With his appointment to the board, Dr. William Morgan continues building bridges for the chiropractic profession.

William Morgan, DC, has been appointed to the United States Navy’s Musculoskeletal Continuum of Care Advisory Board (MCCAB), an entity created to address the prevalent musculoskeletal injuries sustained by U.S. armed forces personnel during active-duty operations.

Dr. Morgan, who also serves on the spine subcommittee within MCCAB – members of which include orthopedic surgeons, sports medicine physicians, physical medicine and rehabilitation physicians and physical therapists – will serve as the sole chiropractic representative to MCCAB, the Bureau of Medicine and Surgery (BUMED) and the U.S. Navy. The spine committee will develop care algorithms for treating musculoskeletal and spinal conditions and in so doing, help determine the future of musculoskeletal management in the U.S. armed forces.

Addressing Musculoskeletal Health Issues in the Armed Forces

The leading cause of medical evacuation from forward-deployed units is musculoskeletal complaints, not combat wounds, with a high percentage of the complaints being back and neck pain. The MCCAB intends to develop guidelines for best practices in the management of musculoskeletal conditions through collaboration between professions, standardized metrics/outcome measurements, evidence-based practices and increased access to care.

William Morgan This is a big step for chiropractic in the armed forces. Never before has a chiropractor been on a military medical board that will have this level of strategic planning and implementation of ideas. This advisory board will make decisions about the future direction of health care within the Navy and the Marine Corps (the Navy provides the medical care for both the Navy and the Marines). The development of the board and Dr. Morgan’s appointment to it suggests the Navy’s open-mindedness in addressing the need for better management of musculoskeletal conditions.

Dr. Morgan’s Long Journey With Navy Health Care

Dr. Morgan has a long history in Navy medicine. Joining the Navy at age 17, he became a hospital corpsman, serving with Marine Corps Infantry and an elite Marine Recon Company. While in the Navy he was qualified in parachuting, military diving, submarine insertion, jungle warfare, combat swimming, explosives, mountaineering, winter warfare, and Arctic survival. He attended anti-terrorist training at the FBI academy. During a deployment to Southeast Asia, Morgan’s unit assisted in the rescue of Vietnamese refugees, whose ship had been attacked by pirates. Morgan provided medical care to the refugees.

After leaving active military service, Morgan began college and transferred to the Navy reserves. He served briefly with a dive and salvage unit and was one of the Navy divers who helped raise the USS Potomac from the San Francisco Bay after she sank in 1980. In 1982, Morgan transferred to a reserve Naval Special Warfare platoon as the unit’s primary hospital corpsman. He was sent to Special Operations Technician training, Coronado, Calif., to learn the principles and practice of dive medicine. For the next eight years he served as a dive medicine corpsman / combat swimmer for a platoon of Navy frogmen in Navy Special Warfare Unit One. (Dr. Morgan is quick to point out that while he served as an operator within a reserve SEAL platoon, his special warfare training took place in Marine Recon, not Navy BUDS.)

Dr. Morgan graduated from Palmer West in 1985 and practiced in California for 13 years. During that time, he pioneered chiropractic care within hospitals. He was credentialed and worked in two hospitals in central California. In 1998, after responding to an advertisement in Dynamic Chiropractic, he accepted a position at the Navy’s premier medical center, National Naval Medical Center (NNMC), Bethesda, Md.

Dr. Morgan has practiced in Bethesda for the past 13 years and works in Navy-supported executive health clinics in the Washington, D.C. region, caring for service members, high-level civilian government leaders, as well as Pentagon leadership. On occasion, Dr. Morgan will make “house calls” or travel with government officials.

While representing chiropractic to the command, Morgan has given scores of lectures to the medical staff. He also lectures on a regular basis to medical residencies and fellowships, and has worked as a consultant to the Veterans Administration and the U.S. Army. He is on faculty at the Uniformed Services University of Health Sciences’ Medical School, a professor for New York Chiropractic College, and has worked as adjunct faculty for Cleveland Chiropractic College, Palmer College, National University of Health Sciences and Texas Chiropractic College.

Interview by Daniel Redwood, DC

Dr. Lance Cohen on the job at the National Naval Medical Center in Bethesda.

Lance Cohen, a 2009 graduate of Cleveland Chiropractic College–Los Angeles (CCCLA), was the first chiropractic student to participate in one of the most prestigious health care fellowships in the nation, at the National Naval Medical Center (NNMC) in Bethesda, MD.

A second generation chiropractor (his father is CCCLA alumnus Dr. Nathan Cohen), Dr. Cohen had the opportunity to work under Dr. Bill Morgan at NNMC, providing care for injured veterans (many of them from the conflicts in Iraq and Afghanistan) at the nation’s premier tertiary care hospital. This experience afforded him unparalleled learning opportunities, which he describes in this Health Insights Today interview. Dr. Cohen now practices in Tahoe City and La Jolla, California.

What first kindled your interest in chiropractic?

My father was a chiropractor for nearly 3 years prior to my birth; chiropractic has always been part of my life. I was one of those kids whose mother received chiropractic care while she was carrying me and I received my first adjustment shortly thereafter. Throughout my younger years I was very active and played lots of sports, so I very quickly became aware of the benefits that chiropractic offered. I clearly remember seeing how grateful my father’s patients were for the improved quality that chiropractic afforded them. That was the deciding factor for me. I remember being about 5 or 6 years old; some children wanted to be firemen, astronauts, or maybe the president of the United States, and I knew that I wanted to be a chiropractor. I wanted to someday be able to emulate my father’s ability to assist others in regaining their health and improving their quality of life.

