AMERICAN COLLEGE OF
CHIROPRACTIC CONSULTANTS

OFFICIAL NEWSLETTER - Volume 2, Issue 1 - Spring 1998

Executive Board:

Thomas Snyder, DC - President
Dr. Paul Davis, DC - VP
David Cox, DC - Secretary
Karl Zimmer, DC - Treasurer
Warren Jahn, DC Past Pres

William Tellin, DC - ABCC Pres
___
Warren Jahn, DC - Contributor

This newsletter is a service of the American College of Chiropractic Consultants and is designed to provide readers with pertinent information concerning the College, its examining board (ABCC) and utilization management activities.

Readers may save and use information contained therein only for personal use. No other use, including reproduction, transmission or editing, of the newsletter information may be made without the prior written permission of the ACCC, which may be requested by contacting the ACCC headquarters.

ACCC makes no warranty, guarantee, or representation as to the accuracy or sufficiency of the information printed within, and the ACCC assumes no responsibility or liability regarding the use or misuse of such information.The opinions expressed in the ACCC newsletter are not necessarily those of the College. Advertisements appearing in the ACCC newsletter do not imply approval nor endorsement. Providers should consult their respective state licensing boards concerning the use of advertised products or services.

Patient Rights - Review the Work of Reviewing Doctors

"Our patients have been victimized long enough, while not every denial is necessarily actionable, if you suspect that one of your patient's has been improperly denied insurance benefits, there is a state agency who can REVIEW the work of the reviewers! Your patients can contact the Capital Bureau of Professional and Occupational Affairs to request a Complaint Form." (The Newsletter of the Pennsylvania Chiropractic Association Vol 3, No 2; Feb 17, 1998)

With the era of managed care reducing revenues of providers 20-40% around the country, there are many providers who are performing UR and IME services without proper credentialing. The ACCC executive board is considering adopting the recent professional policies which were published in FOCUS Jan/Feb 1998 issue of the American College of Medical Quality. Policy 19 states, "a utilization management organization, managed care organization, insurance company or any other entity which utilizes physician reviewers who make determinations concerning medical necessity without appropriate credentials, experience or clinical judgment is operating below the standards of care applicable to the medical review systems." It is of utmost importance that the ABCC become the national certifying board for chiropractic utilization review. Dr. Tellin and the examining board members are researching Missouri, Kansas and Kentucky laws which require state certification.

Please contact your local state association, peer review committee,and/or worker's compensation boards and lobby for them to require ABCC diplomate status as a requirement to perform UR activities.

Board of medical examiner trends

More and more medical examiners are issuing position statements similar to the one released on October 05, 1996 by the Texas State Board of Medical Examiners. "To engage in the determination of medical necessity or appropriateness of an evaluation or care so as to effect the diagnosis or treatment of a patient in Texas requires a Texas medical license.

In their newsletter, the National Health Lawyers Association said, "The Texas Board of Medical Examiners adopted a policy that stated that those who administered managed care plans in Texas must have a medical license to practice in the state. The Board said decisions about what care patients received should rest in the physician's hands."

Denying Chiropractic Care Is the Practice of Chiropractic and Is Under the Jurisdiction of the State Licensing Boards.

In the February 23, 1998 issue of Dynamic Chiropractic the feature article addressed the case of Dr. Murphy and the Arizona Board of Medical Examiners (Domex). Dr. Don Peterson indicated "without a medical or chiropractic director (reviewer, etc.), managed care companies can't deny care on the basis of necessity or appropriateness. Now, instead of being bullet proof, the chiropractors that work for managed care companies are as accountable as the DC in the office." He indicated that a copy of the Appellate court decision has been sent to the Federation of Chiropractic Licensing Boards (FCLB) for dissemination to all licensing boards in the U.S. He is also suggesting that "if you have a solid, well-documented case where a patient was inappropriately denied chiropractic coverage by a DC reviewer for the insurance company or their agent, you should contact your state board." The ACCC members and all reviewers must stay abreast of these potential litigative and medical disciplinary changes in order to continue risk management. Look to Dr. Davis to provide a session within the open forum portion of the convention in the fall, updating you on this important trend.

