The Insurance Industry, HMO Combine
In a way, things were simpler when the Clintons' health care package was still on the table. The twin specters of an autonomous First Lady and "socialized medicine" gave doctors and their professional organizations something very visible and very tangible to be against. Unfortunately, the demise of the Clintons has lifted the veil of illusion; much to our horror, what lurks behind is not the charging dragon of big government, but the cold machinery of an insurance industry-HMO combine already in control. What's more, this insurance industry is so decentralized, so creative in the multiplicity of means by which it exerts control in the different markets around the country, that it provides no easy target, no dragon's head to lop off.
This ABS meeting fully acknowledged for the first time this historical shift in power from physicians to the insurance companies and the managed care organizations. Much to their chagrin, the doctors were forced to recognize a new interpretation of the Golden Rule: "Those who have the gold -- rule." Although most of the doctors seemed furious over this loss of control, some took on an air of enlightened resignation: "The insurance company allowed me six visits." Surprisingly, it took several hours for someone (a representative from HealthNet) to define "managed care."
In previous ABS symposia, speakers basically stuck to their medical/scientific work, pausing only to tack on a few remarks about cost containment and vent from time to time against the evil of "cookbook medicine." This time most of the presentations were organically wed to the concept of health care reform. The scientific part merged into the sobering socioeconomic reality that increasingly governs back care. Everyone felt that health care administrators were blooming, although some would have said like wildflowers in the city center and others like algae in a polluted lake. One or two speakers advocated a sort of counteroffensive, while a few went to the other extreme of welcoming any attempt by managed care to get a grip on the escalating cost of health care. Most of the doctors demurred to a more resigned position, a futuristic vision in which Mom'n'Pop solo practitioners disappear (one talk was entitled "The future of private practice: is there one?"), and doctors form provider groups to collectively bargain with dominant managed care organizations. Moderator Segil noted how interesting it was that without any prior rehearsal all the speakers were saying the same things about managed care; apparently, he failed to note that some were for it, and some were against it.
There was a decidedly strong chiropractic presence at this meeting, constituting probably as much as 20-30 percent of the participants. DCs were featured more than usual in the morning scientific programs, and also conducted a number of afternoon workshops. There was even an osteopath who spoke like a card-carrying applied kinesiologist ("Goodheart found ..."), confirming the truly interdisciplinary nature of the ABS in a novel way: to the well known figure of the "medipractor," and the chiropractic "wannabe," can now be added that of the "chiromed," a medical doctor with chiropractic aspirations. More than once I heard a medical presenter start off on something hostile or patronizing about chiropractic (nothing malicious, just politically incorrect old-talk), only to suddenly remember how many DCs were present and start mumbling about how the "chiropractors here would see it." Yes, times have changed.
Why Managed Care, Why Now?
"Managed care is here" (Dr. Scott Haldeman). Why? The annual direct cost of treating low back pain is 14-18 billion, with the direct and indirect costs totalling 50-100 billion dollars per year. Many different disciplines are involved, each with a somewhat unique diagnostic terminology and treatment approach, adding to the complexity and expense of the problem. Unfortunately, patients generally receive the treatment in which the doctor is trained, which only occasionally equates to the most appropriate treatment. According to Dr. Haldeman, the general perception out there is that there has been a tendency toward overtreatment.
Managed Care and the CEO
Sheldon King, CEO of a health care organization (and no slouch in the sardonic wit department) raised the question of how future patients will arrive for the treatment of low back pain. More precisely, in the context of managed care, he wondered aloud if the patient will get to the doctor at all. He pointed out that the Republican victory clearly spells the end of Clintonesque-style national health care, but this only emphasizes that the ascendancy of managed care is inexorable and party-neutral. Reform in the absence of a national plan will be incremental but real. Although capitation is often touted as the solution to all the problems, the point is greatly exaggerated, because capitation raises as many problems as it solves. It clearly lowers cost, but it does so by shifting risk from the insurance company to the provider, who is thus given an incentive to provide substandard care.
Although the "gatekeeper" concept is an old one, it has been known as such for only about 10 years. Under its aegis, patients wind up not where they want to go, but where someone else thinks they should go. This avoids specialist referrals, which is how the cost is really driven up. Mr. King derided all those who would over-simplify the logical imperative of managed care, by falsely portraying it as a drive toward cost-reduction with no regard for quality assuredness. He sternly warned -- no, admonished -- the doctors that "what would have been laughed off in the 1970s as 'cookbook medicine' is something you will all have to live with." As for rationing, he claimed that rationing has always been an issue in the US, since the rich have had more access to health care than the poor. Rationing in the future will be conducted not so much according to economic criteria as under the more compassionate province of gatekeepers. In closing, he sternly warned about the danger of doctor obsolescence -- that is, if doctors cannot demonstrate effective outcomes in the treatment of low back pain, no gatekeeper will seek their services. Mr. King's stark realism in depicting the brave new world of managed care clearly protects him from being easily cast as an apologist for the new order, despite his CEO position. This same realism sounded a wake-up call for doctors who would feign no contributory role in constructing the health care problem which is addressed, however unattractively in the view of some, by managed care.