What is the procedure for determining which chiropractic student is chosen for the fellowship at National Naval Medical Center, Bethesda?

This is a question that I asked many times prior to applying for the program, a question which I still do not know the answer to. I know that the process differs from school to school with regards to candidate selection. After that I’m not sure how the final decision is reached. At Cleveland we were making it up as we went, because the college had never submitted a candidate for consideration. It was my understanding that the program had not been established previously at the college and there had not been a student demand for it in previous years.

That all changed when I made it my mission to create the student demand for the program after hearing one of Dr. Morgan’s interns speak about the program at the National Chiropractic Legislative Conference in Washington, DC. I wasn’t even sure if I wanted to apply for the program, but my father had graduated from CCCLA in 1980 and I felt a great deal of pride as a legacy at the college. I thought that the college was obligated to offer programs like this to students in order to provide a competitive product in today’s market of education. That is when I brought the issue up with Dr. Cleveland III (the college’s President), Dr. Globe (then the Dean/Provost), and Dr. Henry (Clinic Director).

Drs. William Morgan (l.) and Lance Cohen (r.), with canine companion at the National Naval Medical Center

The process of establishing the agreement between the Navy and the college was not easy and took over a year from when I brought up the project. I was unrelenting, steadfast and committed to seeing this project through even if I was not going to participate in it. I was convinced that someone at our college (either in Kansas City or Los Angeles) should have the opportunity to at least apply. I was very fortunate to have such a hard working team of faculty and staff at the school; if it wasn’t for their dedication and help this project would have never been brought to fruition.

What were your emotions when you first received word that you had been chosen?

I was in the intern lounge of the college clinic catching up on some paperwork while waiting for a new patient, who was late and I later learned didn’t show up for their appointment, when my mobile phone began to vibrate in my pocket. As I picked it up I didn’t recognize the number or even the area code. I answered the call and to my surprise Dr. Morgan was on the other end. My initial thoughts were that he wanted to ask me some questions about my application. After exchanging salutations and some small talk he asked if I was okay. I responded that I was, and apparently he could sense the surprise and bewilderment in my voice over the phone line.

He then proceeded to tell me that I was highly qualified and that I had studied under some of the greats in our profession and he hoped that I would not be disappointed while working with him at Bethesda. He offered me the position if I wanted to accept and he wanted to know how soon I could begin. I almost fell out of my chair, literally. I am sure that I will not be able to adequately put into words how I felt at that moment, but it was the shock and realization that I had achieved a goal that I had been working for tirelessly for several years. Immediately after that I was overcome with the excitement of the unknown. I knew that my future would have in store some truly incredible experiences during this program, but I couldn’t even begin to remotely conceive what they might be.

What advice would you offer to current students who are considering applying for this fellowship at NNMC?

Talk to your administration and faculty early on in your student career, find out about the program and see if it is something that you would be interested in. Declare your intentions early. This is not the sort of program that you sign up for a couple months in advance. Interns and fellows are usually selected 6 months prior to their start date. Contact interns or fellows who are currently at NNMC and talk to them about their experience, build rapport with Dr. Morgan or Dr. Kearney (both are chiropractors at NNMC). Make arrangements to visit the chiropractic clinic at NNMC. An opportune time to do this is while attending the National Chiropractic Legislative Conference.

Most importantly, be active during your student career, get involved with student associations and organizations, become a leader and actively seek mentorship. Dr. Morgan is not looking to mentor chiropractic students who are going to just go out and be successful. Success in practice should be expected. He is looking to mentor students who will leave NNMC and use what they have learned to change the world, change the way in which chiropractic is integrated and utilized in health care on a national or international level.

Please describe a typical day when you were at NNMC.

During my time at NNMC I would see patients in the chiropractic clinic Monday, Wednesday, and Friday. Typical clinic hours were from 0730 to 1600 hours. Tuesdays and Thursdays I would be on rotations either at NNMC or at Walter Reed Army Medical Center (WRAMC) while Dr. Morgan was staffing the health care clinic at the US Capitol. The hours for my hospital rotations were variable and dependent on the schedule of the respective department that I was assigned to. Some days I would report as early as 0400 hours in order to scrub in on a surgery and there were days when I stayed as late as 2000 hours helping out in the postsurgical wards.

On Wednesday afternoons Dr. Morgan and I would travel to Annapolis to the United States Naval Academy in order to care for the Naval Academy football team and some of the other athletes. This was a very memorable experience. I admired seeing the heart the Naval Academy football team displayed. Most always, their opponents were taller and outweighed them due to military height and weight regulations. The Midshipmen would compensate for this by superior physical conditioning, speed, and determination or heart. It was really a privilege to be a small part of that program.

What did you find most satisfying about your fellowship?

