to be included for coverage, but medical professionals pay nothing to be included. Could that be a violation of the nondiscrimination law?

In my opinion, Federal Law is being violated all over the place in regards to Section 2706 of PPACA. I’m not sure how it can be perceived any other way.

New Recommendations For Acute and Chronic Low Back Pain

Now, I would like to move on to the medical field’s updated recommendations I mentioned at the first of this article. It is becoming more and more aggravating that we chiropractors are not seeing a flood of acute and chronic low back pain patients. If you read my articles, watch my videos, or listen to my podcast with any regularity, you have no doubt been informed several times over of these new recommendations. It is my opinion that no long-held beliefs or protocols will change if new information is not continually pounded and yelled about from the top of the roofs. In marketing, experts have said that it takes a target 7 times of being exposed to information before it is received and, hopefully, acted upon.

I know that the medical field has NOT been exposed to this information at least 7 times because of two factors:

  1. I have spoken to several medical practitioners here locally and not a single one of them had heard or were aware of these new recommendations.
  2. I am not seeing an incredible, overwhelming influx of acute and chronic low back pain new patients coming through my doors as a result of medical referrals.

Is this willful disregard for the changing recommendations and a “clinging on” to old dogmatic beliefs passed down from the AMA years ago? I think some of it most certainly is.

Is it that a few bad seeds in the Chiropractic profession are giving the rest of us a bad image? I would say some of it most certainly is.

What I think it is mostly based on is the fact that medical professionals are busy, they’re stressed, and many times over-worked and they simply don’t always have the time or opportunity to stay completely up on every new recommendation or updated protocol.

With that being said, let’s be clear; the issues of low back pain, its economic impact, and the national opioid epidemic crisis in America combine to make these new recommendations that much more important.

Let’s start with the American College of Physicians. Remember, the American College of Physicians was proven in the Wilk vs. AMA case to have played a part in collaborating with the AMA in an attempt to rid the Earth of Chiropractic. I think that’s important to note as we go through the information5. In response to the opioid epidemic gripping the nation currently, the American College of Physicians developed new recommendations for treating acute and chronic low back pain.

Why They Did It

  • The American College of Physicians developed this guideline in order to provide updated recommendations on treatment of low back pain.
  • With these recommendations, the ACP hoped to influence clinicians AND patients to make the correct decision for care in acute, subacute, or chronic low back pain conditions.

How They Did It

  • They based their recommendations on a systematic review of randomized controlled trials and other systematic reviews.
  • The research they reviewed included those papers available through April of 2015.
  • The research included only those on noninvasive pharmacologic and nonpharmacologic treatments.

What They Found

  • Recommendation #1: patients with subacute or acute low back pain should seek nonpharmacologic treatments such as Chiropractic, Massage, Acupuncture, and superficial heat BEFORE resorting to non-steroidal anti-inflammatories such as Ibuprofen, Tylenol, Aleve, etc… (Graded as a strong recommendation)
  • Recommendation #2: patients with chronic low back pain should seek nonpharmacologic treatments such as Chiropractic, Exercise/Rehabilitation, Acupuncture, & Cold Laser Therapy BEFORE resorting to non-steroidal anti-inflammatories such as Ibuprofen, Tylenol, Aleve, etc… (Graded as a strong recommendation)
  • Recommendation #3: In patients with chronic low back pain that have had no relief from nonpharmacological means, the first line of treatment would consist of NSAIDs like Aleve, Tylenol, Ibuprofen, etc.. As a second-line treatment, the clinician may consider tramadol or duloxetine. Opioids would be a last option and only if all other treatments have been exhausted and failed and even then with lengthy discussion with the patient in regards to the risks and benefits of using opioids. (Graded as weak recommendation)

Let’s recap: in February of 2017, the American College of Physicians, historically a Chiropractic profession detractor and attacker, now recommends Chiropractic as a first-line treatment for acute and chronic low back pain.

