How do you evaluate chiropractic care?
How do you evaluate chiropractic care?
Experts offer CMs these guidelines
Many health plans now provide chiropractic benefits, but the case management of chiropractic care remains a challenging area for managed care, say chiropractic peer reviewers. The clinical research clearly supports chiropractic care as an effective clinical tool for acute musculoskeletal complaints; the difficulty for case managers comes when treatment for acute conditions begins exceeding a six-week time frame.
A landmark five-year study of chiropractic care published in 1994 by the Agency for Health Care Policy and Research in Rockville, MD, "opened the flood gates" that moved chiropractic treatment into the mainstream for neck and back problems, says Gerald R. Weis, DC, president of Weis Chiropractic Health in Cincinnati, who also serves as a chiropractic consultant and peer reviewer for managed care plans. "The AHCPR study was a review of more than 10,000 research projects which concluded that the treatment of choice for back pain is manipulation, exercise, and over-the-counter pain relievers. Now, 80% of my new patients are referrals from physicians."
However, even clinicians ready to embrace chiropractic care are sometimes unclear how to evaluate the effectiveness of chiropractic treatment, he says. "Typically, one month is a reasonable time frame to expect significant progress in a chiropractic patient. If no progress is made within one month, the treating chiropractor should be asked to justify further treatment."
"The initial clinical management of acute spinal soft tissue injuries is limited to three visits per week for the first two-week period. The national normal standard for subsequent care should be limited to endpoint management and discharge over the next four weeks," agrees David J. Gottlieb, DC, clinic director of Maple Grove Family Chiropractic in Maple Grove, MN, and chiropractic director for Mid America Chiro practic Consultants in Minneapolis.
"The vast majority of cases treated in managed care setting here in Minnesota have resolution rates of close to 90% within the initial six weeks of chiropractic care," says Gottlieb. He recommends that case managers monitor these clinical indicators when assessing the effectiveness of chiropractic treatment:
• progressive symptomatic improvement;
• progressive objective improvement in terms of clinical findings, such as ability to raise leg or elimination of muscle spasm;
• progressive functional improvement.
"If a case doesn’t meet those three factors, it should trigger peer review and a consideration for referral to other providers," he says.
Chiropractic questions
In addition, case managers should question the routine, or excessive, use of radiographic studies in chiropractic practice, note Weis and Gottlieb. "If a patient with no history of back pain reaches to pick up a heavy load and strains a muscle, there’s no need to X-ray," Weis explains.
"The clinical research to date supports the opinion that radiographic studies are not medically necessary for the clinical case management of the vast majority of chiropractic patients. Most especially, follow-up X-ray studies are almost never appropriate unless it is to monitor a progressive scoliosis or fracture," adds Gottlieb.
However, there are additional exceptions to the X-ray rule. Patients Gottlieb says should undergo radiographic studies prior to chiropractic treatment include those:
• older than 50 to rule out osteoporosis or other significant degenerative disease;
• with a history of significant trauma such as multiple fracture;
• with a history of previous malignancies to rule out metastasis;
• with spondylosis.
"With the exceptions listed above, there is no justification from a clinical standpoint for X-rays in chiropractic practice. Radiographic studies do not change the clinical approach to the patient or the therapeutic outcome of patients," says Gottlieb. "Many chiropractors routinely order X-rays. They like to have the X-rays as a teaching tool, or visual, for their patients, but in most cases, radiographic studies lack clinical necessity."
Both Gottlieb and Weis note that case managers also should be suspicious of any claims for "chiropractic maintenance" care. "Case managers may see a patient who, following a workers’ comp injury or auto accident, presents on a monthly basis for routine maintenance office visits for manipulation of their spine," Gottlieb explains.
"We don’t cover maintenance care in Minne sota, and there’s no indication in the scientific literature to suggest that maintenance of care improves morbidity or mortality. Patients may wish to continue monthly chiropractic visits, but that’s strictly a matter between the chiropractor and the patient and not a benefit consideration issue."
As chiropractors gain acceptance from physicians and health plans, some also have tried to capture more health insurance dollars. "There is a growing trend nationwide that is spreading extensively in Minnesota for chiropractors to form corporations and hire physicians and physical therapists to work under the same roof with them," Gottlieb says.
"There is no evidence that this improves care or outcomes for patients, but we see more and more physicians working for chiropractors and writing orders of rehabilitation. They do this to give an enhanced aura of legitimacy to chiropractic care in the eyes of insurance companies," he explains.
Drawing a line
It’s also a matter of simple economics, he adds. "Just look at the CPT codes. Physicians are reimbursed at higher rates for physical therapy than chiropractors. With a physician order for physical therapy, chiropractors can get much higher reimbursement for services. There are big claims being filed. The average office visit for a chiropractor in these arrangements is $400 — that’s much, much higher than the cost of an average chiropractic visit."
Instead, Weis suggests case managers look for chiropractors who work for physicians. "We have many physicians, especially orthopedic groups, in Cincinnati bringing chiropractors into their practices. Physicians prefer chiropractic care for musculoskeletal conditions. The beauty is that having gone to the physician first, there is no need for the chiropractor to order tests or studies."
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