How Do I Justify the Medical Necessity of My Care? Part I: Overview

In a fee-for-service health care system, providers are reimbursed for the services they render. However, in a managed care system, services are deemed appropriate or inappropriate more strictly. As health care costs escalated out of control over the last 20 years, it became apparent that there was a limited amount of health care resources which could be affordably provided to consumers. Today, managed care organizations (MCOs) attempt to contain costs. This puts great strain on the ability of health care providers to get reimbursed for what they feel is reasonable and necessary care. This article describes how to identify what is reasonable and necessary care and how to justify appropriate reimbursement.

Discussion

First, the natural history of painful disorders of the spine if left untreated must be explored to judge the efficacy of interventions. What is the natural history of spinal conditions? Eighty-five percent of mechanical pain patients are better in six weeks.¹ The 15% of patients that is likely to become chronic can be accurately identified with simple questionnaires early on.^2-5 There is a high recurrence rate of pain, activity intolerances and disability.^6-9 It should be pointed out that most of our patients should recover within the natural history.

It is often incorrectly presumed that since the vast majority (85%) of low-back patients recover quickly, a nonmanagement approach is most appropriate. The majority of the costs arise from the minority of the patients who are nonresponders. Those who do respond have a high recurrence rate of disability, symptoms and activity intolerances.^1,7-9

Judicious allocation of limited resources is the key to optimizing outcomes in the delivery of health care services.¹⁰ Managed care organizations (MCOs) remain keenly aware of issues relating to cost effectiveness. However, the long-term success of an MCO will be determined by their ability to keep health care purchasers (i.e., employers), providers and patients satisfied with their services. Cost containment alone is not sufficient to achieve such customer satisfaction.

Value is defined as the ration of quality/cost.¹¹ Therefore, quality assurance is an essential driving force of a long-term solution to the managed care problem. Providers who can demonstrate that their care improves outcomes involving pain, activity intolerances or disability will have less trouble getting reimbursed. However, if there is a dearth of objective documentation of patient progress with reliable, responsive outcomes and the patient's treatment outlasts the natural history for untreated patients, then reimbursement for services may be denied.

Screening is essential to prevention of chronic pain or disability.¹⁰ It is a prerequisite to prevention, because it allows allocation of limited resources to those most likely to benefit. Without such screening, an aggressive acute care program would be costly, since musculoskeletal pain (MSP) is so common and generally is self-limiting. A screening tool that reliably and validly identifies the high-risk patient is the best way to determine the minority of patients who are likely to benefit from more aggressive care.

It is clear that an MCO must limit resources (treatment visits/cost of care). Screening will enable greater resource allocation to the minority of patients most likely to benefit. Chiropractors need training in the biopsychosocial model, screening techniques, simple active care principles (i.e., McKenzie) for acute pain and outcomes management. Undoubtedly there will still be a subset of patients who are suffering or disabled after 4-6 weeks. Those patients require a more specialized rehabilitation/functional restoration/biobehavioral model.

What Are Some Risk Factors of Chronicity -- "Yellow Flags"

Pain

Duration of symptoms^3,4,8,12 Past history of numerous episodes^5,8,13,14 Severe pain intensity^3,5,8,9,14 Sciatica^8,13-16

Psychosocial

Symptom satisfaction^8,17
Anxiety^3,4,17
Locus of control¹³
Depression^3,4,8,17,18
Self-rated health as poor^8,19
Job dissatisfaction^8,20,21

Anticipation of disability six months into the future⁵

Psychosocial (fear-avoidance)

Belief that you shouldn't work with your current pain^3,4,17 Belief that physical activity will worsen pain^3,4 Belief that normal duty should not be performed^3,4

Function

Light work tolerant for one hour^3,4
Can sleep at night^3,4

Disability

Physically demanding^5,19
Any disability in last 12 months?^3,4

Note: Less than 15% of our patients should receive care which outlasts the natural history. However, those that do should receive care which is reimbursable. Our history and examination should identify and document those risk factors as soon as possible.