The most satisfying part of the internship was having the honor and privilege to be part of the team that administered care to the brave men and women who have sacrificed so much for our great nation. It was also a great honor to represent the chiropractic profession at the world’s most advanced tertiary care facility. Every time I interacted with another health care provider, legislator, or key government leader I took into account that my actions, interactions and responses were not only viewed as my own but were on behalf of the profession that I was there representing. Most of these people have not had much experience with chiropractors in a professional/clinical setting and I was there to dazzle them. I wanted to be able to answer the questions asked in rounds that the other fellows, residents, intern and med students fell silent on, and many times I did.

What surprised you most while you were there?

I was taken aback by the patients at the hospital and their families, who maintained such positive attitudes during the course of their treatment at the hospital. Some of these brave young men and women suffered what I would consider beyond devastating battle injuries, and through it all they kept hope and maintained high morale and the unrelenting desire to fight a new battle, the battle toward their recovery. This was testament to the undying, unrelenting American spirit upon which our country was founded.

What was the most difficult part of your work there?

The most difficult part of the experience was leaving. I really enjoyed my time at NNMC under the tutelage of Dr. Morgan and some of the country’s finest health care providers. During my time there, I didn’t even think about the difficulty of my charge because I was focused on doing the best job that I was capable of doing. There were long hours and challenges to overcome, yet every night I would find myself lying in bed just before falling asleep reflecting on how incredible and horizon-expanding that particular day had been. This occurred every night that I was at Bethesda.

Looking back, were there things you learned at Bethesda that you would have been unlikely to learn elsewhere?

I could write tomes on this question. Nearly a year after the completion of my time at Bethesda, I am still realizing the extent of what I learned during my time at NNMC. Conservatively, I would venture to say that I gained experiences during my fellowship that one could go several careers or lifetimes without accumulating. The vastness of the experience and knowledge available was unparalleled and I am certain that there is no program that even comes close to offering such experiences.

During your stay in Washington, were there aspects of life there (people you met, places you visited) that were meaningful for you, aside from your work at NNMC?

With regards to the people that I met during my time in Washington, by far the most interesting were people that I met at the hospital. I very much enjoyed hearing their stories. I took some time to visit many of the museums, national monuments and the White House. The most memorable of these was my tour to the top of the Washington Monument and a visit to Mount Vernon, George Washington’s estate.

How well are the chiropractors at NNMC integrated into the overall staff structure? Is there a spirit of cooperation and collaboration?

There are two staff chiropractors at NNMC, Dr. Morgan and Dr. Kearney, and at any given time each of them usually has one intern. There is usually some overlap time to aid in the training process. In the history of the program there have been only two fellows, including myself.

I feel that the chiropractic department is well integrated into the hospital. It is my opinion that this is a result of Dr. Morgan’s effort as the department head seeking out and building relationships with other providers in the hospital who refer patients to the chiropractic clinic. There is, of course, some room for improvement as there is always a constant flow of new providers, some of whom are not yet familiar with chiropractic and are hesitant to refer patients to the service. In the military, every patient is assigned to a Primary Care Manager (PCM). These doctors act as central hubs and coordinate the patient’s care. In order for a patient to see any specialist, including a chiropractor, the patient has to go through their PCM. Likewise, if a specialist wants to refer the patient to another specialty, the provider will communicate that to the PCM and the PCM will make the referral. This system may seem a bit convoluted but is helpful in tracking the overall care of a particular patient.

I was very impressed by how patients were co-managed in the multidisciplinary setting of NNMC. One day I was on rotations in the outpatient physical therapy department and the therapist that I was shadowing performed an exam on a patient who we discovered to have what seemed to be a classic presentation of an S1 radiculopathy. She then asked me to examine the patient so that she could see how a chiropractic exam would differ. Most of what we did was very similar with the exception of the motion palpation and some additional neurologic and orthopedic tests that I performed.

The physical therapist and I both agreed on the diagnosis and both agreed that the patient’s L5 vertebra was fixated. The only main difference was that I was able to determine what particular ranges of motion the L5 segment was limited in. After that the physical therapist laid out the exercises that she recommended that the patient do and asked me if I would do anything else to treat the patient. I was surprised that to learn that the exercises were no different than what I was taught in school and then I said that if I were treating the patient, I would adjust the L5 segment to restore normal motion. At this point she said, “Let’s head across the hall to the chiropractic clinic.” I performed the chiropractic adjustment and we sent the patient on his way. I had never seen this sort of collaboration between physical therapists and chiropractors.

The chiropractic clinic had very close ties with the neurosurgery clinic. Many times they would schedule a patient for surgery and then refer them to us. If the patient was able to show improvement from chiropractic care prior to the surgical date, then they would cancel the surgery. I really enjoyed working with the neurosurgeons in co-managing difficult cases. Members of the chiropractic clinic regularly attended the neurosurgery morning report.

Did you have an opportunity to meet and to work with medical and other students who also had fellowship at NNMC?

I had the privilege to work with a number of med students, PT students, residents, interns and fellows. I felt that I was well received by the majority of the abovementioned personnel, especially in physical therapy clinic a the pain clinic. I still keep in touch with some of these connections.

What are you doing these days and what are your plans for the future?

Answer this question:

If I sneeze, and there is a car accident across the street,
have we discovered the *cause* of car accidents?

The scientific method would propose that we sneeze a hundred times, and count the car accidents.

That’s how you begin to determine if there is an actual relationship between one event (like drinking milk) and it’s potential consequences (like developing cancer).

