Proposed Excessive Treatment Admin. Rule

May 3, 2004

As an alternative to the proposed excessive treatment rule I suggest

that the OBCE provide itself as a friend of the insurance industry in

court proceedings where excessive treatment is alleged. With this type

of testimony there should be no problem for the court to rule in favor

of fair treatment guidelines.

Simply put?

The OBCE will draft administrative rules that would allow it to testify

for or against chiropractors in Oregon who have exceeded the written

guidelines for professional conduct. The OBCE would provide such expert

testimony to any who wish to purchase the same.

Adavantages:

1. low cost, as we do not spend the money on prosecution.

2. Make a profit as the insurer would surely pay to get the testimony

3. Control the IME problems by providing the best possible witness for

concluding a case where an IME has created a loophole for insurers to

crawl through.

4. Prevents the rotten apples from spoiling the whole barrel.

Disavantages:

1. your turn.

Willard Bertrand, D.C.

Fw: " Proposed Excessive Treatment Admin. Rule "

Re: " Proposed Excessive Treatment Admin. Rule "

> >

> > > Vern

> > > There already exists a process for excessive treatment and costs

in

any

> > third

> > > party payment system, including PIP. The OBCE has the authority

to

> > receive and

> > > investigate complaints against DC's that appear to charge or treat

> > excessively.

> > > We also have in place a Peer Review Committee that can look at

both

sides

> > of any

> > > issues (DC -vs. - Insurance carrier) on over treatment or over

charging

> > and make

> > > recommendations to the OBCE for action. Your " new " proposal for

ANOTHER

> > > Administrative Rule on this issue is, in my opinion, an extreme

over

> > reaction to

> > > pressure from outside influences, whose only motive is to use the

> > Chiropractic

> > > profession as its " whipping boy " again as it did in 1990.

> > >

> > > What we should be telling those who are pushing to " put us in our

place " ,

> > is

> > > that there are existing avenues to address over treatment or

excessive

> > charging.

> > > For BOTH sides of the equation.

> > >

> > > I also have concerns about " consensus " panels. I repeatedly get

new

> > patients

> > > that have already been to another or other DC's, and without any

> > improvement are

> > > told they are " all well " , or they are released from care as soon

as

they

> > feel a

> > > little better. Yet the patient tells me that they did not improve

and

> > they

> > > still have the same problems they started with. If you have ten

DC's

that

> > only

> > > treat each patient 5 or 6 times and release them from care as have

reached

> > > " MMI " , then their " consensus " is that all patients get " well " in

5-6

> > visits.

> > > This cannot be considered, by any measure, scientific, and at best

is

> > short

> > > sighted, and is an extremely subjective approach to a

multi-faceted

issue.

> > >

> > > I also feel strongly that we should, as a group, be looking very

closely

> > at

> > > implementing the treatment guidelines for PIP cases that Dr. Art

Croft

> > > developed, using the existing scientific literature on outcome

studies.

> > These

> > > studies already show that Chiropractic care is the ONLY treatment

regimen

> > that

> > > has any validity in improving and stabilizing those patients

injured

in

> > motor

> > > vehicle collision, especially CADS and those that develop " Late

Whiplash "

> > > issues. In the Croft guidelines (Grades I-V), a grade II whiplash

injury

> > > (without neurological signs or other complicating factors) has a

treatment

> > > longevity of up to 29 weeks and up to 34 treatments. We need to

educate

> > not

> > > only the insurance industry, but also our own colleagues. Dr.

Croft's

> > > guidelines can be accessed through the Spine Research Institute of

San

> > Diego

> > > (SRISD) and through CRASH. Both are on-line.

> > >

> > > Your example of the case that cost $19K, is at best, extreme, and

in

the

> > least

> > > inflammatory and reactionary. There are those cases where the

injury

> > sustained

> > > has caused structural and functional disability that requires

years of

> > > treatment, not months, and over 10% of those injured in MVC's have

> > permanent

> > > impairment and lifetime disability in one form or another. (When

was

the

> > last

> > > time Allsnake of Snake Farm offered you that information?)