Next, let us discuss the American Medical Association. If you thought the American College of Physicians was guilty of Chiropractic-hating, the American Medical Association is, or was, “Pablo Escobar” or the “El Chapo” of the attacks on the Chiropractic profession. The “El Jefe” of the Chiropractic haters, and the group that not only sat in the driver’s seat but also OWNED the entire truck of destruction back before Wilk vs. AMA came along. I believe I have been watching too much Netflix.

On April 11, 2017, the Journal of the American Medical Association published a study on their website titled “Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain Systematic Review and Meta-analysis,” authored by Neil Page, MD et. al6. In the format of this research paper, they refer to chiropractic treatment as spinal manipulative treatment or SMT. But, because spinal manipulative therapy is what we chiropractors do the most and what we are most identified with, I’m replacing the term “SMT” with “chiropractic adjustment.”

Why They Did It

Considering that spinal manipulation, or the chiropractic adjustment, is a treatment option for acute low back pain, and that acute low back pain is one of the most common reasons for visits to the doctor’s office, the authors wanted to systematically review the studies that have been done in the past dealing with the effectiveness as well as the harms of chiropractic adjustments in the treatment of acute low back pain.

How They Did It

  • The researchers used searches of MEDLINE, Cochrane Database of Systematic Reviews, EMBASE, and Current Nursing and Allied Health Literature.
  • The search spanned 6 years from January 2011 through February 2017 for randomized controlled trials of adults with low back pain comparing spinal manipulative therapy with no treatment or with alternative treatments.
  • The accepted papers also had to measure pain or functional outcomes for up to 6 weeks.
  • The data extraction was done in duplicate.
  • The quality of the study was assessed through use of the Cochrane Back and Neck Risk of Bias tool.
  • Finally, the evidence was assessed using the GRADE criteria, which stands for Grading of Recommendations Assessment, Development, and Evaluation.
  • 26 eligible randomized controlled trials were identified and accepted.

What They Found

  • 15 of the RCTs, totaling 1,699 patients, showed moderate-quality evidence that chiropractic adjustments had a statistically significant association with improvements in PAIN.
  • 12 of the RCTs, totaling 1,381 patients, showed moderate-quality evidence that chiropractic adjustments have a statistically significant association with improvements in FUNCTION.
  • NO RCTs reported any serious harms or adverse events as a result of undergoing chiropractic adjustments.
  • There were only minor events reported like some increased pain, muscle stiffness, and headache in roughly 50%-67% of those treated in the large case series. I would be interested to hear more about this statement by the authors. That is not what we commonly see in our practice. Sometimes, if the patient is new and is not accustomed to chiropractic adjustments, they may experience some soreness or stiffness the next day, which is to be expected following a change in the body.

Wrap It Up

In true AMA fashion, instead of just coming out and saying, “Chiropractic adjustments showed moderate quality evidence for effectiveness in pain as well as in function,” the authors instead stated in conclusion, “Among patients with acute low back pain, spinal manipulative therapy was associated with modest improvements in pain and function at up to 6 weeks, with transient minor musculoskeletal harms. However, heterogeneity in study results was large.” Heterogeneity is defined as, “The quality or state of being diverse in character or content.” In my opinion, this is to give themselves and “out” by implying there was not enough focus to the RCTs to truly state their findings as fact.

Nonetheless, where the AMA is comes even remotely close to endorsing anything having to do with Chiropractic, I’ll take it. And so should those in the medical field that commonly come in contact with those seeking help for their acute and chronic low back pain.

We Should Be All Set For Success Now, Right?

That is what you would think but there is new information from the White House that this simply is not the case despite the obvious ramifications. On page 57 of The President’s Commission On Combating Drug Addiction and The Opioid Crisis7 report, the authors say, “A key contributor to the opioid epidemic has been the excess prescribing of opioids for common pain complaints and for postsurgical pain. Although in some conditions, behavioral programs, acupuncture, chiropractic, surgery, as well as FDA-approved multimodal pain strategies have been proven to reduce the use of opioids, while providing effective pain management, current CMS reimbursement policies, as well as health insurance providers and other payers, create barriers to the adoption of these strategies.” This is straight from the White House.