The Bone and Joint Decade Task Force was appointed by the World Health Organization (WHO) to look at the causes of, and treatments for neck pain, and after years of review, they published their results in the prestigious Spine Journal. One of the most relevant articles (to this conversation) was titled:

“Risk of Vertebrobasilar Stroke and Chiropractic Care: Results of a Population-based Case-control and Case-crossover Study”
Spine 2008 (Feb 15); 33 (4 Suppl): S176–183

CONCLUSION: VBA stroke is a very rare event in the population. The increased risks of VBA stroke associated with chiropractic and PCP visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke. We found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care.

There was an association between chiropractic services and subsequent vertebrobasilar artery stroke in persons under 45 years of age, but a similar association was also observed among patients receiving general practitioner services. This is likely explained by patients with vertebrobasilar artery dissection-related neck pain or headache seeking care before having their stroke.

This Blog (and our website in general) has published regularly on this topic:

Podcast Interview with J. David Cassidy: No Increased Risk of Stroke With Chiropractic
http://www.chiro.org/wordpress/?p=4963

This interview, with author, researcher and epidemiologist J David Cassidy, DC, DrMedSc, PhD, should quell the fears of even the most vehement critics who would normally carry on on by mis-quoting, ignoring, or twisting the existing scientific literature to suit their pre-conceived notions and biases.

The Stroke and Chiropractic Page has been online since early 1996, compiling the literature which documents how chiropractic care has been mis-labeled as the “proximal event” in reported cases of vertebral artery injury.

Most telling is Terrett’s seminal work Misuse of the Literature by Medical Authors in Discussing Spinal Manipulative Therapy Injury, which clearly demonstrates that many of the reported injuries ascribed to chiropractic actually occurred following care provided by MDs, PTs and even hair-dressers, even though the authors of those works knew the truth. Where I come from, that’s called bald-faced lying, not *misuse*.

The unadorned FACT is that there is ZERO scientific evidence that a chiropractic adjustment has EVER *caused* a stroke. None.

The Texas Chiropractic Association reports that on Thursday, April 14, 2011, the Texas Senate passed Senate Bill 1001. Says the Texas Chiropractic Association:

“This landmark legislation is significant for two reasons: It allows chiropractors to form professional associations with medical doctors, and it ensures that chiropractors will be treated fairly by insurance companies that decide to cover services that can legally be provided by chiropractors and other types of practitioners. …We have been trying to pass this type of legislation for more than 20 years.”

The Senate Journal reflects that “Senator Carona offered the following amendment to the bill”: These amendments include:

“A COLLABORATION BETWEEN PHYSICIANS AND CHIROPRACTORS. a person licensed under Subtitle B, Title 3, and a person licensed under Chapter 201 are authorized to: (1) collaborate with each other in providing services to a client ….”

Title 3 is the Health Professions portion of the Occupations Code.
Subtitle B relates to Physicians.
Chapter 201 of Subtitle C relates to Chiropractors.

“ASSOCIATIONS. (a) a person licensed under Subtitle B, Title 3, and a person licensed under Chapter 201 of this code may form a partnership, professional association, or professional limited liability company according to the requirements of this section and any other applicable law.

(b) When persons licensed under Chapter 201 of this code form a professional entity with persons licensed under Subtitle B, Title 3 of this code, as provided by this section, the authority of each practitioner is limited by that practitioner’s scope of practice, and a practitioner may not exercise control over another practitioner’s clinical authority granted by the other practitioner’s license, either through agreements, bylaws, directives, financial incentives, or other arrangements that would assert control over treatment decisions made by the practitioner.

(c) The state agencies exercising regulatory control over professions to which this section applies continue to exercise regulatory authority over their respective licenses.

(d) A person licensed under Subtitle B, Title 3 of this code, who forms a professional entity under this section shall report the formation of the entity and any material change in agreements, bylaws, directives, financial incentives, or other arrangements related to the operation of the entity to the Texas Medical Board no later than the 30th day after the entity is formed or the material change is made.”

“If physical modalities and procedures are covered services under a health benefit plan and within the scope of the license of a chiropractor and one or more other type of practitioner, a health benefit issuer may not: (1) deny payment or reimbursement for physical modalities and procedures provided by a chiropractor if: (A) the chiropractor provides the modalities and procedures in strict compliance with laws and rules relating to a chiropractor’s license; and (B) the health benefit plan issuer allows payment or reimbursement for the same physical modalities and procedures performed by another type of practitioner; (2) make payment or reimbursement for particular covered physical modalities and procedures within the scope of a chiropractor’s practice contingent on treatment or examination by a practitioner that is not a chiropractor; or (3) establish other limitations on the provision of covered physical modalities and procedures that would prohibit a covered person from seeking the covered physical modalities and procedures from a chiropractor to the same extent that the covered person may obtain covered physical modalities and procedures from another type of practitioner.”

The amendment was adopted, the Senate Journal reports, with “all members … deemed to have voted ‘Yea’” with the exception of one absent-excused Senator. The bill passed to the third reading by a vote of 30 yeas and 0 nays. On final reading the bill passed the Senate 30 to 0 with one senator excused-absent.

The TCA reports that “Dallas state Sen. John Carona deserves our thanks and praise for successfully guiding SB 1001 through the Senate. … SB 1001 now goes to the Texas House, where it must also be approved.”