Therefore,

one

> > must

> > > ask, was the $19K helpful to the patient in that it returned them

to

there

> > > pre-functional status? What was the diagnosis? Were there risk

factors

> > or

> > > other complicating factors, or other factors for a more serious

injury

or

> > for a

> > > poor prognosis? If one looks at the existing scientific

literature

> > verifies the

> > > known risk factors for injury and for a poor prognosis, especially

in

> > Cervical

> > > Acceleration-Deceleration trauma (CADS). These include:

> > > 1) Female gender

> > > 2) History of prior spinal injury

> > > 3) Poor head restraint geometry/tall occupant (80th percentile

male)

> > > 4) Rear vs. other vector impacts

> > > 5) Use of seat belts/shoulder harness (standard three-point

restraints)

> > > 6) Body mass index/head neck index

> > > 7) Out-of-position occupant (e.g., leaning forward/slumped)

> > > 8) Non-failure of seat back

> > > 9) Having the head turned at impact

> > > 10) Non-awareness of impending impact.

> > > 11) Increasing age (i.e., middle age and beyond)

> > > 12) Front vs. rear seat position

> > > 13) Impact by vehicle of greater mass (i.e., 25% greater)

> > > 14) Crash speed under 10 mph

> > >

> > > Additionally, the literature points to known risk factors for late

> > whiplash,

> > > including:

> > > 1) Female gender

> > > 2) Lower BMI (body mass index)

> > > 3) Immediate/early onset of symptoms (i.e., within 12 hours)

and/or

severe

> > > initial symptoms

> > > 4) Ligamentous instability on radiographs.

> > > 5) Initial back pain

> > > 6) Greater subjective cognitive impairment

> > > 7) Greater number of initial symptoms

> > > 8) Use of seat belt shoulder harness for neck (not back) pain;

non-use

had

> > > a protective effect.

> > > 9) Initial physical findings of loss of ROM

> > > 10) Initial neurological symptoms

> > > 11) Past history of neck pain or headache

> > > 12) Degenerative changes seen on radiographs

> > > 13) Loss or reversal of cervical lordosis

> > > 14) Increasing age (i.e., middle age and beyond)

> > > 15) Front seat position

> > >

> > > Also, did you check to see if, in this particular case, whether

there

were

> > > complicating factors that lead to a poor prognosis and long term

treatment

> > or

> > > disability?, i.e.:

> > > 1) Metabolic disorders, i.e. diabetes, etc.

> > > 2) Lower BMI

> > > 3) Immediate/early onset of symptoms (i.e., within 12 hours)

and/or

> > > severe initial symptoms

> > > 4) Initial back pain

> > > 5) Spondylosis

> > > 6) Use of seat belt and shoulder harness

> > > 7) Facet arthrosis

> > > 8) History of neck pain or headaches

> > > 9) Rheumatoid arthritis or other arthritides

> > > 10) Degenerative changes on radiographs of the spine

> > > 11) Ankylosing spondylitis or other spondylarthropathy.

> > > 12) Loss/reversal of cervical lordotic curve

> > > 13) Scoliosis

> > > 14) Increasing age (i.e., middle age and beyond

> > > 15) Prior cervical spinal surgery

> > > 16) Front seat position in car

> > > 17) Prior lumbar spinal surgery

> > > 18) Prior vertebral fracture

> > > 19) Osteoporosis

> > > 20) Osseous diseases

> > > 21) Spinal stenosis and/or foraminal stenosis

> > > 22) Paraplegia or quadriplegia

> > > Of course, these factors must be documented in the patient history

and

the

> > DC's

> > > chart notes, in an accurate and concise manner.

> > >

> > > Then, in closing, is the $19K truly excessive? Compared to what?

