Conceptualizing the end of something is always a subject ripe for discussion. Our reactions follow one of two paths, one of which harks back to when I was on my way to Provincetown, Mass., with my father at the tender age of 8 and asked the perennial question: "Are we there yet?" No need to imagine what kind of response I got. The other is somewhat of a Delphic mystery that, for example, seems to have eluded the insurance industry when it comes to reimbursing chiropractors for what has been called supportive or maintenance care.
With the latter, I'm addressing what is known in the industry as maximum therapeutic benefit.1 At some point in care, a decision is made that further treatments to a patient are not expected to produce additional benefits, the result being the termination of therapy.
When Cost Savings Takes Priority Over Quality Care
In its very worst form, the insurance industry, rather than the physician, slams the door on treatment, an egregious abrogation of health care as we know it. In what has to be one of the most hair-raising and/or head-scratching examples in the scientific literature, we have encountered a study declaring that the primary driver for the improvement of health and physical condition of whiplash patients is not innovative physician care, as one might expect, but rather – get this – the transformation of the auto insurance industry from a tort to a no-fault system.2
The assumption here seems to be that costs are saved since litigation is bypassed; but in so doing, patient or doctor input as to the attainment of maximum therapeutic benefit is reduced to diddly squat. Since when does an insurance industry, rather than the doctor or patient, know from Adam what maximal medical improvement really is about?
Why Maintenance Care Matters: The LBP Example
Consider what Peter Croft so eloquently stated about chronic low back pain years ago:
"Rather than fully resolving spontaneously within one month, as commonly believed, the vast majority of back pain sufferers continue to report symptoms after 1 year of follow up. Rather than presenting as an acute condition, back pain has been redefined as a chronic problem with an untidy pattern of grumbling symptoms and periods of relative freedom from pain and disability interspersed with acute episodes, exacerbations, and recurrences.3"
Another literature review states that 62 percent (42-75 percent] of chronic back pain patients still experience pain after one year,4 while yet an additional survey disclosed that only 10 percent of people with pain at the initial reading were pain-free at one and five years.5 In other words, with regards to reaching a clear-cut and definitive end to chronic low back pain treatment – going back to my father's emphatic reply to his 8-year-old son's whining: No, Junior, we are not there yet.
The point here is that repeated flare-ups of chronic low back pain may be anticipated, and the most realistic and sensible means of meeting this problem head-on for the chiropractor is to embark upon a program of supportive or maintenance, care.
This is to argue that above and beyond fostering what one may object is creating illness or dependency behavior, periodic interventions for maintaining initial improvements would be preferable to prematurely dismissing a patient and then having to readmit such a person who experiences a recurrence of pain and disability once treatments have stopped.
In the latter scenario, what would be most likely needed would be a new evaluation, workup and cluster of more intensive interventions at substantially greater expense and time than if the patient were retained for a somewhat extended period with a few more widely space visits. Indeed, leading health care economists have weighed in with cost-effectiveness reports which employ more accurate definitions of episodes by extending the period of chronic ailments.6-8
Research Support for Maintenance Care
The literature supporting the efficiency of maintenance care is indeed promising. We begin with Descarreaux's study of patients with chronic low back pain in which, after a block of 12 treatments within a single month, adding one treatment every three weeks for an extended nine months produced an additional 12-14 visits. In terms of disability, the group receiving the supplementary maintenance treatments continued to improve throughout the entire nine-month period, while the cohort lacking the additional visits reverted to baseline levels within the same period.9
By demonstrating the proper understanding of the chronicity of back pain, the nine periodic visits prescribed in this investigation would be expected to incur costs of about $700, a miniscule fraction of what would be required to treat a recurring case as if it were an entirely new episode.
But the latter course is precisely what some insurance companies have embarked upon by categorically rejecting extended periodic visits when they are indicated. Instead, the patient (or the third-party payer if it grants reimbursement to a patient for more than 12 visits a year) would normally have to consider the flare-up as an entirely new episode with additional workups and expense, rather than simply an extension of the original treatment period with judiciously spaced visits.
The Descarreaux study was followed by a similar design involving supplementary treatments every two weeks for nine months following an initial block of 12 treatments within one month to treat chronic, nonspecific low back pain. The result was that only those patients receiving the supplementary, spaced treatments at the end of nine months reported significantly lower Visual Analog Pain and Oswestry Disability scores, increased spinal flexion and lateral bending, and better global assessment ratings.10
Taking the Next Steps
To achieve truly maximum medical improvement and cost-effectiveness – and to remain loyal to the patient's best interest – third-party payers would be well advised to focus upon the overriding principle of successful patient care, which is to efficiently restore the injured to full premorbid functional capacity.
By its very nature, spinal manipulation is designed to achieve four objectives: (1) reduction of pain, (2) reduction of muscle spasms, (3) reduction of joint hypomobility and (4) reduction of articular soft-tissue inflexibility.11 Only when this is achieved with some provision for the sustainability of benefits can we truly believe we "are there yet."
References
- Dull VT, Lansky D, Davis N. Evaluating a patient satisfaction survey for maximum benefit. Joint Commission J Quality Improvement, 1994;20(8):444-453.
- Cassidy JD, Carroll L, Cote P, Holm L, Nygren A. Mild traumatic brain injury after traffic collisions: a population-based inception cohort study. J Rehabil Med, 2004;43:15-21.
- Croft PR, Macfarlane GJ, Papageorgiou AC, et al. Outcome of low back pain in general practice: a prospective study. British Med J, 1998;316:1356-1359.
- Hestbaek L, Lebouef-Yde C, Engberg M, et al. The course of low back pain in a general population: results from a 5-year prospective study. J Manip Physiological Therapeutics, 2003;26(4):213-219.
- Hestbaek L, Leboeuf-Yde C, Mannice C. Is low back pain part of a general health pattern or is it a separate and distinctive entity? A critical literature review of comorbidity with low back pain. J Manip Physiological Therapeutics, 2003;26(4):243-252.
- Stano M, Haas M, Goldberg B, et al. Chiropractic and Medicare costs of low back care: results from a practice-based observational study. Amer J Managed Care, 2002;8(9):802-9.
- Stano M, Smith M. Chiropractic and medical costs of low back care. Medical Care, 1996;34(3):191-204.
- Smith M, Stano M. Costs and recurrences of chiropractic and medical episodes of low-back care. J Manip Physiological Therapeutics 1997;20(1):5-12.
- Descarreaux M, Blouin J-S, Drolet M, Papadimitriou S, Teasdale N. Efficacy of preventive spinal manipulation for chronic low back pain and related disabilities: a preliminary study. J Manip Physiological Therapeutics, 2004;27(8):509-514.
- Senna MK, Machaly SA. Does maintained spinal manipulation therapy for chronic non-specific low back pain result in better long term outcome? Spine, 2011;36(18):1427-37.
- Vogel AR, Paul S, Follow-up: bridging the gap between discharge and home. Occupational Ther Health Care, 2000;13(1):61-80.
