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Beyond Spinal Manipulation: Should Medicare Expand Coverage for Chiropractic Services?

By Frank M. Painter|January 12, 2015|Expanded Practice, Medicare|

Beyond Spinal Manipulation: Should Medicare Expand Coverage for Chiropractic Services? A Review and Commentary on the Challenges for Policy Makers

SOURCE: Journal of Chiropractic Humanities 2013 (Aug 28); 20 (1): 9–18

James M. Whedon, DC, MS, Christine M. Goertz, DC, PhD,
Jon D. Lurie, MD, MS, and William B. Stason, MD, MSc

The Dartmouth Institute for Health Policy and Clinical Practice,
Dartmouth College, 30 Lafayette St, Lebanon, NH 03756, USA.
james.m.whedon@dartmouth.edu

OBJECTIVES: Private insurance plans typically reimburse doctors of chiropractic for a range of clinical services, but Medicare reimbursements are restricted to spinal manipulation procedures. Medicare pays for evaluations performed by medical and osteopathic physicians, nurse practitioners, physician assistants, podiatrists, physical therapists, and occupational therapists; however, it does not reimburse the same services provided by chiropractic physicians. Advocates for expanded coverage of chiropractic services under Medicare cite clinical effectiveness and patient satisfaction, whereas critics point to unnecessary services, inadequate clinical documentation, and projected cost increases. To further inform this debate, the purpose of this commentary is to address the following questions:

(1) What are the barriers to expand coverage for chiropractic services?
(2) What could potentially be done to address these issues?
(3) Is there a rationale for Centers for Medicare and Medicaid Services to expand coverage for chiropractic services?

METHODS: A literature search was conducted of Google and PubMed for peer-reviewed articles and US government reports relevant to the provision of chiropractic care under Medicare. We reviewed relevant articles and reports to identify key issues concerning the expansion of coverage for chiropractic under Medicare, including identification of barriers and rationale for expanded coverage.

RESULTS: The literature search yielded 29 peer-reviewed articles and 7 federal government reports. Our review of these documents revealed 3 key barriers to full coverage of chiropractic services under Medicare: inadequate documentation of chiropractic claims, possible provision of unnecessary preventive care services, and the uncertain costs of expanded coverage. Our recommendations to address these barriers include the following: individual chiropractic physicians, as well as state and national chiropractic organizations, should continue to strengthen efforts to improve claims and documentation practices; and additional rigorous efficacy/effectiveness research and clinical studies for chiropractic services need to be performed. Research of chiropractic services should target the triple aim of high-quality care, affordability, and improved health.

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Emphasis On Various Subtopics in the Anatomy Curriculum For Chiropractic Training

By Frank M. Painter|January 10, 2015|Education|

Emphasis On Various Subtopics in the Anatomy Curriculum For Chiropractic Training: An International Survey of Chiropractors and Anatomists

The Chiro.Org Blog

SOURCE: Journal of Chiropractic Education 2014 (Dec 17); 29 (1): 37-42

Peter D. Chapman, MChiro, Amanda Meyer, PhD,
Kenneth Young, DC, MAppSc, Daniel Wibowo, MD,
and Bruce Walker, DrPH

Objective: The aim of this study was to conduct an international survey of the perceived optimal level of anatomy teaching from anatomy academics and practicing chiropractors. We hypothesized that the optimum level of anatomical understanding for chiropractic students does not differ between the anatomists teaching the students and practicing chiropractors.

Methods: The opinion of anatomists teaching in a chiropractic course (n = 16) was compared to practicing chiropractors (n = 589). The students’ level of understanding was based on the revised Bloom’s taxonomy for 16 different curriculum areas. Anatomists were recruited by contacting the accredited chiropractic courses worldwide. Snowball sampling was used for the practicing chiropractors. Independent-samples Mann-Whitney U tests were used to compare the results of anatomists and chiropractors.

Results: Opinions differed between anatomists and chiropractors on 9 out of the 16 questions. Where opinions differed, chiropractors recommended a higher standard of anatomical knowledge. The level suggested by chiropractors for these curriculum areas is equal to the “evaluating” level where chiropractic students can remember, understand, apply, and analyze anatomical knowledge to be able to justify a clinical decision.

