Can I Defend My Care in Testimony, Deposition, or Insurance Appeal?

What is the natural history of spinal conditions?

1. 85% of mechanical pain patients are better in 6 weeks.
2. Patients with nerve root problems sometimes take longer.
3. There is a high recurrence rate.

Note: Most of our patients should recover within the natural history.

What are the risk factors for a slower recovery?

1. history of >4 episodes¹
2. severe pain¹
3. patient had pain for >7 days before seeing doctor¹
4. sciatica^2,3
5. nerve root tension or compression signs^2,3,4
6. job dissatisfaction^2,3
7. abnormal illness behavior^2,3
8. job disability in the previous 12 months³
9. decreased cardiovascular fitness³
10. decreased static trunk extension endurance³
11. psychologic distress³
12. heavy smoking³
13. trauma³

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. Your history and examination should identify and document these risk factors as soon as possible.

What treatments are evidence based and can therefore be defended vigorously?³

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.^2,3 Your SOAP notes should reflect that you are utilizing evidence based treatments. Transition patients from passive to active care procedures before the end of 6 weeks. Page 125 of the Mercy document says, "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."¹ And page 110 of the Mercy document says, "It is beneficial to proceed to rehabilitation phase as rapidly as possible, and to minimize dependency upon passive forms of treatment/care."¹

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.¹ Outcomes are the surest way to demonstrate patient progress or lack thereof with your care. What outcomes are simple, inexpensive, and time efficient and yet are also reliable, responsive and valid?

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

According to the AHCPR's acute low back pain guidelines, the goal in treating back pain is to reduce activity imitations/intolerances due to pain.² 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. Oswestry: sitting, standing, lifting etc.
2. NDI: driving, reading, sleeping, etc.
3. SF-36: carrying, walking, etc.

This information once obtained 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. PPOs, IPAs and PPNs, with leaders such as Dr. Larry Lubke (Oregon) and Dr. Joe Johnson (Florida), are joining the ranks of progressive payors like the workmens' compensation boards of Alberta and Manitoba, 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 over-treaters. We can create an international database and prove that we can beat the natural history of spine disorders and reduce recurrences.^5-7 Ultimately, small bands of chiropractors who commit themselves to quality assurance will improve customer satisfaction, reduce disability, and cut health care costs, thus insuring at least for themselves, if not the chiropractic profession as a whole, reasonable reimbursement for their honest services.

References

1. Haldeman S, Chapman-Smith D, Petersen DM. Frequency and duration of care. In: Guidelines for Chiropractic Quality Assurance and Practice Parameters. Aspen 1993, Gaithersburg.
2. Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in Adults. Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, 1994.
3. Waddell G, Feder G, McIntosh A, Lewis M, Hutchinson A. Low Back Pain Evidence Review. London: Royal College of General Practitioners, 1996.
4. Spitzer WO, et al. Scientific monograph of the Quebec task force on whiplash-associated disorders. Spine 20:8S; 1S-73S, 1995.
5. CareTrack Outcome System. Grand Rapids, MN. (800) 950-8133.
6. Yeomans SG, Liebenson C. Applying outcomes to clinical practice. JNMS 5:1;-14, 1997.
7. Liebenson C, Yeomans SG. Outcomes assessment in musculoskeletal medicine. Manual Therapy 2:2; 67-74, 1997.

Craig Liebenson, DC
Los Angeles, California