> > Compared to

> > > spinal surgery, at a minimum of $80K? Compared to PT, MD,

Radiology,

> > long-term

> > > pharmacologic dependence, Occupational Therapy, ad nauseum, with

their

> > related

> > > costs of $100K+? In addition, what are the costs of lost time,

loss of

> > familial

> > > consort, loss of social function, premature death from the

sequelae of

the

> > > effects of the injury and the gradual, stead deterioration of the

quality

> > of

> > > life? Personally, it is about time that we tell the world the

truth

about

> > how

> > > the insurance industry is duping the public. Our efforts will be

better

> > served

> > > to broadcast to the public that we are more effective, less

costly,

and

> > more

> > > efficient than any other form of treatment and stop acting as if

we

are

> > the

> > > poor cousins in the health care delivery field. Our treatment

should

be

> > worth

> > > more than standard medical care. Our true value is the marked

effect

we

> > have on

> > > the functionality we return to our patient's lives and the reduced

> > long-term

> > > costs we actually save with our treatment.

> > >

> > > My advice: Stop crying that the sky is falling and tell those

that

> > " think " we

> > > treat or charge excessively to contact the OBCE and our Peer

Review

> > Committee.

> > >

> > > But, that's just my opinion. I could be wrong.

> > >

> > > G. Ray, DC

> > >

May 3, 2004

I would also like to send a big thank you

to the OBCE. Thank you, you have done enough to help. Now please set down your

tools and go home. It is time to simply administer the tests and the rules we

have. Thank you.

Willard Bertrand, D.C.

Re:

" Proposed Excessive Treatment Admin. Rule "

Well put Minga....does me heart good to know we have some of

the " sharper knives in the drawer " sitting on the OBCE.

Generally its a thankless job, a huge commitment of time and

energy.....well here is one GREAT BIG THANK YOU Minga and to all the

members of the OBCE!

Vern Saboe, DC

Re:

" Proposed Excessive Treatment Admin. Rule "

Vern,

I am very greatful for all the work you're doing to help our profession towards

self-regulation. You are asking for DC input. You are reporting back to

us all regularly. You are clear in your motives, adgenda and goals. For those

in our profession who have no time to participate, I would urge you to please

trust the process. I trust that you, Vern, know more than I do with respect to

legislative directions. As you've put in volumes of hours for our profession.

For those of you in doubt or disagreement, please please come forward with your

time, energy and suggestions to help our profession with the problems we

currently face. If you disagree, present an alternative plan in writing at one

of the meetings, or here on this listserv. But do so immediately.

Minga Guerrero DC

OregonDCs

rules:

1. Keep correspondence professional; the purpose

of the listserve is to foster communication and collegiality. No personal

attacks on listserve members will be tolerated.

2. Always sign your e-mails with your first and

last name.

3. The listserve is not secure; your e-mail could

end up anywhere. However, it is against the rules of the listserve to copy,

print, forward, or otherwise distribute correspondence written by another

member without his or her consent, unless all personal identifiers have been

removed.

OregonDCs

rules:

1. Keep correspondence professional; the purpose

of the listserve is to foster communication and collegiality. No personal

attacks on listserve members will be tolerated.

2. Always sign your e-mails with your first and

last name.

3. The listserve is not secure; your e-mail could

end up anywhere. However, it is against the rules of the listserve to copy,

print, forward, or otherwise distribute correspondence written by another

member without his or her consent, unless all personal identifiers have been

removed.

May 11, 2004

Dear Colleagues:

As per the need for an Administrative Rule that is specific in language so to act as a measuring stick (outcomes assessment tools) that all stakeholders can use in the realm of PIP in Oregon, to determine that chiropractic treatment frequency and duration of curative care has indeed been reasonable and necessary....

I just received a post from a colleague in another state who just reviewed a PIP case that ran right at 10 months of care and close to $19,000 in charges. Yes, we have this same level of abuse here in Oregon, what % of colleagues? I have no idea but it matters not as it will indeed be these cases that the PIP carriers will use to convince the legislators that change is needed.