Chiropractic Scores a Big Blow
Against Unscientific Neuroradiologist's

"Drive- By" Peer Review of MRI Films and Expands Scope of Chiropractic Testimony. Chiropractic reviewers must be aware of the sentinel case of Badke v. Barnett, 35 A.D. 2d 347, 316 N.Y.S.2d 177 (2d Dept. 1970). Badke is a 27 year old high court case from Suffolk County in which a chiropractic was permitted to review x-ray films and give his chiropractic opinion before a jury on orthopedics and neurology, as well as causation, diagnosis, and prognosis.

"There is an unscrupulous practice currently in vogue by neuroradiologists. As a direct attempt to contain chiropractic treatments, a carrier hires a radiologist to date the cause of discal injuries without clinical examinations or review of all medical records. Chiropractic referrals for spinal MRIs are being denied retroactively, six months after the fact. A recent William Urdahl v. State Farm case is a modern and refreshing look at the chiropractor both as radiologist, clinician, and quality professional. The Urdahl case represents a long overdue extension of the Badke concept. It proves that chiropractors are not only different than radiologists, they are often better. They provide a higher quality opinion because they have examined the patient, reviewed the films, and compared their own tests." - Staten Island District #5 Newsletter March 1997.

President's Message

Happy New Year! I trust one and all had a joyous holiday and are looking forward to the joys of 98. Your elected officers have been extremely busy since we last met in September. The number of issues is mind boggling! The pay is the incentive! This or any organization is only as successful as the people who contribute to it. The ACCC has approximately 90 members, and we (the board) need each of you to contribute to our continued success.

When asked to serve in some capacity - do so. All of us read various journals, periodicals, etc. If each of you would copy pertinent articles, manuscripts, etc., and send them to David Cox, for distribution to entice membership. We all win and increase our knowledge. Dr. Jahn has worked hard to assemble this edition of your newsletter. I'm sure you'll find it interesting, and provocative.

Recruit new members - they are our life blood in addition to bringing fresh thoughts and ideas to our organization. Don't forget the membership contest: Free convention to the member with the most new members. The runner up gets half his convention fee paid.

Dues are due, and there has been no increase. Please be prompt in remitting, so Dr. Cox doesn't have to send reminders. You will be considered an inactive member if your dues are not paid in time, and your name removed from the ACCC Web Page and other advertising.

Dr. Davis is working hard to assemble top notch speakers and topics of interest for all of you at our September meeting. If you have any speakers or ideas, let us know. We're working for YOU.

Dr. Tellin and his board are working hard to obtain certification for diplomate status, as well as other matters of importance. Mark your calendars now - September 17, 18, 19 and 20, 1998 at the Schaumburg Marriott.

- Thomas A. Snyder, DC

The Florida Board of Chiropractic has enacted and has made significant changes

to the numerous Board rules over the past several years. There are many ACCC members who have maintained active licenses in the state of Florida. Should you wish to receive an updated copy of all Rules in effect, contact the Florida Board office by writing to Board of Chiropractic, 1940 North Monroe Street, Tallahassee, FL 32399-0757.

The managed care industry and providers are looking to 1998 as a year to recoup some of the losses which occurred in 1997. A free report, Ten Top Tips: How to Make a Managed Care Profit is available. For a copy, send a self addressed 9x12 business envelope with $.78 prepaid postage to the Care Information Center, Dept. 14MCTR98, P.O. Box 456, Allenwood, NJ.

Utilization Review Classes

Logan, New York, and Texas Chiropractic Colleges are presenting UR educational programs. ABCC has excepted the Logan program and is currently reviewing the one from Texas. NYCC has not submitted their program for review. We encourage our members to attend and complete the Diplomate process.

The Doctor May Be Liable to Unknown Third Persons Injured by

Patient-Driver After leaving his physician's office, a patient lost consciousness while driving his car, killing the plaintiff's decedent. The defendant physician owed a duty of care to unknown third persons potentially jeopardized by the patient's driving if the physician had actual knowledge that vaccinations provided by defendant caused the patient to lose consciousness, as such knowledge made it reasonably foreseeable that the patient, is permitted to drive, would injure third persons.

The court emphasized that it's decision did not suggest the physician should have refrained from appropriately treating his patient, but rather should have monitored the patient for a sufficient period of time before permitting him to leave his office, and warned the patient of the dangers of operating a vehicle. Cram v Howell, 680 N.E.dd 1096 (Ind.)