Conclusion: Compared to anatomists working in chiropractic programs, chiropractors suggest a higher standard of anatomy be taught to undergraduates. Collaboration between chiropractors and anatomists would likely be beneficial in creating or modifying anatomy curricula for chiropractic students.

From the FULL TEXT Article:

INTRODUCTION

A sufficient knowledge or mastery of human anatomy is required by those working in the health professions. The level of knowledge differs among the different professions, with some requiring an in-depth knowledge of specific parts of the body rather than general anatomical knowledge. For example, dental students require emphasis on the oral cavity and podiatrists on the feet. For chiropractors, there is little research on the depth and breadth of research required for safe and effective practice. In Australia this situation is not unique to chiropractic; studies at medical schools have found that there is no consensus on exactly what students need to know. [1] Excerpts from accreditation requirements of several chiropractic bodies are shown in the Appendix (available online as supplemental material at www.journalchiroed.com).

The Council on Chiropractic Education Australasia [2 has broad accreditation standards for teaching basic sciences, including anatomy. The documentation outlines that chiropractic student basic science should cover ‘‘a core of information on the fundamental structures, functions and interrelationships of the body systems.’’ [2] The vagueness of this statement and the lack of a national standardized anatomy curriculum in chiropractic education make teaching anatomy to chiropractic students quite challenging. A review of a convenience sample of the websites of 6 chiropractic schools indicates that the teaching of anatomy differs. We selected these programs because their anatomy syllabi were available online. The reasons for the differences observed are not clear. In addition, it is not clear if the syllabi surpass or meet the level required by the various accreditation authorities. Thus, what is the optimum level of anatomy to be taught? This study attempts to address this question.

From a pedagogical perspective, a synergy exists between the retention of anatomical knowledge and clinical application in chiropractic students. [3] The ability to differentially diagnose patients requires that chiropractic students have sufficient anatomical knowledge. The majority of patients seeking chiropractic care are affected by back and neck problems. [4] However, some serious and life-threatening medical conditions, such as a dissecting aortic aneurysm, ectopic pregnancy, or myocardial infarction, can in fact present as acute back pain. [5] As point-of-entry health care professionals, chiropractors must have enough anatomical knowledge and the ability to apply it clinically to diagnose a patient in order to decide if the patient should be referred to another medical professional. It is therefore necessary to design a suitable course of anatomy that provides fundamental knowledge that enables the chiropractor to be able to diagnose or treat a patient within his or her special interest area.

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A Culture of Collaboration at an Integrative Health Center

By Frank M. Painter|January 8, 2015|Integrative Care|

A Culture of Collaboration at an Integrative Health Center –
An Interview with David Fogel, MD –
Interviewed by Daniel Redwood, DC

The Chiro.Org Blog

SOURCE: Topics in Integrative Health Care 2014, Vol. 5(3)

Daniel Redwood, DC

David Fogel, MD, is the cofounder (with his wife, Ilana Bar-Levav, MD), of the Casey Health Institute (CHI) in Gaithersburg, Maryland, a nonprofit integrative primary care practice that includes Internal Medicine, Family Practice, Chiropractic, Acupuncture, Massage Therapy, Yoga Therapy, Naturopathic Medicine and more. He is board certified in Internal Medicine with additional specialty training in mind/body focused individual and group psychotherapy.

As an internist, he served in the National Health Service Corps and on the staff at Johns Hopkins University School of Medicine, providing primary care to medically underserved inner city Baltimore residents. He has held positions as Medical Director of Employee Health at NASA Headquarters and as Medical Director of Integrative Medicine Associates in Washington, DC. Dr. Fogel holds a B.A. from Hampshire College and is a graduate of the George Washington University School of Medicine. He completed his residency at Washington Hospital Center.

In this interview, Dr. Fogel describes his journey from conventional to integrative medicine, the unique circumstances surrounding CHI’s founding, the collaborative relationships that comprise its core, and the ways he hopes it can serve as a model for new methods of healthcare delivery that are both effective and cost-effective.

Tell us how you first branched out from the conventional approaches you were taught in medical school.

I was first exposed to the concept of chi as a teenager. It’s kind of the classic story — I was beaten up, and as a result I got into the martial arts. There, I learned this incredible concept, that there was energy running through your body. That you can channel it, that it can be used for healing. So that opened me up at a young age to exploring other things. Then, I went to a kind of hippie college, Hampshire College, which opened me up to non-conventional alternatives of all kinds. This included mind-body approaches. I concentrated in humanistic psychology.