At the bottom of page 57, you will also see that it says, “The Commission recommends CMS review and modify rate-setting policies that discourage the use of non-opioid treatments for pain, such as certain bundled payments that make alternative treatment options cost prohibitive for hospitals and doctors, particularly those options for treating immediate post-surgical pain.”

Essentially, the United States Government is admitting there is professional discrimination at the highest levels (Medicare and health insurance plans) that creates barriers to doing the smart thing. The smart thing is seeing a chiropractor for your back pain. The “Big Guys” (AKA: American College of Physicians and the American Medical Association) recommend it and the government says policies are in place to prevent patients from following those recommendations. In addition, policies that discriminate against chiropractic or chiropractors run in violation of Section 2706 of PPACA. It comes full circle.

How do we deal with this? It has to be through either the legislature at the state and federal levels or it has to be through the legal system. A guarantee I feel comfortable making is that the insurance companies will not begin enforcing it on their own. Mobilization and unification of the Chiropractic profession is likely the first step.

Some steps toward that end include:

  • Join or get involved with your state association. They’re the only ones effectively fighting for you and your rights on the state level.
  • Join or get involved with your national association. They’re the only ones effectively fighting for you and your rights on the national level.
  • If possible, build relationships with your state and national legislators.
  • Donate to all of the above in the largest amounts you are comfortable with.
  • Tell your friends and your colleagues about what is going on and help them get involved if they’re so inclined.
  • Follow the news of your industry closely and stay knowledgeable about your profession. Both the good AND the bad.

A Chiropractic profession that is unified and playing offense instead of defense is powerful and is one of the worst nightmares of some folks I know out there in the world. Personally, as a side note, I like to see people like that squirm just a little so won’t you consider helping if you haven’t before? If you do not know where to start, email me at dr.williams@chiropracticforward.com and I will help you get on your way.

Did you know that research and clinical experience shows that, in about 80%-90% of headaches, neck, and back pain, in comparison to the traditional medical model, patients get good or excellent results with Chiropractic? Chiropractic care is safe, more cost-effective, it decreases your chances of having surgery, and it reduces your chances of becoming disabled. We do this conservatively and non-surgically. In addition, we can do it with minimal time requirements and minimal hassle on the part of the patient. And, if the patient develops a “preventative” mindset going forward from initial recovery, we can likely keep it that way while raising the general, overall level of health!

Please feel free to leave a comment and tell me your thoughts. I’d love to hear what you think.And….SHARE, SHARE, SHARE!! We cannot make a difference without your help.

Till next time……

The Amarillo Chiropractor Blog is written by Dr. Jeff Williams.
Amarillo TX Amarillo Pain & Accident Chiropractic Clinic provides customized chiropractic care to the Amarillo TX, Canyon TX, Pampa TX, Happy TX, White Deer TX, Dumas TX, Groom TX, Conway TX, Panhandle TX, Claude TX, Clarendon TX, Borger TX, Tulia, TX, Hereford TX, Fritch TX, Bushland TX, and Vega TX communities.
Visit our main website at www.amarillochiropractor.com for customized Chiropractic in Amarillo TX. Choose several options to schedule your appointment: call (806) 355-3000 or click the button below for our contact info.

by Jeff S. Williams, D.C.

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References and Source Material

https://www.amarillochiropractor.com/startling-medical-professional-attacks-chiropractic/

https://www.amarillochiropractor.com/healthcare-in-texas-the-battle-against-a-monopoly-a-true-story-about-david-goliath/

https://www.whitehouse.gov/sites/whitehouse.gov/files/images/The%20Underestimated%20Cost%20of%20the%20Opioid%20Crisis.pdf

https://www.acatoday.org/Portals/60/Docs/Advocacy%20and%20Reimbursement/2706/2706-FAQs.pdf?ver=2015-12-23-125425-503

http://annals.org/aim/fullarticle/2603228/noninvasive-treatments-acute-subacute-chronic-low-back-pain-clinical-practice

https://jamanetwork.com/journals/jama/article-abstract/2616395?widget=personalizedcontent&previousarticle=2616379

https://www.whitehouse.gov/sites/whitehouse.gov/files/images/Final_Report_Draft_11-3-2017.pdf