Medical E/M Guidelines Are Now Available at HCFA's Website

The Healthcare Financing Administration (HCFA), in conjunction with the AMA has produced new medical record documentation guidelines to explain appropriate use of the evaluation and management codes related to "Comprehensive Multi-System Examinations and Single System Examinations."

If you are curious about medical guidelines, the HCFA has posted a full version of the guidelines on it's website. Go to www.hcfa.gov/medicare/mcarpti.htm The Documentation Guidelines for Evaluation and Management Services section.

UR Providers Evolving to Manage Utilization, Not Just Review It

Many companies that got their start by providing employer's with retroactive review of medical bills are now taking a much broader role in managing claim costs. The companies today offer such services as demand management, disease management, and provider profiling, as well as time-proven specialties such as case management and operating preferred provider networks.

But there is less demand for stand-alone utilization management services among employers - or in regions such as California, where managed care enrollment is high. The reason being that utilization management is already bundled in most management care plans.

While many employers leave utilization and case management to their management care plans, plenty of self-insured companies still rely on outside vendors to provide additional oversight, according to consultants. The medical community had a distaste for utilization review. But as health care providers have taken on more financial risks, such as through capitated managed care arrangements, they have grown more interested in practices that save money by improving people's health. As a result, the medical community has pushed the refinement of utilization management towards the focus on quality outcomes, believing that we will save money. Utilization management companies are also looking to educate the consumer and offer demand management services in the form of 24-hour toll-free hotlines staffed by nurses.

Demand management programs generally aim to reduce healthcare expenses through increased education and by helping individuals practice healthy habits and to encourage them to participate more in healthcare decisions. - Business Insurance Feb 03, 1997

Medical Discount Cards Eliminate the Need for UR Services

Membership cards cost between $25.00 and $65.00 a year, depending on the level of coverage selected, whether an individual or family is enrolled and which company is backing the card. Consumers present their cards to doctors, hospitals, dentists, pharmacies and others who have agreed to participate. Those medical providers will lop between 10-50% off the price of their treatment or product, depending on their pre- negotiated discount agreement with the card company. The patients then pay their bill in full, with either cash, check or a credit card. By paying the provider directly and without submission of paper claims, the need for utilization review is eliminated. - Miami Herald Jan 1998

Dated to Improve Quality Outcomes
Are Plentiful in Medical Literature,

but "Economic Force" Drives Health Plans to Institute Change The director of RAND's Health Sciences program, Mr. Robert Brook, states that there is no economic force that fuels efforts to improve the quality of healthcare services. He suggests that the government could do more to promote the science of clinical decision making by funding more outcomes research that analyzes what treatment protocols work best for which patients based on both near-term results and long-term follow-up. This approach is even more important as managed care plans increasingly make key treatment decisions that are one step removed from those made by individual practitioners in fee-for-service medicine. - Health News Daily Jan 1998

Current Trends: Fraud and Abuse

There are laws that must be reviewed in order to better understand the consequences of fraud and abuse. They are the Medicare and Medicaid Patient Protection Acts (anti- kickback law) and the Ethics In Patient Referral Acts of 1989 (Stark law). Additionally the federal government has been using the Civil False Claims Act as a tool against fraud and abuse. There are new penalties and prohibitions contained within the Health Insurance Portability and Accountability Act (HIPAA).

There must be an active awareness of fraud and abuse laws and an understanding of how these regulations affect billing programs. There will be increasingly prosecutorial and legislative activity in the area of fraud and abuse during this coming year. http://www.ChiroACCESS.com - Jan 07, 1998

Alignis, Inc. Receives First Chiropractic-Only Utilization Management

Accreditation The Commission/URAC's executive committee granted to Alignis, Inc. for it's chiropractic specialty review organization. URAC newsletter 1998

Many Medical Screening Tests May Be Unnecessary

In this University of Michigan article the authors point out that there is considerable disagreement in the medical community which may not support by scientific evidence that routine screening meets a minimum criteria of effectiveness. The ethical issue becomes more complicated when doctors provide controversial screening tests because they fear a future law suit by a patient who later develops a disease.