Review the text of the final Senate Bill 1001

As health care reform implementation begins, making the case for chiropractic inclusion on the federal and state levels remains a priority.

Nearly 500 chiropractic physicians, students and supporters converged on the nation’s capital Feb. 14-15 as part of the American Chiropractic Association’s 2011 National Chiropractic Legislative Conference (NCLC) with the Chiropractic Summit. Those in attendance listened to speeches from government leaders, received advocacy training and urged elected officials to support pro-chiropractic measures that seek to provide patients, veterans and active-duty military personnel with greater access to the essential services provided by chiropractic physicians.

While last year’s conference focused on the first phase of health care reform, congressional debate surrounding the Patient Protection and Affordable Care Act (PPACA), this year’s meeting concentrated on the next phase, implementation of the law.

Among the speakers this year, Iowa State Sen. Jack Hatch (D-Des Moines), a member of the White House Legislative Working Group on Health Care Reform, stressed that While the work being done on Capitol Hill to expand patient access to chiropractic care is vital to improving health care for all Americans, at this stage important work is also being done in every state capital. “This is both a challenge and an opportunity,” he said.

The meeting’s keynote speakers were Sen. Tom Harkin (D-Iowa) and Ret. Brig. Gen. Becky Halstead, spokesperson for the Foundation for Chiropractic Progress. Harkin, who was instrumental in the inclusion of the provider non-discrimination language in PPACA emphasized chiropractic’s role in transforming the U. S. health care delivery system.

“Patients want options, alternatives and noninvasive care,” said Harkin. “We need to keep moving forward, away from the current sick care system to a health care system. Chiropractic physicians must be a part of the health care team.”

Halstead, a fierce advocate for chiropractic care for our nation’s veterans and active-duty military talked about prescription drug addiction in the military as a result of widespread chronic pain. She cited a recent USA Today article about another general’s struggle with addiction and back pain, cautioning, “If it’s happening in leadership, it’s rampant at lower levels.” Halstead then shared her personal struggle with fibromyalgia and chronic pain, which was finally resolved through chiropractic care.“If I had had more access to sustained chiropractic care [when I was in active duty], I would probably still be in the military,” she said.

Also on behalf of the nation’s armed forces, Rep. Michael Rogers (R-Ala.) urged attendees to ask their congressional representatives to support H.R. 409, the Chiropractic Health Parity for Military Beneficiaries Act [1], which would require the Secretary of Defense to develop a plan to allow any beneficiary covered under TRICARE to select and have direct access to a chiropractic physician. Rogers recently re-introduced this legislation in the House of Representatives.

HHS Secretary Kathleen Sebelius addressed NCLC attendees in a Video message. Sebelius said that chiropractic care has been “proven to be effective care that is also cost-effective,” and that chiropractic physicians are a “vital part” of the U.S. health care system. Like Harkin, Sebelius called for an end to the current “sick care” system.

ACA President Rick McMichael, DC, told attendees, “This is about a transformation in health care. This is about our patients and the public we serve. We have a window of opportunity — right now — and we must rise to the challenge, take action and persist. Working together as one team with one voice and one message, we can, and we will, help improve health care for America.”

Following NCLC, Chiropractic Summit XII took place on Feb. 16. First convened in September 2007, the Chiropractic Summit represents leaders from more than 40 organizations within the profession who meet regularly to collaborate, seek solutions and support collective action to address challenges facing the profession. [2]

Each year NCLC is held in conjunction with an official business meeting of the ACA House of Delegates. Dr. McMichael presided over both meetings and opened each with praise for the profession for working together to address critical issues.

REFERENCES:

1. H.R.409 – Chiropractic Health Parity for Military Beneficiaries Act
   http://www.opencongress.org/bill/112-h409/show

By Daniel Redwood, DC

“Doctors of chiropractic are a vital part of our nation’s health care system. Your services have been proven both effective and cost-effective and every day you help countless Americans with a variety of health conditions.”

~ Kathleen Sebelius,
Secretary of Health and Human Services
2011 National Chiropractic Legislative Conference

Health care costs in the United States continue to rise and now account for 17.6% of the economy. In the public sector, Medicare and Medicaid budgets are under continual strain, while accelerating private sector insurance premium increases are pricing millions of American families out of the market each year.

Aside from outlawing pre-existing condition exclusions and providing premium subsidies for those who need them most, the Patient Protection and Affordable Care Act of 2010 (PPACA) empowers the Department of Health and Human Services to take a variety of steps toward controlling costs. But attempts to utilize these powers will trigger strong opposition from groups facing adverse impact to their bottom lines. Further complicating matters, the future of PPACA remains uncertain as opponents seek to vilify, defund and repeal it.

In the current economic and political climate, one of the most important arguments to be made for any health care method is that it is cost-effective. As a result, researchers are redoubling their efforts to identify cost-effective approaches. This includes a growing number of studies addressing the cost-effectiveness of chiropractic services. Chiropractors and chiropractic students need to understand this information and to share it with others.