In the late 80's we needed to do something about the % of the profession that were truly abusing the system of Worker's Compensation. What was missing was a universal evidence based measuring stick to apply to these casualty (accident) insurance type cases, to help determine if curative treatment had been reasonable and necessary.

Bottom-line was I heard some of the same arguments then against not "boxing ourselves in, etc.," so we did nothing and we lost nearly everything and colleagues history is about to repeat it's self in PIP if we again fail to act decisively and in a timely manner.

I would like your thoughtful comments?

Vern Saboe

May 11, 2004

Hi Vern,

Yesterday I spoke with Mr. Phil Barnhart, State Representative for District 11 here in Eugene. He is very interested in our issues: most specifically IME and PIP. He told me about an anticipated battle during the next session but is fully 'on our side' and most interested in assisting us with this. He is a seasoned legislator with, from the discussion we had, a seemingly good understanding of our concerns. If he is already gearing up for this conversation within the legislature, it behoves us to pay attention...to put our mouths and money where our interest is, so to speak.

While we are still coordinating the dates (it will most likely happen in mid July), Mr. Barnhart is offering to meet with us here in Eugene to fully discuss our issues and concerns. He states he is very interested in our feedback.

Thank you, Uncle Vern, for setting the stage for this meeting. I call on DCs throughout the state (and especially here in Eugene) to attend this session. It promises to be most informative. We will get the date to you asap so you can mark your calendars.

Sunny

Sunny Kierstyn, RN DCFibromyalgia Care Center of Oregon59 Santa Clara St.,Eugene, Oregon, 97404541-689-0935

"Proposed Excessive Treatment Admin. Rule"

Dear Colleagues:

As per the need for an Administrative Rule that is specific in language so to act as a measuring stick (outcomes assessment tools) that all stakeholders can use in the realm of PIP in Oregon, to determine that chiropractic treatment frequency and duration of curative care has indeed been reasonable and necessary....

I just received a post from a colleague in another state who just reviewed a PIP case that ran right at 10 months of care and close to $19,000 in charges. Yes, we have this same level of abuse here in Oregon, what % of colleagues? I have no idea but it matters not as it will indeed be these cases that the PIP carriers will use to convince the legislators that change is needed.

In the late 80's we needed to do something about the % of the profession that were truly abusing the system of Worker's Compensation. What was missing was a universal evidence based measuring stick to apply to these casualty (accident) insurance type cases, to help determine if curative treatment had been reasonable and necessary.

Bottom-line was I heard some of the same arguments then against not "boxing ourselves in, etc.," so we did nothing and we lost nearly everything and colleagues history is about to repeat it's self in PIP if we again fail to act decisively and in a timely manner.

I would like your thoughtful comments?

Vern Saboe

OregonDCs rules:1. Keep correspondence professional; the purpose of the listserve is to foster communication and collegiality. No personal attacks on listserve members will be tolerated.2. Always sign your e-mails with your first and last name.3. The listserve is not secure; your e-mail could end up anywhere. However, it is against the rules of the listserve to copy, print, forward, or otherwise distribute correspondence written by another member without his or her consent, unless all personal identifiers have been removed.

May 11, 2004

Vern,

I am very greatful for all the work you're doing to help our profession towards self-regulation. You are asking for DC input. You are reporting back to us all regularly. You are clear in your motives, adgenda and goals. For those in our profession who have no time to participate, I would urge you to please trust the process. I trust that you, Vern, know more than I do with respect to legislative directions. As you've put in volumes of hours for our profession. For those of you in doubt or disagreement, please please come forward with your time, energy and suggestions to help our profession with the problems we currently face. If you disagree, present an alternative plan in writing at one of the meetings, or here on this listserv. But do so immediately.

Minga Guerrero DC

May 11, 2004

Howdy:

While I certainly don't know the details in this particular case, I'd like to see what clinical findings supported the average $1900/month/10 months for chiropractic care.....with the appropriate documentation there may be no problem at all in demonstrating this level of care is needed.....

