Operating under a 1994 mandate from the state legislature, the California Industrial Medical Council has produced draft "treatment guidelines." These guidelines apply to all classes of health care providers: MDs, chiropractors, orthopedic surgeons, osteopathys, psychologists, licensed acupuncturists and physical therapists. The most controversial of the draft guidelines is the treatment guidelines for low back problems.
The California Chiropractic Association devotes significant staff and volunteer resources to assuring a favorable practice environment in workers' compensation in California. This includes testifying in person and in writing, and advocating on behalf of the chiropractic profession at more than 50 meetings per year. This means time out of the office for volunteer leaders.
Despite all of CCA's efforts, and the efforts of other chiropractic organizations, as of this writing the treatment guidelines for low back problems present a problem for chiropractors in the area of use of diagnostic x-ray. The guidelines, as drafted on March 21, 1997, contain a provision stating that plain x-ray is not recommended for routine evaluation of patients with acute low back problems within the first month of symptoms unless a "red flag" is noted on clinical examination. Red flags include suspicion of fracture due to significant trauma, recent mild trauma, history of prolonged steroid use, osteoporosis, or for any patient over the age of 60.
The following chronology details how these guidelines came into existence and CCA's efforts to modify the x-ray provision:
1994: Industrial Medical Council (IMC) is mandated by the state legislature to produce treatment guidelines.
1994-1995: IMC convenes consensus panels to look at numerous draft guidelines. Many CCA members, as well as medical doctors, osteopaths, physical therapists, orthopedists, and other classes of providers, are invited by the IMC to participate on the panels. Chiropractors are outnumbered by medical providers.
The first draft of treatment guidelines for low back problems is released, containing the language hammered out by consensus panels.
November 7, 1995: CCA President Dr. Michael Pedigo writes a letter to the president of the National Chiropractic Mutual Insurance Company for a supportive letter concerning the risk to chiropractic providers of NOT x-raying when x-ray is needed in the provider's clinical judgment.
November 15, 1995: NCMIC responds to Dr. Pedigo's request with a two-page letter outlining their concern that chiropractic providers not be hindered from utilizing their clinical judgment in the use of x-ray in the first 30 days of treatment.
November 16, 1995: CCA President Michael Pedigo addresses a letter to the IMC (through its agent), arguing that the limitation on x-ray is unacceptable because it will force practitioners to practice below the standard of care. Dr. Pedigo quotes NCMIC's letter.
April 8, 1996: An updated draft of the guidelines is released. X-ray language is unchanged.
May 1, 1996: CCA is asked by the administrative director of the Division of Workers' Compensation (DWC, the final decision-maker in all workers' compensation regulations and guidelines) to submit comments on the April 8, 1996 draft of the guidelines.
May 14, 1996: As requested, CCA submits a letter to Mr. Young, in which CCA protests the x-ray language, and discusses at length the need for providers to have professional discretion with respect to the use of diagnostic tools.
June 5, 1996: CCA submits a letter to IMC counsel, reiterating its position concerning x-ray.
May, 1996 to December, 1996: CCA is present at every IMC meeting. Arguments to change the x-ray provision are received by the IMC, but not adopted.
Lawrence Tain, DC, IMC member, and Gayle Walsh, DC, IMC co-chair, make every attempt to modify the guidelines to a more reasonable form, but are outnumbered on the medically-dominated IMC.
December 12, 1996: IMC adopts guidelines without any change to the x-ray provision.
February 14, 1997: A revised draft of the guidelines is circulated by the IMC. A note in the draft indicates that Dr. Tain recommends inserting a provision that plain x-ray may be necessary in advance of manipulation or mobilization procedures. Dr. Tain's recommendation is NOT incorporated in the final draft.
April 9, 1997: CCA submitted a third letter as testimony to the IMC on the x-ray issue. At the time of this writing, it is not known whether chiropractic will prevail on this issue.
CCA leaders are committed to this issue and plan to pursue all means available to address this issue favorably for the chiropractic profession. The volunteers of CCA have exhibited uncommon devotion and selflessness in advocating for the chiropractic profession on the guidelines, as well as numerous other issues facing the profession. Go team CCA!
Craig Little, DC
Chair, Insurance & Industrial Relations Department
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