Low Cost Plus High Effectiveness Is the Goal

The most critical point when seeking cost savings is to distinguish between high-value and low-value services. On the scale of relative value per dollar spent, health economists identify the highest value services as those that effectively prevent or treat disease and cost less than competing approaches; services of the lowest value are those that have less satisfactory outcomes and cost more than the alternatives. The goal is to incentivize the use of high-value services and discourage the use of low-value services. Across-the-board budget cuts that fail to make such qualitative distinctions are the equivalent of substituting a meat cleaver for a surgeon’s scalpel, or a sledgehammer for a chiropractic adjustment.

We need both solid data and insightful analysis of that data. If we accept that high-value services should be incentivized, then we must engage in a rigorous, ongoing search for health care services that effectively prevent and treat illnesses and do so at a reasonable cost.

Within the past few years, there have been several key developments in the evaluation of the effectiveness and cost-effectiveness of various approaches for back pain and neck pain. These conditions comprise a significant majority of cases seen by chiropractors.

National Guidelines: American Pain Society and American College of Physicians (2007) [1]

As has been true of low back pain guidelines worldwide, the 2007 guidelines prepared by a panel of the American Pain Society and American College of Physicians recognized spinal manipulation (over 90 percent of which is delivered by chiropractors) [2] as an effective procedure for both acute and chronic low back pain. This is consistent with the 1994 Guidelines on Acute Lower Back Pain in Adults [3] from the U.S. Agency for Healthcare Policy and Research (AHCPR). Both the APS-ACP guidelines and the earlier AHCPR guidelines were prepared by expert panels based on a full review of all existing research.

A 2011 systematic review [4] of the cost-effectiveness of treatments endorsed in the APS-ACP guidelines found that spinal manipulation was cost-effective for subacute and chronic low back pain, as were other methods usually within the chiropractor’s scope of practice (interdisciplinary rehabilitation, exercise, and acupuncture). For acute low back pain, this review found insufficient evidence for reaching a conclusion about the cost-effectiveness of spinal manipulation. It also found no evidence at all on the cost-effectiveness of medication for low back pain.

Mercer Health and Benefits (2009) [5]

In 2009, Arnold Milstein, MD, MPH, of Mercer Health and Benefits, and Niteesh Choudhry, MD, PhD, of Harvard Medical School, compared chiropractic care to that provided by medical physicians, and concluded that, “When considering effectiveness and cost together, chiropractic physician care for low back pain and neck pain is highly cost effective [emphasis in original], represents a good value in comparison to medical physician care and to widely accepted cost-effectiveness thresholds.”

Blue Cross Blue Shield of Tennessee (2010) [6]

An important 2010 study evaluated low back pain care for Blue Cross Blue Shield of Tennessee’s intermediate and large group fully insured population over a two-year period. The 85,000 BCBS subscribers in the insured study population had open access to MDs and DCs through self-referral, and there were no limits applied to the number of MD/DC visits allowed and no differences in co-pays. Thus, the data from this study reflect what happens when chiropractic and medical services compete on a level playing field.

The researchers, led by an actuary, compared the costs of low back pain care initiated with a doctor of chiropractic with care initiated through a medical doctor or osteopathic physician. They found that costs for the chiropractic group were 40 percent lower. Even after factoring in the severity of the conditions with which patients presented, costs when initiating care with a DC rather than an MD/DO were 20 percent lower. The researchers concluded that insurance companies that restrict access to chiropractic care for low back pain treatment may inadvertently pay more for care than they would if they removed such restrictions. According to this analysis, had all of the low back cases initiated care with a DC, this would have led to an annual cost savings of $2.3 million for BCBS of Tennessee.

Center for Health Value Innovation Report (2010) [7]

The Center for Health Value Innovation (www.vbhealth.org) is a membership organization of employers and insurance plan sponsors that “shares actionable health data, strategies and tools for better business performance.” This organization’s core mission is to align incentives for individual responsibility and corporate accountability. CHVI’s 2010 report, “Outcomes-Based Contracting™: The Value-Based Approach for Optimal Health with Chiropractic Services,” addresses the role of chiropractic services as part of the continuum of care in value-based benefit design.

After analyzing available data on clinical effectiveness and cost-effectiveness, CHVI concluded that “the addition of chiropractic coverage for the treatment of low back and neck pain at prices typically payable in US employer-sponsored health plans will likely increase value-for-dollar.”

Three Other Studies Demonstrate That Chiropractors Deliver a High-Value Service
(ACN/UnitedHealth Group, [8] University of British Columbia, [9] and University of Calgary [10)

Two newly released studies comparing chiropractic and medical care highlight a central theme in current health care planning – the critical importance of having health care practitioners follow evidence-based guidelines. These two studies, one from Minnesota and the other from British Columbia, Canada, convey the same clear message – that when chiropractic services for back pain and neck pain are compared to medical services for these conditions in head-to-head competition on a level playing field, chiropractic consistently demonstrates superiority in effectiveness and cost-effectiveness. This was also the case in a recent Canadian study comparing outcomes for microdiskectomy and spinal manipulation in patients with low back pain with sciatica.

ACN Group (UnitedHealth Group) Report (2007) [8]

A 2007 report from ACN Group, a subsidiary of UnitedHealth Group (the nation’s largest health insurer), has recently become publicly available. After demonstrating that orthopedic conditions account for more medical expenses than any other condition (surpassing even cardiology), and that back and neck pain account for a far higher percentage of orthopedic expenses than any other orthopedic condition, the report goes on to show that chiropractic services for back and neck pain are significantly more cost-effective than all competing approaches. In particular, precisely as was shown in the Blue Cross Blue Shield of Tennessee study cited earlier, UHC concludes that the single most important factor in holding down costs is the profession of the doctor with whom care is initiated.