On the other hand, in way too many instances in the past, chiros have failed to document exactly the exam findings and progress or lack thereof that gives credible support for rational care of this intensity....

J. Pedersen DC

May 11, 2004

Garreth,

Xs care is absolutely not defined by time alone. And I'm sure Vern didn't intend that message. I think the key parts of his email, as I remember, were that there were no re-exam or objective justifications for continued care. that picture combined with an inflated fee, will do harm to the patient's case. The patient you describe sounds like an easy exception to continued care. It could also justify more drastic measures to stabalize. Just document the exams, treatments and outcomes. I've seen poor documentation ruin a great case. It's so sad when a patient comes to your office after months of poorly documented care. The bill is incredibly high. PIP is nearly exhausted and the patient is still in significant pain. I've been in business for 20 years and have no idea how long you've been practicing. Please rest assured that the vast majority of chiropractors understand the need for continuing care when there are circumstances beyond normal. Diabetes, previous surgery, pregnancy, rheumatoid arthritis and age of patient just to name a few. I've never seen or heard any docs at the meetings in peer review or with rules advisory committee neglect to think of these possibilities. That said, I've also never heard of any plan to give exact weeks for care of a given condition. It can't be done. there are too many variables. I think the rules that are being suggested are simply for a group of peers to be able to evaluate our work and see if it's reasonable when a complaint is filed. BTW, I'm not speaking for Vern, just my very own opinion of what I percieve from the time I've volunteered.

Minga Guerrero DC

May 11, 2004

Exactly Jack you hit the nail on the head. A lot of our problem is not true excessive treatment but rather very likely problematic medi-legal musculoskeletal cases that are indeed receiving appropriate care, it's just that the documentation is missing.

This proposed administrative rule would force the issue of generating proper documentation of injury (evidence based outcome assessments, both subjective patient driven and objective doctor driven), a progression of care, and as such help to determine both when the patient has reached maximal chiropractic improvement and if there is any spinal impairment/residuals requiring supportive care.

Vern Saboe

Re: "Proposed Excessive Treatment Admin. Rule"

Howdy:

While I certainly don't know the details in this particular case, I'd like to see what clinical findings supported the average $1900/month/10 months for chiropractic care.....with the appropriate documentation there may be no problem at all in demonstrating this level of care is needed.....

On the other hand, in way too many instances in the past, chiros have failed to document exactly the exam findings and progress or lack thereof that gives credible support for rational care of this intensity....

J. Pedersen DC

OregonDCs rules:1. Keep correspondence professional; the purpose of the listserve is to foster communication and collegiality. No personal attacks on listserve members will be tolerated.2. Always sign your e-mails with your first and last name.3. The listserve is not secure; your e-mail could end up anywhere. However, it is against the rules of the listserve to copy, print, forward, or otherwise distribute correspondence written by another member without his or her consent, unless all personal identifiers have been removed.

May 11, 2004

Well put Minga....does me heart good to know we have some of the "sharper knives in the drawer" sitting on the OBCE. Generally its a thankless job, a huge commitment of time and energy.....well here is one GREAT BIG THANK YOU Minga and to all the members of the OBCE!

Vern Saboe, DC

Re: "Proposed Excessive Treatment Admin. Rule"

Vern,I am very greatful for all the work you're doing to help our profession towards self-regulation. You are asking for DC input. You are reporting back to us all regularly. You are clear in your motives, adgenda and goals. For those in our profession who have no time to participate, I would urge you to please trust the process. I trust that you, Vern, know more than I do with respect to legislative directions. As you've put in volumes of hours for our profession. For those of you in doubt or disagreement, please please come forward with your time, energy and suggestions to help our profession with the problems we currently face. If you disagree, present an alternative plan in writing at one of the meetings, or here on this listserv. But do so immediately. Minga Guerrero DC OregonDCs rules:1. Keep correspondence professional; the purpose of the listserve is to foster communication and collegiality. No personal attacks on listserve members will be tolerated.2. Always sign your e-mails with your first and last name.3. The listserve is not secure; your e-mail could end up anywhere. However, it is against the rules of the listserve to copy, print, forward, or otherwise distribute correspondence written by another member without his or her consent, unless all personal identifiers have been removed.