Managed Care: an Opposing View
Dr. Bronow, decidedly less sympathetic to the managed care point of view that had been defended by the previous speaker, spoke on the future of the private practice of medicine. He situated himself on the lofty plane of morality and ethics, where the rhetoric runs deep. His standpoint was decidedly that of the consumer advocate, and indeed, this was a blistering address. He reviewed some recent judicial disasters sustained by HMOs who had engaged in cost-cutting decisions that resulted in substandard medical practice. HealthNet, which had refused to authorize a bone marrow transplant in a breast cancer case, was recently ordered to pay $89 million in damages to the survivors.
Dr. Bronow finds that the traditional fee-for-service setting in the office of the private practitioner provides the highest quality and most cost-efficient species of health care. The most affordable way for health care consumers to purchase fee-for-service health care would be to take out policies with large deductibles. By doing so they would wind up paying out of pocket for the great majority of health problems, which luckily tend to be easily and inexpensively treated. Ultimately, this would cost less than sustaining the expense of HMOs and low-deductible PPO plans. He raised the following question: Doctors, for whom do you work for, the patients or the profit maximizing HMOs? Do you work for HealthNet, which spends $4,000,000 on television advertising to tout their $5,000 dollar program to save redwood trees, or for the patients? "Capitation is selling out your principle," because it provides an incentive to do less. At the least, patients should be informed as to how much doctors are rewarded by the HMOs for providing less care. Finally: "Crisis? The insurance companies have brought on the crisis."
Managed Care: a Supportive View
In perfect counterpoint, the next speaker (whose name I missed; unfortunately, it does not appear on the program) represented HealthNet, balancing the cynicism expressed by the previous two speakers on the motives of insurance companies. He resisted an obvious temptation to respond to the various remarks that had been made about HMOs in general and his HealthNet in particular, sticking to his prepared remarks on quality assuredness under a managed care system. He had the courtesy to define "managed care," which someone should have done earlier: cost containment through (a) changes in access to physicians; (b) discounted fees; and (c) changes in utilization management. The speaker opined that "any willing provider" legislation can stall, but cannot stop, the process by which managed care unrolls. He explained that having participating doctors discount fees is not enough, because this often encourages them to make up the shortfall by simply increasing the frequency of patient visits. Effective managed care must control the level of utilization as well, affecting both the point expense and intensity of care.
Risk-shifting through capitation is the future, whether doctors approve or disapprove of the process. The HealthNet representative spoke glowingly of another wave of the future, already a reality in California: HMOs will get into the workers' compensation business. Not unlike previous speakers, he was concerned with the issue of quality, but with an interesting twist: quality refers not only to quality care (i.e., good diagnosis, good treatment), but to a high-quality outcome. The doctor is accountable for everything, especially for the de facto functional outcome of care. Accountability also means accountability for treatment failure. To the managed care organization, data acquisition enables correcting the medical treatment as necessary, and ultimately drives outcomes assessment. The final goal of treatment is to end treatment.
We all know that insurance companies make profits. Classically, their profits are said to accrue as just reward for risk-taking, the service provided by the insurer in return for the insured's premium payments. Conventional wisdom notwithstanding, capitation plans, by which contracting physicians agree to attend to the needs, at a certain level of service, of a certain number of patients for a pre-negotiated fee, transfer the risk from the insurance company, which knows therefore what its costs are going to be up-front, to the treating physicians, who do not. That being the case, what exactly is the insurance company being paid for? The HealthNet representative had a chance during the question and answer period to explain that the insurer is still taking on risk, even when it shifts risk to the doctors with capitation arrangements; the risk is that it may not be able to sign up participating physicians, who will sign on with PPOs or make some other arrangement instead.
The McKenzie Method
Dr. Ronald Donelson made his case for the McKenzie method of treating low back pain, which may be briefly described as: back care based on the principle of centralization or abolition of spinal or referred pain, through the augmentation of directional preference. "'Centralization' of referred pain commonly occurs when a beneficial or 'preferred' direction of repeated end-range spinal bending is identified during a dynamic spinal assessment (Donelson). The material was presented in two parts, the first devoted purely to treatment efficacy, and the second to the diagnostic efficacy of the McKenzie protocol. (Some of the references provided: Spine (15)3, 1990; Physiotherapy, 73:4,1993; Spine (16)S206-212, 1991.)
The evidence assembled for the clinical and cost-effectiveness of the McKenzie protocol was quite impressive. Dr. Donelson favors an incompetent annulus fibrosis model, whereby non-centralizers would have a compromised discal load distribution system. Making a point that Dr. Roger Minkow often makes at ABS symposia, he emphasized that the ideal way to reduce the cost of back care is to find a way to screen those patients who are unlikely to benefit from a particular plan of care and get them into a clinical situation where they are more likely to do better. Of any 100 patients with low back pain, 58 will be centralizers, 40 of them in extension, 7 in flexion, and 11 in lateral flexion. They will do well in the McKenzie clinical setting, improving dramatically in about six visits over 1-2 months. The other 42 non-centralizers will not respond well to the McKenzie method, and should be treated in some other way.
