Editor's note: Part 1 of this article appeared in the March 15 issue and discussed Medicare's Program for Evaluating Payment Patterns Electronic Report (PEPPER), which recently placed spinal fusion surgeries on its target list.
PEPPER for Chiropractors
What does the PEPPER paradigm mean for the chiropractic profession? One hell of a lot, that's for sure, if we play our cards right to climb this ladder of opportunity. But our ascension requires that we become a voice in this process.
If our leadership has ever made a strong case to expand our market share by positioning DCs as the portal of entry for SRDs, now is the time to do it. The obvious challenge for the chiropractic profession is to position itself to be the only physician-level leader in conservative spine care as America's "primary spine provider" (PSP).
This is an easy case to make in light of the revelations about the dubious management of back pain by medical PCPs who have been shown to be "inept" in their training on musculoskeletal disorders,26 more likely to ignore recent guidelines27 and more likely to suggest spine surgery than surgeons themselves.28
Moreover, patients don't realize that 50 percent of all medical schools do not even teach one class in musculoskeletal disorders.29 Indeed, researchers have found that medical primary care physicians are actually the least educated to diagnose and treat musculoskeletal chronic pain problems,30 and only 2 percent of medical PCPs refer to DCs.31
The "national scandal" in spine care is fueled not only by their incompetence and misrepresentation of qualifications, but also is another example of medical fraud causing inefficiency.
The paradox of this ineptness of medical PCPs is that patients with chronic low back pain are more likely to see a family physician (65 percent) for their pain compared with orthopedists (56 percent), physical therapists (51 percent) and chiropractors (47 percent).32
Obviously the clinical effectiveness by DCs has proven our benefit as primary spine care providers. For example, a Washington state worker's comp study found that for patients whose first provider was a chiropractor, only 1.5 percent ultimately underwent surgery, in contrast to 42.7 percent of workers who went through the typical medical system.33
Indeed, satisfied patients have always been the mainstay of chiropractic care throughout the medical war against chiropractors. In a congressionally mandated pilot project conducted from April 2005 to March 2007, testing the feasibility of expanding chiropractic services in the Medicare program, 87 percent of patients in the study gave their chiropractor a score of 8 or higher, with 56 percent rating their chiropractor a perfect 10.34
The growing number of comparative research studies35 cannot be clearer in showing chiropractic stands at the top of cost-effective spinal treatments. As Anthony Rosner, PhD, testified in 2003 before the Institute of Medicine: "Today, we can argue that chiropractic care, at least for back pain, appears to have vaulted from last to first place as a treatment option."36 This is the message we must take to CMS and Capitol Hill if we are to ascend to the top of our ladder of opportunity.
The Hard Climb Up the Medicare Ladder
Let me give you a short history lesson of chiropractic in Medicare to show the difficult climb up this ladder by our predecessors. Although the CMS crackdown on this national scandal of unnecessary spine surgeries and hospitalizations will eventually play out to our benefit, the climb to inclusion and equality up the Medicare ladder has been a treacherous one; with missteps along the ascent, to say the least, and occasionally having the ladder pulled from beneath our feet, to say the worst.
The AMA bitterly opposed JFK's legislation in 1960 for Medicare / Medicaid in a PR campaign dubbed Operation Coffee Cup, led by actor Ronald Reagan, but once signed into law by LBJ in 1965, the AMA quickly took control in its typical tyrannical fashion.
Although chiropractors were included in the original language of the bill,37 after clandestine political skullduggery by the AMA's Committee on Quackery, chiropractors found themselves excluded in the enactment.38 Before Medicare was even enacted, we were one step in the hole.
In 1972, President Richard Nixon gave chiropractors one step up on the Medicare ladder with limited inclusion, but by 1994 the chiropractic profession found itself withering on the Medicare vine when Sec. Donna Shalala pulled the ladder out from beneath our feet by allowing Medicare+Choice managed groups to exclude chiropractors by allowing PTs to render our service. She also mandated that patients needed MD referrals to see DCs.39
In fact, when Medicare managed care groups went to medical gatekeepers to enforce a "medically necessary" rule, utilization of the chiropractic service dropped by 85 percent.40
The American Chiropractic Association (ACA) filed suit against HHS in November 1998, and after much legal haggling as a direct result of the ACA's lawsuit, the HHS, headed by Sec. Tommy Thompson, issued a new policy directive on Jan. 15, 2002, by the Center for Beneficiary Choices that suddenly gave DCs four steps up the Medicare ladder:41
However, in October 2004, chiropractors took a fall down the rungs when the U.S. District Court ruled that since MDs and DOs had universal (plenary) licenses, they were qualified to deliver the service and act as gatekeepers for the medical necessity of the chiropractic service. Two steps back down the Medicare ladder for DCs.
The ACA again appealed and on Dec. 13, 2005, the U.S. Court of Appeals for the District of Columbia ruled the District Court had no jurisdiction to render the decision approving the use of MDs and DOs to render the chiropractic service. One step back up the ladder for DCs.
However, chiropractic took an unexpected step back up the Medicare ladder when the appeals panel also questioned the District Court's opinion on the issue of which health care providers are qualified to provide chiropractic services, not just which providers are licensed to provide such services.