I went on to medical school. This was the era when Nixon went to China, and suddenly there were acupuncturists in the DC area. I said to myself, I need to go to an acupuncturist just to experience what it is. The Traditional Acupuncture Institute in Columbia, Maryland was just opening up (now Maryland University of Integrative Health). I kept reading and exploring these sorts of things throughout medical school. Then, in the 1990s, when David Eisenberg published his landmark article in the New England Journal of Medicine, about how many people were using complementary and alternative approaches, that gave a lot of people permission to start experimenting with different models, in a more mainstream or public way.

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An interview with Dr Greg Stewart, president of the WFC

By John Wiens DC|January 8, 2015|Public Health|

Dr Greg Stewart

Source Canadian Chiropractor

Mari-Len De Guzman of Canadian Chiropractor magazine talked with the president of the World Federation of Chiropractic Dr Greg Stewart about global opportunities, collaboration and the chiropractic values.

What Dr Stewart is most excited about is the opportunity to help advance the chiropractic profession as an equal player in the global health care arena, helping solve some of the world’s most pressing health issues.

“The opportunities have never been better. It’s a matter of whether we have the courage to walk through the doors that are open”, says Stewart. The World Health Organization has acknowledged the need for leadership in the area of spinal disorders, which are now a greater contributor to the burden of disease than HIV/AIDS, malaria, stroke, lung and breast cancer, and diabetes.

Says Stewart, “We have the ability to change the way the world is dealing with their health care. It’s cost-effective, it’s drugless, it has unlimited possibilities to help improve the health of the world and decrease the burden of disability world-wide.”

There are many reasons to be encouraged. “We have situations like in Denmark and Switzerland, where the curriculum for chiropractic and medicine is the same for the first three years, with chiropractic and medical students in the same classes until they branch off to their different streams in later years, “ Stewart notes. This early exposure to one another is enabling a new generation of health care practitioners that is much more inclined to collaboration.

“We have to leave our little comfortable areas and actually go into areas that are challenging, and sometimes confrontational, in order to get ahead,” he says.

Stewart acknowledges there are still ongoing issues that may have to be ironed out within the profession, but cautions against letting these internal disagreements get in the way of progress for the profession.

Stewart is confident the profession can effect big changes in health care, nationally and globally. “It’s my personal goal to really move away from chiropractic just trying to survive, into a world where we flourish.”

Read the full interview at Canadian Chiropractor.

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Risk of Traumatic Injury Associated with Chiropractic Spinal Manipulation in Medicare Part B Beneficiaries Aged 66-99

By Frank M. Painter|December 12, 2014|Chiropractic Care, Stroke|

Risk of Traumatic Injury Associated with Chiropractic Spinal Manipulation in Medicare Part B Beneficiaries Aged 66-99

The Chiro.Org Blog

SOURCE: Spine (Phila Pa 1976). 2014 (Dec 9) [Epub ahead of print]

James M Whedon, DC, MS; Todd A Mackenzie, PhD;
Reed B Phillips, DC, PhD; Jon D Lurie, MD, MS

The Dartmouth Institute for Health Policy and Clinical Practice,
Lebanon, NH

Southern California University of Health Sciences,
Whittier, CA

Study Design. Retrospective cohort study

Objective. In older adults with a neuromusculoskeletal complaint, to evaluate risk of injury to the head, neck or trunk following an office visit for chiropractic spinal manipulation, as compared to office visit for evaluation by primary care physician

Summary of Background Data. The risk of physical injury due to spinal manipulation has not been rigorously evaluated for older adults, a population particularly vulnerable to traumatic injury in general.

Methods. We analyzed Medicare administrative data on Medicare B beneficiaries aged 66-99 with an office visit in 2007 for a neuromusculoskeletal complaint. Using a Cox proportional hazards model, we evaluated for adjusted risk of injury within 7 days, comparing two cohorts: those treated by chiropractic spinal manipulation vs. those evaluated by a primary care physician. We used direct adjusted survival curves to estimate the cumulative probability of injury. In the chiropractic cohort only, we used logistic regression to evaluate the effect of specific chronic conditions on likelihood of injury.

