For acute low back conditions, the California Industrial Medical Council (IMC) has currently approved guidelines excluding the use of routine x-rays to chiropractors for the first 30 days of care. The exception is to rule out fractures, tumors or infections. To rule out tumors and infections a chiropractor would need "clinically appropriate laboratory studies." That leaves chiropractors with fractures from "recent significant trauma" (significant is not defined). The low back guidelines were originally modeled verbatim from the national AHCPR guidelines.
As of March 17, 1997, the ICAC successfully solicited 328 responses from chiropractors, patients and students on the issue of x-ray examination and chiropractic care. Of the three questions proposed, overwhelming support was received in favor of discretionary use of x-rays by chiropractors prior to applying manual forces to an acute lumbar spine. Standards and quality of care, contraindications and public safety, professional liability and adverse influence from third-party payers making clinical judgments were all issues of debate.
Asked the question, "Do you feel a chiropractor should first take x-rays before applying a manual force to an 'acute low back'?", only ten chiropractors said "no." Seventeen left it blank. Some felt that x-rays should not be mandatory for acute low back, or that it should depend on technique. Several felt that each case was different, and should be on a case by case basis. Several felt it should be left up to the doctor based on cause of onset and physical findings. ICAC agreed and proposed the following language to the IMC.
After considering all comments and by unanimous recommendation of the ICAC Board, the following was presented to the IMC subcommittee on guidelines on March 20th for consideration:
"If clinically indicated and x-rays have not been taken since the onset of an acute low back condition, plain x-rays of the lumbar spine may be necessary prior to manipulation (i.e., corrective adjustments, mobilization or traction)."
The subcommittee acted on the recommendation of Drs. Larry Tain and Gayle Walsh, both chiropractors on the committee. One minor change was made. The word "plain" was substituted with "limited" to read: "... limited x-rays of the lumbar may be necessary ..." The recommendation then went to the full council.
The vote of the IMC to carry the action required a nine vote majority. It failed with seven opposing and the chair abstaining. Six members were in favor.
The IMC subsequently approved the low back guidelines. It is now out to 15 day public comment. Public comments will conclude at 5:00 pm on April 9, 1997. All public comments will be forwarded to the IMC guidelines subcommittee. They will again meet prior to the next council meeting and act on any comments received in the allotted 15 days. The subcommittee can act on or recommend any other changes to the guidelines. The committee will report to the full council their recommendations, if any, on April 17, 1997.
If the committee recommends any other changes on the x-ray issue, the profession may have an opportunity to further comment and amend the guidelines. If not, the IMC could approve the guidelines as they are, without any amendments. The guidelines would then be forwarded to the Office Administrative Law (OAL) for legal review. If approved it will be adopted as Title 8, California Code of Regulations 70, "Treatment Guideline for Low Back Conditions". The guidelines will be applicable to the provider community as reimbursed by the payer community.
The ICAC feels that x-ray language proposed in the guidelines is without consideration to quality chiropractic care. The ICAC also feels that the proposed language will improperly influence third-party payers to routinely deny payment for x-rays taken within the first 30 days. The ICAC feels that chiropractors' "judgement" will be adversely influenced by third party-payers and, as the result, failure to order x-rays prior to applying manual forces to the lumbar region will place both the chiropractor and patient at greater risk.
Public Safety Problem
At risk, the chiropractor applies manual forces to the spine to restore or improve normal range-of-motion and related conditions. The more acute the patient, the more specific, or exact, corrective forces need to be. The more severe the patient, the more dependent the chiropractor is on x-ray information for anatomical factors and lines of correction. The more acute the low back, the more the patient and doctor are at risk, if x-rays are not taken and improper manual forces are applied.
ICAC Objection
The ICAC objects to any adverse influence or restrictions placed on our membership for the use of plain x-rays for acute low back conditions within the first 30 days of care. ICAC recommends x-rays where clinically indicated and where better judgment of the chiropractor would normally dictate their use. The ICAC is recommending additional language, recognizing that there are more considerations for diagnostic imaging than just ruling out fractures, tumors or infections. Patient Concern
If manual forces are to be applied to the spine, the decision to take x-rays, if needed, should be up to patients in consultation with their doctors. Health care decisions should not be determined by any other person or an insurance company, especially if it's in the payer's financial interest to deny x-ray studies. If a chiropractor is restricted from performing diagnostic or analytical examinations, the ability to apply corrective procedures may be restricted. Quality health care and safety may be adversely influenced. Proper health care may be delayed and costs may be increased.
Payer Review Companies to Benefit
Want to get mad? There are four common ways a review company or third party administrator (TPA) contracts with a payer: 1) capitated (per insured in the group); 2) retainer (flat fee per month); 3) per claim reviewed ($10-20 per claim); or 4) a percent of the savings on a successfully repriced claim (the savings standard is 25% of the differential). Under such a contract, if the review company successfully denies and reprices your claim, they will get 25% of your original x-ray fee. Financial incentive will shift from the provider side to the payer side of the equation. The provider assumes all the risks, provides the work and services, and someone else gets paid.
Support of the IMC
The profession should not support the decision of the IMC relative to x-ray standards in chiropractic. Irrespective of the current situation, we should support the fundamental concept of the IMC. They take their job seriously and work hard. We do not want to do anything to hurt the existence of the IMC. There are political cliques that would like to eliminate them and us altogether.
The IMC is a quasi-governmental body charged with the responsibility of cost-effective health care in workers' compensation in California. It is still far better to work with a medically biased board with direct input from chiropractor members than to work with 120 legislators over two years, only to have the governor veto our effort.
The obvious problem is fitting chiropractic into a medical model. That is the rub. X-ray is more than a diagnostic tool; it is an analytical tool which means as much to the chiropractor as the hammer does to a carpenter. X-ray is part of our standard of care, utilized in the chiropractic community since the early 1900s. We would expect carpenters to rally to defend tools of their trade, as the IMC should expect chiropractors to rally to defend the tools of our trade.
James E. Musick, DC, FICA, FICAC(H)
Milpitas, California
Dr. Musick is the president of the ICAC and chairman of the ICAC-PPO. A summa cum laude graduate (Palmer College, 1972), he has served on executive staffs of the ICA and ICAC. He is a former incorporator and staff member of Pacific States Chiropractic College (now Life West) and former president of Northern California College of Chiropractic (now Palmer West). Dr. Musick has served as a commissioner on accreditation and a member of the board of directors of the CCE. He is currently serving on California's OMFS Advisory Committee and OMFS Physical Medicine Subcommittee.
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