What Treatments Are Evidence-Based and Can Therefore Be Defended Vigorously?^19,22-34

1. manipulation in acute low back pain
2. McKenzie in acute low back pain
3. education in acute low back pain
4. exercises for subacute back pain 5. multidisciplinary functional restoration in chronic low back pain

Note: Bed rest for more than three days is known to slow recovery and should be avoided.^19,23 Your SOAP notes should reflect that you are utilizing evidence-based treatments. Transition patients from passive to active care procedures before the end of six weeks. The Guidelines for Chiropractic Quality Assurance and Practice Parameters ("Mercy guidelines") states: "All episodes of symptoms that remain unchanged for 2-3 weeks should be evaluated for risk factors of pending chronicity. Patients at risk for becoming chronic should have treatment plans altered to de-emphasize passive care and refocus on active care approaches."^>22 (p. 125) This document also states, "It is beneficial to proceed to rehabilitation phase as rapidly as possible and to minimize dependency upon passive forms of treatment/care."(p. 110)

Can Outcome Measurements Help You Defend Your Appropriate Care?

According to the Mercy document, if a patient does not have signs of objective improvement in any two successive two-week periods, referral is indicated.²² Outcomes are the surest way to demonstrate patient progress or lack thereof with your care. What outcomes are simple, inexpensive and time-efficient, yet are also reliable, responsive and valid?

1. VAS 2. Roland-Morris, Oswestry or Neck Disability Index (NDI) 3. range-of-motion measurements 4. strength/endurance measurements (i.e., Sorensen's back extensor endurance test)

How Do We Determine Appropriate Goals of End Points of Care?

According to AHCPR, the goal in treating back pain is to reduce activity limitations/intolerances due to pain.²³ The "functional restoration" model also focuses on restoration of function, not just pain relief as a goal for care. Objective ways to capture information about such functional end points of care include:

1. Roland-Morris or Oswestry -- sitting, standing, lifting, etc.
2. NDI -- driving, reading, sleeping, etc. 3. SF-36 -- carrying, walking, etc.

Once obtained, this information should be included in your reports under a section titled "end points of care." Removing the subluxation complex may be a means to this end, but reducing activity limitations caused by pain is a more defensible goal.

The Future

Enlightened individuals are beginning to promote quality care and outcomes as a way to unite the benefits of chiropractic with the public's dissatisfaction with traditional options. Presently, PPOs, IPAs and PPNs with leaders such as in California with Casey Terribilini, Wisconsin with Steven Yeomans, Pennsylvania with Dick Erhard, Oregon with Dr. Larry Lubke and Florida with Dr. Joe Johnson, are joining the ranks of progressive payors. These payors include the workers' compensation boards of Alberta and Manitoba in Canada in facilitating the paradigm shift. Great Britain will soon be reimbursing for chiropractic care in their national health service. Networks from Maine to southern California will also be rewarding quality care with fairer reimbursement schedules and greater access to patients.

Conclusion

PPOs who can measure outcomes, classify patients and identify high risk patients can position themselves for aggressive competition in managed care. What is needed are providers who are prepared to practice in a quality assurance manner. Those same providers will benefit by being able to better defend all their care and market their practices effectively to attorneys, adjusters and medical doctors.

The chiropractic profession is poised to either prove that we are the most cost-effective front line for managing neuromusculoskeletal conditions or that we are inefficient overtreaters. We can create an international database and prove that we can beat the natural history of spine disorders and reduce recurrences.^{6-9,17,35,36.} Data collection tools such as the CareTrak software (www.caretrak-outcomes.com) can serve as a vehicle for aggregating outcomes data collected from chiropractic centers throughout North America.³⁵ Evidence suggests (and skeptics insist) that the natural history is difficult to influence.^10,17,37 However, cost-effectiveness studies also demonstrate that early active intervention from a biobehavioral perspective shows promise for reducing the costs associated with chronic disability.³⁸

Ultimately, small bands of chiropractors who commit themselves to quality assurance will improve customer satisfaction, reduce disability and cut health care costs. Working towards these goals will insure reasonable reimbursement for honest service and open chiropractors to larger number of patients.

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