To briefly sum up these findings – when care is initiated with a chiropractor, the severity adjusted total episode cost is lower than for care initiated with a primary care medical physician, and drastically lower than for care initiated with an orthopedist, physical medicine and rehabilitation physician, or other practitioner. Among the other findings in this report are (1) “When first provider seen is a conservative provider [i.e., a chiropractor], treatment appears to be characterized by spinal manipulation and active/passive therapies” and; (2) “When first provider seen is a PCP [primary care physician], spine care appears to be characterized by radiology, pharmacy, hospitalization and surgery.” Moreover, the report continues, “… by aligning decision-making with current clinical evidence Minnesota chiropractors produce large improvement in disability at a low episode cost.”

Award-Winning Canadian Study Supports Value of Guidelines and Chiropractic (2010) [9]

A hospital-based study at the University of British Columbia led by Paul Bishop, DC, MD, PhD, was the winner of the North American Spine Society’s 2010 Award for Outstanding Paper in Medical and Interventional Science. Bishop’s team compared guidelines-based care (including chiropractic spinal manipulation) for low back pain of less than 16 weeks versus usual care administered by primary care medical physicians. Its key findings were that (1) guidelines-based care including chiropractic spinal manipulation is significantly more effective than “usual care” and (2) usual care by primary care MDs is highly guideline-discordant. Dr. Bishop’s team at the University of British Columbia and Canada’s National Spine Center is currently engaged in an ongoing series of studies to further illuminate these issues.

Canadian Study Compares Chiropractic to Microdiskectomy for Low Back Pain with Sciatica (2010) [10]

In an excellent example of the kind of comparative effectiveness research needed to distinguish the relative quality of competing treatment approaches, researchers in Alberta, Canada studied the relative costs and benefits of lumbar microdisckectomy and chiropractic spinal manipulation for patients with low back pain and sciatica associated with lumbar disk herniation for whom usual medical care had failed. The results were dramatic: 60 percent of patients with sciatica who had failed medical management benefited from spinal manipulation to the same degree as if they had undergone surgical intervention, at a far lower cost.

The economic implications of these findings are far-reaching. In the U.S., at least 200,000 microdiskectomies are performed annually at a direct cost of $5 billion, or $25,000 per procedure. Avoiding 60 percent of these surgeries would mean a reduction savings of $3 billion annually. In the Canadian study, patients receiving chiropractic care averaged 21 visits during their course of care. If a cost of $100 per patient visit is assumed for the care provided by the chiropractor, then the total cost per patient would be $2,100, yielding per patient savings of $22,900, or $2.75 billion dollars annually.

Conclusion:

For the conditions treated most often by chiropractors, chiropractic services are more cost-effective than competing methods. Health policy that encourages effective and cost-effective methods leads to superior outcomes and lower costs.

“In the U.S., at least 200,000 microdiskectomies are performed annually at a direct cost of $5 billion, or $25,000 per procedure. Avoiding 60 percent of these surgeries [by sending the patients to chiropractors] would mean a reduction savings of $3 billion annually. In the Canadian study, patients receiving chiropractic care averaged 21 visits during their course of care. If a cost of $100 per patient visit is assumed for the care provided by the chiropractor, then the total cost per patient would be $2,100, yielding per patient savings of $22,900, or $2.75 billion dollars annually.”

Daniel Redwood, DC, is a Professor at Cleveland Chiropractic College–Kansas City. He is the Editor-in-Chief of Health Insights Today and The Daily HIT, and serves on the editorial boards of the Journal of the American Chiropractic Association, Journal of Alternative and Complementary Medicine, and Topics in Integrative Healthcare.

Dana Lawrence, D.C., the first Editor of the beloved JMPT journal, draws our attention to this article: (Thanks Dana!)
Primer on Cost-Effectiveness Analysis.

REFERENCES:

1.   Chou R, Huffman LH. Nonpharmacologic Therapies for Acute and Chronic Low Back Pain: A Review of the Evidence for an American Pain Society/American College of Physicians Clinical Practice Guideline
Ann Intern Med. Oct 2 2007;147(7):492-504.

http://www.chiro.org/LINKS/ABSTRACTS/Nonpharmacologic_Therapies_for_LBP.shtml

2.   Shekelle PG, Adams AH. The appropriateness of spinal manipulation for low back pain: project overview and literature review.
Santa Monica: RAND;1991. R-4025/1-CCR-FCER.

3.   Bigos S, Bowyer O, Braen G. Acute Lower Back Pain in Adults. Clinical Practice Guideline, Quick Reference Guide Number 14. Rockville: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research;1994. AHCPR Pub. No. 95-0643.

http://www.chiro.org/LINKS/GUIDELINES/Lowback.shtml

4.   Lin C-WC, Haas M, Maher CG, Machado LAC, Tulder MW. Cost-effectiveness of guideline-endorsed treatments for low back pain: a systematic review.
European Spine Journal. 2011.[ePub ahead of print]

5.   Choudhry N, Milstein A. Do Chiropractic Physician Services for Treatment of Low-Back and Neck Pain Improve the Value of Health Benefit Plans? An Evidence-Based Assessment of Incremental Impact on Population Health and Total Health Care Spending. San Francisco: Mercer Health and Benefits;2009.