Dr. Donelson made another point well-worth reiterating: "To be productive, assessment tools must be both objective and relevant." However, "objectivity is of no value if the item tested is not relevant" to the patient's complaint. For example, it would be of little value to obtain an MR on a mildly symptomatic patient, knowing in advance that there is a 40 percent chance of demonstrating a completely irrelevant disk bulge.
Despite his emphasis on treatment success, Dr. Donelson did undertake to comment on recent evidence for the pathoanatomical entity that underlies the centralization phenomenon. He is currently involved in a study with the eminent discographer Dr. Aprill which raises the following question: Are discographic outcomes predicted by centralization of pain and directional preference? In a word, their answer is yes. The clinicians in the study were able to consistently identify both the level of disk pathology, and the location, direction, and extent of nucleus pulposus fissure patterns. The provisional conclusion of the study is that "The McKenzie spinal assessment appears to be a dynamic, non-invasive functional evaluation of symptomatic disc pathology." The results of this study are printed in the syllabus for the program, under the title discographic pathology predicted by "directional preference" and the centralization phenomenon: a prospective, blinded study (Donelson, Aprill, and Grant).
Electrophysiology of the Active Trigger Point
Dr. David Simons, who co-authored with Janet Travel two classic textbooks on trigger point therapy, discussed the electrophysiological findings of active and latent trigger points. Noting that previous speakers had made the point that many low back patients get over the acute crisis stage relatively quickly and cheaply, only to enter a prolonged and expensive to treat phase of residual functional impairment, Dr. Simons opined that many of these chronics suffer from persistent and secondary trigger points. Strongly disagreeing with the common view that trigger points display no positive laboratory results, nor manifest any established pathology, he presented evidence that myofascial trigger points display spontaneous needle EMG activity markedly different from that elicited in immediately adjacent areas. In work done by Hubbard and Berkoff, a needle inserted into a palpably taut, tender muscular band, one which referred pain in a characteristic TP distribution, produced low voltage activity with spikes. A needle inserted into another point as little as one millimeter away would not produce this same result. Active trigger points show larger spikes than latent trigger points. What precisely are trigger points? They are found precisely at abnormal motor end plates, at the myoneural junctions. Although the precise pathology is still not entirely clear, at least the location of TPs appears to be more definable at this time.
How a Profession Validates Its Procedures
Scott Haldeman, DC, MD, PhD, explained to the assemblage how a profession goes about getting its procedures included within practice guidelines that would be considered appropriate in a managed care context. He explained why some heavily-practiced procedures, like injections, don't get in, and why some other historically controversial procedures, like manipulation, do. Chiropractors and others have spent the last decade demonstrating that SMT reduces pain, raises the pain threshold, alters paraspinal evoked potentials, improves ADL measures, is cost effective, returns workers to work relatively quickly, and maintains a high level of overall patient satisfaction. Throw in a few prospective RCTs, and it becomes clear how SMT was validated. The point of weakness right now has shifted from clinical utility to a question of overutilization. Chiropractors have established their ability to treat back pain, now they must demonstrate that they know when to quit, whether because treatment has failed or because further improvement is unlikely.
Osteopath Introduces Applied Kinesiology
Although every now and then there is a fairly "esoteric" presentation in an afternoon or evening workshop, it is very unusual to witness such a presentation during a morning scientific program. I can recall one meeting in which a well known expert in manual medicine, who usually sticks to well trodden topics such as spinal and sacroiliac manipulation, unexpectedly spoke on cranial manipulation -- but not without a plethora of "now this may seem weird" and "I ask you to suspend judgment" type of remarks.
At this current meeting, osteopath Jay Sandweiss was prone to no such reservations, as he introduced "Applied Kinesiology -- a unique system of diagnosis and treatment for back pain." It seemed funny to hear it proclaimed over and over again, before such an august body of researchers and health care professionals, that "Goodheart found" this or that -- without mentioning precisely how Goodheart would have made all these unbelievable discoveries. Dr. Sandweiss, much to his credit (and to that of the ABS for finding a place in its program for such controversial views) championed AK in a matter of fact, uncompromising way: the five factors of the IVF, neurolymphatic and neurovascular points, the organ/muscle relationship, eyes-into-distortion, therapy localization, the vertebral challenge, and humming and counting backwards with the patient to see if a previously strong indicator muscle would go weak. I must admit, it seemed like like having an astrologer address a meeting of the Astrophysics Society, or perhaps like Tiny Tim performing "Tiptoe Through the Tulips" during an intermission of the Julliard String Quartet, but then again, all views should be represented, I guess.
Robert Cooperstein, DC
American Back Society
Editor's Note: Part II of Dr. Cooperstein's article will appear in the March 27, 1995 issue of "DC."
Click here for previous articles by Robert Cooperstein, MA, DC.