The article describes several potential risks of screening tests with controversial benefits including:

Reliance on screening tests before their effectiveness has been corroborated by adequate research.-Creating the impression that such exams can reduce a patient's risk to zero-possibly leading them to make uninformed medical decisions.
Inaccurate, false positive results which can cause profound anxiety and require additional testing that can be increasingly invasive and costly, and depleting society's limited medical resources.

The article asserts physicians have a responsibility to inform patients of the limitations and risks of screening tests and to refuse to order tests that would violate their medical and ethical judgment. Physicians can counsel patients about the lack of scientific evidence regarding a test's benefits and the fact that no test can assure zero-risk of disease. Physicians also may chose to administer a test if initial scientific evidence supports a claim of benefit and the patient is aware of the risk. Alternatively, the physician has the option to refuse to provide the test, or refer the patient to another doctor who will provide it. - Archives of Family Medicine Oct 1997

Worker's Comp Outcomes made easy

There's a hard way and an easy to measure and improve worker's come outcomes-and the problem is,. employers most often chose the hard way. Outcomes measurement is easier that most employers think. Attention should be focused primarily on how quickly an employee is returned to work after an injury and whether that return to work is sustained. There are three specific factors to measure: Cost, productivity and employee satisfaction. - Business Insurance Nov 3, 1997

Integrated Disability as the Wave of the Future

Integrated disability management programs are expected to see dramatic gains in 1998 as a means to address workplace trends such as accelerating medical inflation; the aging of baby bloomers; the shifting definition of disability: mounting pressure to regulate the workplace; and increasing restriction on medical records. "These trends suggest that our challenges in the worker's come arena aren't over yet, "says Dwight Davis, President and Chief of Wausau Insurance COs. of Wisconsin, who gave the key note address at the 1997 National Worker's Compensation & Disability Conference held in November in Chicago. "With disability costs rising and employers seeking return employees to work faster - whether they're injured on or off the job-the integration of worker's compensation, short-and long-term disability and sometimes group medical absence management is becoming more and more of a reality."
- Risk & Insurance 12/97, p 20 and Business Insurance 12/15/97, p 12

Difficulty Assessing Workplace Injury Prevention

According to a recent study by the University of Iowa, employers are wasting money on expensive and unproven injury prevention programs because they inaccurately measure program success and effectiveness. The year-long study focused on the design, conduct and evaluation of various occupational injury prevention and educational programs. The study specifically looked at areas such as low back injuries, which comprise 30-40% of worker's compensation claims payments. Such injuries can be aggravated by activities away from the job, making it difficult to link certain symptoms with corresponding workplace functions. -Best's Review P&C, 12/97, p 105

United Healthcare Supplies Physicians with Comparison Data

United HealthCare has developed a program that allows its physicians to see how they match up with national accepted standards of care. The program, Clinical Profiles, focuses on six medical conditions and allows physicians to determine the percentage of their patients receiving the recommended care and compare that to other United physicians. Experts believe that the program will strengthen physician relationships by giving physicians information on how to improve their practice while simultaneously improving patient care. - Management Care Outlook Nov 14, 97, p 8

Spelling Myths about Practice Guidelines

Clinical practice guidelines are experiencing renaissance. Here is a prospective on six half-truths that plague guidelines:

1. Guidelines are cookbook medicine. Evidence-based guidelines require the application of judgment, assessment, and decision making in their use. This is far from rote "cookbook medicine" that dictates the elements of care.

2. Guidelines are a legal hazard. Good guidelines specify good medicine in that they are evidence-based and not opinion-driven. Consequently, they may actually reduce the legal risk, if properly adopted and implemented.

3. Guidelines don't work. Riding alone, guidelines don't improve care. But when incorporated into an organized, systematic improvement approach that includes, among other tools, performance measures, they do improve care by reducing variations in practice.

4. Time and effort shouldn't be wasted on developing guidelines, since they are available from other sources. Internal guideline development is an opportunity to introduce a wide group of physicians to the improvement process; and a balanced approach to modifying established guidelines to fit local practices ideal.

5. The task of implementing guidelines is the task of getting physicians to use it. Getting physicians to use guidelines is just part of the task of implementation and should not be considered the entire task. A team- oriented attitude is warranted.