The Court of Appeals emphasized the importance of "scope of competence" and "qualified to furnish," rather than the outmoded model of a plenary license being all the qualification required to deliver a skilled service.42
Indeed, if that were the case, a medical general practitioner would be qualified to render brain surgery simply due to their medical license.
Attorney George McAndrews put it bluntly during the Trigon case: "When patients are forced to take their health problems from a chiropractor to a medical physician [or PT] who isn't skilled in that area ... that is a funneling of business from the most-skilled to the least-skilled providers."43
Then-ACA President Richard Brassard, DC, announced: "We are happy that the issue is now whether or not a practitioner is 'qualified,' not whether or not a practitioner is simply licensed. The ACA's position has been and remains that only chiropractors are qualified by education and training to correct subluxations. Because of the Appeals Court's decision, chiropractors can continue to fight to safeguard their right to be the sole providers of this service, and to ensure Medicare patients' rights to access doctors of chiropractic."44
This point remains paramount today in regards to who is best qualified to render "conservative care" for patients with acute LBP in Medicare.
Although back pain can have various causes that are helped by various professionals, such as disc derangement, radiculopathy and muscle trigger points, the single-largest source is due to joint pain. Two studies by Murphy and Hurwitz found joint dysfunction was the cause of neck pain in 69 percent of cases and the cause of low back pain (lumbar and sacroiliac) in 50 percent of patients.45-46
Considering there are more than 300 joints in the entire spinal column,47 it should not come as a surprise why spinal manipulative therapy (SMT) is considered the leading treatment in the majority of cases.
The question as to whether or not SMT and chiropractic care is the best type of conservative care for the pandemic of low back pain was also explained in testimony by John McMillan Mennell, MD, who enlightened the court as to the value of spinal manipulation during his testimony at the Wilk trial:
"Eight out of ten patients [who] come out of any doctor's office complain of a musculoskeletal system problem, regardless of what system the pain is coming from ... I will say 100 percent of those complaints [are] due to joint dysfunction in the musculoskeletal [system] ... If you don't manipulate to relieve the symptoms from this condition of joint dysfunction, then you are depriving the patient of the one thing that is likely to relieve them of their suffering."48
In this light, spinal manipulative therapy to correct joint dysfunction must be considered the leading treatment for neck and low back pain. Certainly a case can easily be made that DCs stand heads above MDs, DOs and PTs in regards to rendering SMT by virtue of our training and practice.
DCs as America's Primary Spine Providers
If we are to ascend to the top of the Medicare ladder of opportunity during this "national scandal" in spine care, we must assert to CMS, the bellwether for all payors, that DCs are the best practitioners offering the best service for the majority of back pain cases. This must become the goal for both the ACA and the Foundation for Chiropractic Progress (F4CP) during the upcoming year.
Obviously there is the need to train DCs in the clinical PEPPER protocols and best practices to assume this role. Just as all conservative treatments are not equivalent, certainly not all chiropractic methods have the same effectiveness for acute low back pain in adults. If general-practitioner DCs want to assume the role of PSPs, it behooves them to realize the best practices for acute LBP.
We must address the same issue as the Court of Appeals; that is, "whether or not a practitioner is 'qualified,' not whether or not a practitioner is simply licensed."
For example, a 2001 comparative study published in JMPT49 rated on a scale of 1-10 the effectiveness of procedure ratings for acute low back pain for 10 procedures. Ranking them in descending order for low back pain revealed the following:
Certainly not all DCs utilize the top treatments for LBP, nor do all DCs care to treat SRDs in favor of other specialties such as upper cervical, pediatrics, etc. Nor is SMT alone the only treatment required to control pain and stabilize the spine, as Dr. Murphy notes in his book. Nonetheless, if a chiropractor wants to qualify as a PSP for LBP, the use of the top adjusting methods, along with differential diagnosis including the biopsychosocial model, for SRD treatments is a good place to begin.
Today the evidence is on our side. If our profession is vigilant on keeping chiropractic care at the forefront of "conservative care," as the comparative studies agree, this will be great leverage to channel prospective patients with acute LBP into our offices before PT, drugs, shots and spine surgeries.
Beginning in the days when we were called "rabid dogs and killers who practice an unscientific cult" by the AMA propagandists,50 after a steep and perilous climb we can now see the light of truth at the top of this Medicare ladder of opportunity. As Lou Sportelli, DC, noted: "If the doctors of chiropractic only cornered the market on one condition, back pain, there would not be enough now to handle the volume."51
References
When sports chiropractors first appeared at the Olympic Games in the 1980s, it was alongside individual athletes who had experienced the benefits of chiropractic care in their training and recovery processes at home. Fast forward to Paris 2024, where chiropractic care was available in the polyclinic for all athletes, and the attitude has now evolved to recognize that “every athlete deserves access to sports chiropractic."
It is estimated that 61% of patients with CTS avoid taking surgical options due to postoperative complications and costly surgical procedures. Chiropractic care offers a comprehensive and effective treatment for carpal tunnel syndrome, addressing the condition from multiple angles. Recent studies also have unveiled a game-changing adjunct to chiropractic treatments for CTS: nerve flossing.
Some doctors thrive in a personality-based clinic and have a loyal following no matter what services or equipment they offer, but for most chiropractic offices who are trying to grow and expand, new equipment purchases help us stay relevant and continue to service our client base in the best, most up-to-date manner possible. So, regarding equipment purchasing: should you lease, get a bank loan, or pay cash?