Results. The adjusted risk of injury in the chiropractic cohort was lower as compared to the primary care cohort (hazard ratio 0.24; 95% CI 0.23-0.25). The cumulative probability of injury in the chiropractic cohort was 40 injury incidents per 100,000 subjects, as compared to 153 incidents per 100,000 subjects in the primary care cohort. Among subjects who saw a chiropractic physician, the likelihood of injury was increased in those with a chronic coagulation defect, inflammatory spondylopathy, osteoporosis, aortic aneurysm and dissection, or long-term use of anticoagulant therapy.

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The Medical Monopoly: Protecting Consumers Or Limiting Competition?

By Frank M. Painter|December 10, 2014|Editorial|

The Medical Monopoly: Protecting Consumers Or Limiting Competition?

The Chiro.Org Blog

SOURCE: The Cato Institute Policy Analysis No. 246

by Sue A. Blevins

Writer and health policy consultant, based in Boston.

Executive Summary

Nonphysician providers of medical care are in high demand in the United States. But licensure laws and federal regulations limit their scope of practice and restrict access to their services. The result has almost inevitably been less choice and higher prices for consumers.

Safety and consumer protection issues are often cited as reasons for restricting nonphysician services. But the restrictions appear not to be based on empirical findings. Studies have repeatedly shown that qualified nonphysician providers–such as midwives, nurses, and chiropractors — can perform many health and medical services traditionally performed by physicians — with comparable health outcomes, lower costs, and high patient satisfaction.

Licensure laws appear to be designed to limit the supply of health care providers and restrict competition to physicians from nonphysician practitioners. The primary result is an increase in physician fees and income that drives up health care costs.

At a time government is trying to cut health spending and improve access to health care, it is imperative to examine critically the extent to which government policies are responsible for rising health costs and the unavailability of health services. Eliminating the roadblocks to competition among health care providers could improve access to health services, lower health costs, and reduce government spending.

Introduction

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Although broad-based health care reform has temporarily moved to the back of the public agenda, there remain serious problems of cost and access in the American health care system. The underlying reason for those problems is the lack of a functioning free market in health care in this country. There is privately owned health care, but there is not a living, vibrant free marketplace in health care like there is in other products and services.

Healthy markets have certain common characteristics. On the supply side, there is a choice of providers, in competition with one another, trying to gain customers on the basis of price and quality. And on the demand side, there are consumers seeking the best deal for their dollar. In today’s health care system, neither of those conditions obtains.

During the 1994 health care reform debate, much attention was given to the demand side of the market. [1] That attention led to the development of ideas such as medical savings accounts to make health care consumers more cost conscious. [2]

However, true reform requires that the supply side of the health care market be addressed as well. Currently, a wide variety of licensing laws and other regulatory restricions limits the scope of practice of nonphysician professionals and restricts access to their services. Moreover, at the same time that it is restricting the practices of nontraditional health care professionals, government is providing subsidies for the education and training of physcians who fit the medical orthodoxy. The result has been the creation of a de facto medical monopoly, leading to less choice and higher prices for consumers.

Therefore, true health care reform must involve ending the government-imposed medical monopoly and providing consumers with a full array of health care choices.

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Beyond Spinal Manipulation: Should Medicare Expand Coverage for Chiropractic Services?

Beyond Spinal Manipulation: Should Medicare Expand Coverage for Chiropractic Services? A Review and Commentary on the Challenges for Policy Makers

Emphasis On Various Subtopics in the Anatomy Curriculum For Chiropractic Training

Emphasis On Various Subtopics in the Anatomy Curriculum For Chiropractic Training: An International Survey of Chiropractors and Anatomists

A Culture of Collaboration at an Integrative Health Center

A Culture of Collaboration at an Integrative Health Center – An Interview with David Fogel, MD – Interviewed by Daniel Redwood, DC

An interview with Dr Greg Stewart, president of the WFC

Risk of Traumatic Injury Associated with Chiropractic Spinal Manipulation in Medicare Part B Beneficiaries Aged 66-99

Risk of Traumatic Injury Associated with Chiropractic Spinal Manipulation in Medicare Part B Beneficiaries Aged 66-99

The Medical Monopoly: Protecting Consumers Or Limiting Competition?

The Medical Monopoly: Protecting Consumers Or Limiting Competition?

A Culture of Collaboration at an Integrative Health Center –
An Interview with David Fogel, MD –
Interviewed by Daniel Redwood, DC