In today's environment of manage care, the attending clinician's care is constantly being reviewed and challenged. The chief areas of concern for the third-party payers is overutilization and costs. Overutilization is a problem in chiropractic, whether it be real or only perceived by outside reviewers. This perception can only be overcome on a case by case basis by objectively proving that care provided was reasonable and necessary.
Due to the acceptance of the Mercy guidelines (Guidelines for Chiropractic Quality Assurance and Practice Parameters) by the insurance industry, the document is the authoritative reference to counter the insurance industry's attempt to limit quality and the quantity of care. The primary reason the Mercy guidelines carry a high level of acceptance and credibility by the insurance industry, is because its ratings are based on scientific evidence.
A synopsis of today's situation reveals that the care rendered by the attending clinician is constantly being challenged by the third-party carriers. IME opinions of excessive care or no permanent impairment are detrimental to the patient's medical/legal case. Cases that involve acute injury with associated liability frequently require the intervention of the court system or workers' compensation system to resolve the case. This inherent intervention leaves the door wide open for the probing eyes and opinions of the IME. Due to a lack of knowledge and documentation by the attending physician, patients receive inadequate medical care and inferior documentation of their injury, rational for therapeutic care, determination of maximum improvement, and final impairment. Third-party carriers are aggressive in their review of care to determine the point of maximum improvement. Many clinicians feel that if patient care is within the guideline numbers, their fees will be paid. However, the therapeutic necessity of care is frequently being challenged. A lack of knowledge of the practice guidelines does not substantiate the patient's contractual right to receive care to the maximum ability of the injury to respond to active care and improved function.
Chaplan (JMPT, 1991) stated: "Third-party payers wield enormous power... the 1980s witnessed a shift in power from the providers of health care to the payers of it ... and those practitioners whose services are labeled worthless could face financial ruin ... chiropractors are especially vulnerable."
IME was originally an acronym for independent medical examination, but the IME doctor is now chosen by and paid by the insurance industry. The acronym now stands for insurance medical examination.
The most recent development in the insurance medical examination has been the multidisciplinary examination, where a chiropractor and a medical doctor, both with higher credentials than the average clinician, examine the patient simultaneously. This creates an appearance of a high level of specialization and expertise. The opinion in a majority of these reviews is that care beyond two months is not needed. The rational is that the laying down of scar tissue is completed by the eighth week and therefore further treatment in not medically necessary or therapeutic. They state that the patient is at maximum improvement and no further treatment is necessary. This rational does not consider the remodeling and strengthening of scar tissue, nor the need to restore maximum joint function. However, without an attending physician who is knowledgeable about the guidelines and who has accumulated objective data of improvement, the professional response to this rational will be based solely on opinion and not fact.
Mercy specifically does not give a limit for reasonable care, but observations, assessments and the definitions of care based on scientific evidence. It states that these guidelines are not designed to be a cookbook. The listed time for acute stage of care ranges from 8-16 weeks, depending on which of three cited references you go by. In reviewing those references, I believe that the eight weeks refer to the acute healing cycle of the injury, and the 16 weeks to the acute physiology or rehabilitative healing time.
The healing and rehabilitative acute stages are followed by the subacute stage, before the unresponsive chronic phase of function and pain begin. Rebuttals of IME opinions using the Mercy guidelines increase your credibility when justifying your clinical rational to claims adjudicators. The insurance industry recognizes the Mercy document as the authority in the chiropractic profession. The parameter of clinical practice that Mercy most fully addresses is the trauma induced patient. Perhaps if "Acute Traumatic Cases" had been added to the title of the guidelines the criticism of the document would have been muted. Mercy creates a solid, well thought out guideline for the traumatic personal injury and workers' compensation case. Mercy very effectively deals with narrow minded, nonflexible professional rational and makes the third-party payers conform to a set of standards which is fair to the patient and respectful of the attending physician's opinion.
In 1992, David Chapman Smith, commission counsel to the Mercy guidelines, stated: "There must be a better method of judging whether a patient's condition or health status has changed, one that has scientific credibility, can withstand scrutiny by others, and provides strong evidence of good outcomes appropriateness and quality of care."
The use of outcome assessments is imperative for the practicing clinician. Only by objective documentation of improvement can the attending physician prove that his care was therapeutically necessary; thereby staving off the onslaught of critical opinions by claims adjudicators of third party payers, insurance medical examinations, retroactive governmental utilization reviews and defense attorneys.
The Mercy Conference guidelines defines "outcome assessment" as a procedure or method of measuring a change in patient status over time, primarily to evaluate the effect of the treatment. The Mercy guidelines go on to list the benefits of implementing outcome assessment into one's practice procedures for they can:
- document improvement to the patient, doctor, and third parties;
- consistently evaluate the effect of care over time;
- suggest modifications of the goals of treatment if necessary;
- help indicate the point of maximum therapeutic improvement;
- justify the type, dose, and duration of care.
(Mercy, chapter 10, page 8.)
This list closely mirrors the points the IME focuses on in delivering his professional opinion. The accumulation of the patient's objective outcome assessment data during the course of care, will provide the information necessary to make these critical clinical determinations in the medical legal case. This will individualize you opinion concerning the course of care and the length of care. Treating every patient plan as a continual living, analyzing and ongoing evaluation process.
The RAND study, "Appropriateness of Spinal Manipulation for Low-Back Pain," makes this statement on treatment duration: "No scientific evidence in the literature supports any of the treatment durations for different indications that have been proposed."
Using objective outcome assessment data that Mercy rates as established and necessary in your clinical examinations, will result in clinical decisions that are defensible against review opinions. This will create objective data upon which your expert professional opinion will determine the therapeutic necessity of care rendered. My vision is to give the practicing chiropractor the knowledge and expertise to provide to every patient the care they deserve, and to provide objective evidence for every patient and their third-party carrier for reasonable and necessary care; thereby creating an analysis system that is fair to all concerned parties.
In future articles, we will discuss how to use the latest technology to gather objective data. It is important to use the guidelines as an authority not only to guide your practice, but to insist that the IME also follow the same standard.
Mark van Hemert, DC, DACS
Montesano, Washington