May 11, 2004

Vern et al, When I returned from practicing in Hawaii in 1996 I presented cases of impairment based upion the current AMA guides as a Certified Impairment Rating DC, through LACC as instructed by Stan Kaplan, the long standing expert in the field of impairment rating. I was told by attorneys and insurance carriers that my rating would not be given weight in this state, even though my impairment ratings were frequently the decisive factor in the outcome of workers comp settlements, and no fault settlements and arbitrations in Hawaii.(and in the 80's here)

I recall in the early eighties when Mazion certified a bunch of us here in Oregon in Impairment rating that our opinions meant something, so my question is will excessive treatment rules lead to our being recognized more in the future than we are presently or is our destiny unrelated to any actions we may make at this time?

I am not opposed to the concept of cleaning up the fringe, just nervous that it won't accomplish what the intent is, but just create big grief for some unsuspecting honest DC, who happens to not have done his/her due diligence regarding assessments, but may very well have done just fine treating the patient.

In 2002 a paper review and IME was performed on a patient of mine who underwent cervical fusion, after a year or more of chiropractic care and many other opinions at my request and at the request of the carrier.

One neurologist stated that I had "provided excessive chart notes, over one and one half inches thick", and went on to say that my diagnosis and content of my notes were irrelevant. I was the one who dx'd the exact level of the lesion, (confirmed shortly therafter by MRI) after she had been diagnoised with cervical strain. We all do that day in and out, don't we? But nobody is noticing,(except for the neurosurgeons who are on the receiving end of our referrals, not out of respect for our abilities, but for the work,and appreciate us for that, but rarely would in public give credit where credit is due).

It seems that no matter what we do there will always be disregard, disrespect, etc. and if we don't remember that we are setting ourselves up for further disappointments and future finger pointing(within our ranks) depending on which way the wind is blowing.

Too bad we can't survive on cash paying folks, because as I see it that would be the one true way to win a full blown victory. Never happen, and that is the shame.

Your devils advocate, Sherm

Re: "Proposed Excessive Treatment Admin. Rule"

Howdy:

While I certainly don't know the details in this particular case, I'd like to see what clinical findings supported the average $1900/month/10 months for chiropractic care.....with the appropriate documentation there may be no problem at all in demonstrating this level of care is needed.....

On the other hand, in way too many instances in the past, chiros have failed to document exactly the exam findings and progress or lack thereof that gives credible support for rational care of this intensity....

J. Pedersen DC

OregonDCs rules:1. Keep correspondence professional; the purpose of the listserve is to foster communication and collegiality. No personal attacks on listserve members will be tolerated.2. Always sign your e-mails with your first and last name.3. The listserve is not secure; your e-mail could end up anywhere. However, it is against the rules of the listserve to copy, print, forward, or otherwise distribute correspondence written by another member without his or her consent, unless all personal identifiers have been removed. OregonDCs rules:1. Keep correspondence professional; the purpose of the listserve is to foster communication and collegiality. No personal attacks on listserve members will be tolerated.2. Always sign your e-mails with your first and last name.3. The listserve is not secure; your e-mail could end up anywhere. However, it is against the rules of the listserve to copy, print, forward, or otherwise distribute correspondence written by another member without his or her consent, unless all personal identifiers have been removed.