6.   Liliedahl RL, Finch MD, Axene DV, Goertz CM. Cost of Care for Common Back Pain Conditions Initiated With Chiropractic Doctor vs Medical Doctor/Doctor of Osteopathy as First Physician: Experience of One Tennessee-Based General Health Insurer.
J Manipulative Physiol Ther. November – December 2010;33(9):640-643.

7.   Nayer C, Sherman B, Mahoney J. Outcomes-Based Contracting: The Value-Based Approach for Optimal Health with Chiropractic Services. St. Louis: Center for Health Value Innovation;2010.

8.   Elton D. Conservative Treatment of Spinal Complaints: ACN Group (UnitedHealth Group);2007.

9.   Bishop PB, Quon JA, Fisher CG, Dvorak MF. The Chiropractic Hospital-based Interventions Research Outcomes (CHIRO) Study: A Randomized Controlled Trial on the Effectiveness of Clinical Practice Guidelines in the Medical and Chiropractic Management of Patients with Acute Mechanical Low Back Pain
. Spine J. Oct 2 2010.

http://www.chiro.org/LINKS/ABSTRACTS/Chiropractic_Hospital-based_Interventions.shtml

SOURCE: Preventive Medicine 2011 (Feb 4) [Epub ahead of print]

Davis MA, Smith M, Weeks WB.

Center for Health Policy, The Dartmouth Institute for Health Policy & Clinical Practice, 35 Centerra Parkway, Lebanon, NH 03766, United States; Grace Cottage Hospital, Townshend, VT, United States.

OBJECTIVE: Previous studies suggest a possible association between using chiropractic care and lower influenza vaccination rates. We examined adult influenza vaccination rates for chiropractic patients to determine if they are different than those for users of other complementary and alternative medicine (CAM).

METHOD: We used the 2007 National Health Interview Survey to examine influenza vaccination rates among adult respondents who were considered high priority for the influenza vaccine (n=12,164). We separated respondents into clinically meaningful categories according to age and whether or not they had recently used chiropractic care, some other type of CAM, or neither. We used adjusted logistic regression to determine whether user status predicted influenza vaccination.

RESULTS: Only 33% of younger and 64% of older high priority Chiropractic Users were vaccinated in 2007; these rates approximated those of Non-CAM Users. However, younger Non-Chiropractic CAM Users were more likely than Non-CAM Users to have been vaccinated (p-value=0.05). In adjusted logistic regressions, we found statistically insignificant differences when comparing Chiropractic Users to Non-CAM Users for younger adults (OR=0.93(95% CI:0.76-1.13), or for older adults OR=0.90 (95% CI:0.64-1.20).

This article is of particular interest because the Department of Defense was instructed during the Clinton Administration to start providing chiropractic care through the Department of Veterans Affairs to American servicemen, and even after all these years, chiropractic care is only available at 36 VA facilities across the country. This still leaves (at least) 100 major VA medical facilities without a chiropractic physician on staff. [1]

In this study, therapists at the School of Exercise and Nutrition Sciences in Victoria, Australia designed an 18-question survey to determine type and effectiveness of various strategies used by Royal Australian Air Force (RAAF) fast jet (FJ) aircrew in self-referral and management of flight-related neck pain.

They provided this questionnaire to 86 eligible RAAF aircrew to determine aircrew demographics, their incidence of flight-related neck pain, and their self-referral strategies to manage these neck injuries. The results are quite dramatic:

• Ninety-five percent of the respondents experienced flight-related neck pain.

• The most commonly sought treatment modalities were on-base medical and physiotherapy services.

• Many respondents reported using on-base treatment and ancillary services such as chiropractic care.

• This same group reported that chiropractic care was the most effective in alleviating their symptoms.

Ranking member of the House Veterans Affairs Committee, Rep. Bob Filner (D-Calif.), has again introduced the Chiropractic Care to All Veterans Act (H.R. 329), a bill similar to legislation that was overwhelmingly passed by the entire House in 2010 but was not considered in the Senate. H.R. 329 would require the VA to have a chiropractic physician on staff at all major VA medical facilities by 2014. (as reported on February 4th, 2011).

It would also amend the current statute, the Department of Veterans Affairs Health Care Programs Enhancement Act of 2001, ensuring that chiropractic benefits are included in the U.S. Code of Federal Regulations and therefore, cannot be denied. Considering that a 2010 report from the Veterans Health Administration indicated that over half of all veterans returning from the Middle East and Southwest Asia, who have sought VA health care, were treated for symptoms associated with musculoskeletal ailments – the top complaint of those tracked for the report– it is imperative that Congress stop sandbagging important legislation solely because of political agendas.

If you would like to support our troops, please write to Congress to support H.R. 329.

You can use this easy tool to contact your Congressional Representative.

There’s more information like this at:
The Whiplash Page and the
Chiropractic and Chronic Neck Pain Page

REFERENCES:

1. Congress Moves to Expand Chiropractic Services to Veterans and Military Beneficiaries
Chiro.Org Blog ~ February 4th, 2011
http://www.chiro.org/wordpress/?p=4491