6. Guidelines used should be validated by outcomes data. It depends on your working definition of outcome. If outcome means results of improvement processes, then this is true. But if outcomes are referring to individual adverse events, these data are of little value and should not be a routine part of the guideline process. - Group Practice Journal Vol 46 No 4, Jul-Aug 1997, pp 34-40

Medical Malpractice-Loss of
Chance Doctrine Adopted

The loss of chance doctrine permits recovery for harm resultant to a patient when negligent medical treatment is alleged to have decreased the patient's chance of survival or recovery. The problem with the doctrine is that it appears to lessen the traditional proximal cause of standard under circumstances where the patient's chance of recovery was less than 50% and thus, improbable. The court rejected those cases which hold a plaintiff may not recover from medical malpractice injuries if he is unable to prove that he would have enjoyed a greater than 50% chance of survival recovery absence the malpractice of the defendant. The court held that a jury may properly conclude that ineffective treatment may have been a cause of injury.
- Holton v. Memorial Hosp., 69 N.E. 2d 1202 (Ill.)

ABSTRACTS

Absent Ankle Reflex Significance The significance of an absent ankle reflex has long been regarded as a neurological sign of nerve root compression. There is indication the ankle reflex diminishes with age, possibly due to peripheral neuropathy. In one study it was judged that from 0-2% of the adult population under the age of 50 will sustain a unilateral loss of ankle reflex, increasing to 4% by the age 80-90. However, persons over the age of 80 may have bilateral loss of ankle reflex up to 27% of the time. Bilateral loss may indicate a central or systemic cause. A unilateral loss of ankle reflex remains a highly useful diagnostic sign. The predictive value of the absent ankle reflex for a herniated lumbar disc is about 90% between 20 and 45 years of age, and about 60%over 50 years of age. - Journal of Bone Surgery Mar 1996; 78-Be: 276-9

Education and Job Changes Are Better Than Bed Rest and Work Restrictions

for Back Pain Management much work is physically demanding and may (frequently) lead to some discomfort and pain. These transient symptoms may be a normal consequence of life, but if the worker erroneously believes that the job is to blame, there is the potential for psychosocial factors to intervene. A proportion of back-injured workers having inappropriate beliefs about the nature of their problem and its relation to work will develop fear-avoidance behaviors relation to work because of inadequate pain-coping strategies. They then begin to function in a disadvantageous manner and drift into chronic disability. Once a worker has developed back pain, it would seem that therapeutic programs combining physical challenges to the back, together with operant conditioning, organizational changes, (particularly involving management) and education are more successful than the traditional approaches involving rest and work restrictions. - Spine 1997; 22(21): 2575-2580

A Shorter Roland-Morris Questionnaire for Subjective Evaluation

The item analysis suggested that six items could be deleted from the Roland-Morris Questionnaire. The validation study demonstrated that the shorter version, named the RM-18, has measurement properties that are equal to those of the longer version. The RM-18 can be used as an outcome measure in clinical trials or as a tool to aid in decision making concerning individual patients. In either case, its measurement properties are equal to those of the24-item Roland-Morris Questionnaire. - Spine 1997; 22(20): 2416-2421

Patient Pain Measuring Devices Are Reasonably Reliable

Reliable pain measuring instruments are extremely valuable for both patient evaluation as well as monitoring their response to treatment. A University of Miami School of Medicine study evaluated the relative patient test-retest reliability of evaluation instruments i.e. the visual analog scale, pain drawing and pain response to activity and position questionnaire. All three were considered reliable enough for "clinical decision making in measuring treatment outcomes." - Journal of Orthopaedic & Sports Physical Medicine 1997:26(5): 253-259

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This newsletter is a service of the American College of Chiropractic Consultants and is designed to provide readers with pertinent information concerning the College, its examining board (ABCC) and utilization management activities.

Readers may save and use information contained therein only for personal use. No other use, including reproduction, transmission or editing, of the newsletter information may be made without the prior written permission of the ACCC, which may be requested by contacting the ACCC headquarters.

ACCC makes no warranty, guarantee, or representation as to the accuracy or sufficiency of the information printed within, and the ACCC assumes no responsibility or liability regarding the use or misuse of such information.The opinions expressed in the ACCC newsletter are not necessarily those in the College Advertisements appearing in the ACCC newsletter do not imply approval nor endorsement. Providers should consult their respective state licensing boards concerning the use of advertised products or services.