May 11, 2004

Minga, I think if you obtain a copy of Art Croft's book or if you have it, review the section on treatment guidelines. These are very specific but allow for latitude depending on a varity of variables. Sincerely, Sherm

Re: "Proposed Excessive Treatment Admin. Rule"

Garreth,Xs care is absolutely not defined by time alone. And I'm sure Vern didn't intend that message. I think the key parts of his email, as I remember, were that there were no re-exam or objective justifications for continued care. that picture combined with an inflated fee, will do harm to the patient's case. The patient you describe sounds like an easy exception to continued care. It could also justify more drastic measures to stabalize. Just document the exams, treatments and outcomes. I've seen poor documentation ruin a great case. It's so sad when a patient comes to your office after months of poorly documented care. The bill is incredibly high. PIP is nearly exhausted and the patient is still in significant pain. I've been in business for 20 years and have no idea how long you've been practicing. Please rest assured that the vast majority of chiropractors understand the need for continuing care when there are circumstances beyond normal. Diabetes, previous surgery, pregnancy, rheumatoid arthritis and age of patient just to name a few. I've never seen or heard any docs at the meetings in peer review or with rules advisory committee neglect to think of these possibilities. That said, I've also never heard of any plan to give exact weeks for care of a given condition. It can't be done. there are too many variables. I think the rules that are being suggested are simply for a group of peers to be able to evaluate our work and see if it's reasonable when a complaint is filed. BTW, I'm not speaking for Vern, just my very own opinion of what I percieve from the time I've volunteered. Minga Guerrero DC OregonDCs rules:1. Keep correspondence professional; the purpose of the listserve is to foster communication and collegiality. No personal attacks on listserve members will be tolerated.2. Always sign your e-mails with your first and last name.3. The listserve is not secure; your e-mail could end up anywhere. However, it is against the rules of the listserve to copy, print, forward, or otherwise distribute correspondence written by another member without his or her consent, unless all personal identifiers have been removed.

May 11, 2004

Vern

There already exists a process for excessive treatment and costs in any third

party payment system, including PIP. The OBCE has the authority to receive and

investigate complaints against DC's that appear to charge or treat excessively.

We also have in place a Peer Review Committee that can look at both sides of any

issues (DC -vs. - Insurance carrier) on over treatment or over charging and make

recommendations to the OBCE for action. Your " new " proposal for ANOTHER

Administrative Rule on this issue is, in my opinion, an extreme over reaction to

pressure from outside influences, whose only motive is to use the Chiropractic

profession as its " whipping boy " again as it did in 1990.

What we should be telling those who are pushing to " put us in our place " , is

that there are existing avenues to address over treatment or excessive charging.

For BOTH sides of the equation.

I also have concerns about " consensus " panels. I repeatedly get new patients

that have already been to another or other DC's, and without any improvement are

told they are " all well " , or they are released from care as soon as they feel a

little better. Yet the patient tells me that they did not improve and they

still have the same problems they started with. If you have ten DC's that only

treat each patient 5 or 6 times and release them from care as have reached

" MMI " , then their " consensus " is that all patients get " well " in 5-6 visits.

This cannot be considered, by any measure, scientific, and at best is short

sighted, and is an extremely subjective approach to a multi-faceted issue.

I also feel strongly that we should, as a group, be looking very closely at

implementing the treatment guidelines for PIP cases that Dr. Art Croft

developed, using the existing scientific literature on outcome studies. These

studies already show that Chiropractic care is the ONLY treatment regimen that

has any validity in improving and stabilizing those patients injured in motor

vehicle collision, especially CADS and those that develop " Late Whiplash "

issues. In the Croft guidelines (Grades I-V), a grade II whiplash injury

(without neurological signs or other complicating factors) has a treatment

longevity of up to 29 weeks and up to 34 treatments. We need to educate not

only the insurance industry, but also our own colleagues. Dr. Croft's

guidelines can be accessed through the Spine Research Institute of San Diego

(SRISD) and through CRASH. Both are on-line.

