The health care world was different back then. Providers treated patients as they saw fit. Most patients paid cash, so a chiropractor's only real obligation was to satisfy the patient. Numerous practice management consultants taught DCs techniques that would only later come under scrutiny. It was an era that came closest to unlimited prosperity, the greatest the profession had ever seen.
Then seemingly out of nowhere it happened. Some group of know-it-alls decided the chiropractic profession needed their own practice guidelines. While at the time this seemed quite unnecessary, a careful look back reveals that practice parameters were already being developed by almost all third-party payers. These chiropractic guidelines merely gave the profession a means of formal input into the internal guides that were dictating who got paid for what.
If you are like most DCs, you haven't really read the Guidelines for Chiropractic Quality Assurance and Practice Parameters (Mercy guidelines), even though it is being used to review your claims. It sits there on your bookshelf waiting for you to have a reason to read it. Your opinion of this document may be based on what you have read or heard other people say about the guidelines.
Meanwhile the health care world continues to change. The Agency for Health Care Policy and Research (AHCPR) has decided that all health care providers, not just chiropractors, need practice guidelines for acute low back care. Their 14th guideline will soon be followed by guidelines for headaches, sure to have additional impact on your practice.
If you haven't read the Mercy guidelines, you probably don't even have a copy of the AHCPR guidelines. Too bad the same can't be said for the third-party payers you deal with.
Clinical guidelines are a reality. The federal government is involved, third-party payers have their own, and managed care organizations are utilizing them heavily.
While the AHCPR acute low back pain guidelines have brought greater respect for spinal manipulation and subsequently the chiropractic adjustment, there are certain conflicts with the Mercy findings. While traction, TENS, acupuncture, diathermy and ultrasound were found to be "of insufficiently proven benefit to justify their cost," according to the AHCPR guidelines, they were all rated "promising" to "established" at the Mercy Conference.
This raises the obvious questions:
Should I throw out my Mercy guidelines and replace them with AHCPR guidelines? What about the areas where they don't agree?
How do I respond to third-party payers who use the AHCPR guidelines to deny payment?
Clinical practice guidelines were developed (and demanded) because much of the health care given (and paid for) was found to be extremely inefficient. This search for efficiency is bringing the benefits of spinal manipulation into the spotlight.
While there was a tremendous amount of good work done by the members of the AHCPR panel, only two of the 22 were chiropractors. By their very nature, the AHCPR guidelines are not specific to any one health care discipline.
In contrast, the Mercy guidelines were developed by chiropractors for chiropractic practice. Obviously, what may work well in the context of a chiropractic practice may be ineffective in a medical practice.
Currently most managed care organizations utilize profession-specific guidelines about twice as much as federal guidelines in establishing their internal guidelines. In speaking with a number of insurance professionals, it appears that a profession's own guidelines are given greater weight.
But the bottom line remains the same: care must be effective and efficient. Additional modalities or diagnostic tests must be done in an effort to increase efficiency, not cost. As one insurance man sardonically remarked, "Without surface EMG diagnosis, a patient used to require 12 visits, with it they only require a dozen."
Fortunately, the Mercy guidelines are not the last word from the chiropractic profession. The Council on Chiropractic Guidelines and Practice Parameters (CCGPP) have been established to revise and improve our chiropractic guidelines. With representation from almost every major chiropractic organization, the CCGPP will keep the profession in a position to speak for itself where clinical guidelines are concerned.
You are still the doctor. The chiropractic profession still has control over chiropractic practice guidelines. Working together will make chiropractic care even more efficient and in greater demand. This is what the world is looking for.