Your example of the case that cost $19K, is at best, extreme, and in the least

inflammatory and reactionary. There are those cases where the injury sustained

has caused structural and functional disability that requires years of

treatment, not months, and over 10% of those injured in MVC's have permanent

impairment and lifetime disability in one form or another. (When was the last

time Allsnake of Snake Farm offered you that information?) Therefore, one must

ask, was the $19K helpful to the patient in that it returned them to there

pre-functional status? What was the diagnosis? Were there risk factors or

other complicating factors, or other factors for a more serious injury or for a

poor prognosis? If one looks at the existing scientific literature verifies the

known risk factors for injury and for a poor prognosis, especially in Cervical

Acceleration-Deceleration trauma (CADS). These include:

1) Female gender

2) History of prior spinal injury

3) Poor head restraint geometry/tall occupant (80th percentile male)

4) Rear vs. other vector impacts

5) Use of seat belts/shoulder harness (standard three-point restraints)

6) Body mass index/head neck index

7) Out-of-position occupant (e.g., leaning forward/slumped)

8) Non-failure of seat back

9) Having the head turned at impact

10) Non-awareness of impending impact.

11) Increasing age (i.e., middle age and beyond)

12) Front vs. rear seat position

13) Impact by vehicle of greater mass (i.e., 25% greater)

14) Crash speed under 10 mph

Additionally, the literature points to known risk factors for late whiplash,

including:

1) Female gender

2) Lower BMI (body mass index)

3) Immediate/early onset of symptoms (i.e., within 12 hours) and/or severe

initial symptoms

4) Ligamentous instability on radiographs.

5) Initial back pain

6) Greater subjective cognitive impairment

7) Greater number of initial symptoms

8) Use of seat belt shoulder harness for neck (not back) pain; non-use had a

protective effect.

9) Initial physical findings of loss of ROM

10) Initial neurological symptoms

11) Past history of neck pain or headache

12) Degenerative changes seen on radiographs

13) Loss or reversal of cervical lordosis

14) Increasing age (i.e., middle age and beyond)

15) Front seat position

Also, did you check to see if, in this particular case, whether there were

complicating factors that lead to a poor prognosis and long term treatment or

disability?, i.e.:

1) Metabolic disorders, i.e. diabetes, etc.

2) Lower BMI

3) Immediate/early onset of symptoms (i.e., within 12 hours) and/or severe

initial symptoms

4) Initial back pain

5) Spondylosis

6) Use of seat belt and shoulder harness

7) Facet arthrosis

8) History of neck pain or headaches

9) Rheumatoid arthritis or other arthritides

10) Degenerative changes on radiographs of the spine

11) Ankylosing spondylitis or other spondylarthropathy.

12) Loss/reversal of cervical lordotic curve

13) Scoliosis

14) Increasing age (i.e., middle age and beyond

15) Prior cervical spinal surgery

16) Front seat position in car

17) Prior lumbar spinal surgery

18) Prior vertebral fracture

19) Osteoporosis

20) Osseous diseases

21) Spinal stenosis and/or foraminal stenosis

22) Paraplegia or quadriplegia

Of course, these factors must be documented in the patient history and the DC's

chart notes, in an accurate and concise manner.

Then, in closing, is the $19K truly excessive? Compared to what? Compared to

spinal surgery, at a minimum of $80K? Compared to PT, MD, Radiology, long-term

pharmacologic dependence, Occupational Therapy, ad nauseum, with their related

costs of $100K+? In addition, what are the costs of lost time, loss of familial

consort, loss of social function, premature death from the sequelae of the

effects of the injury and the gradual, stead deterioration of the quality of

life? Personally, it is about time that we tell the world the truth about how

the insurance industry is duping the public. Our efforts will be better served

to broadcast to the public that we are more effective, less costly, and more

efficient than any other form of treatment and stop acting as if we are the

poor cousins in the health care delivery field. Our treatment should be worth

more than standard medical care. Our true value is the marked effect we have on

the functionality we return to our patient's lives and the reduced long-term

costs we actually save with our treatment.

My advice: Stop crying that the sky is falling and tell those that " think " we

treat or charge excessively to contact the OBCE and our Peer Review Committee.

But, that's just my opinion. I could be wrong.

G. Ray, DC

May 11, 2004