rending: this word is what should be the guiding force behind the future of every practice and business worldwide. Why is it that some offices seem to thrive in any economy, yet others are always struggling to pay the rent, the staff, the bills and often oneself? How many weeks a year do you NOT take a paycheck? In 1982, John Naisbitt wrote the New York Times
, which accurately prognosticated shifts in the world economy and changed the relationship of people to economics. The principles of success in foretelling the future that held true in 1982 still hold true today. If you know where to look and how to interpret the economic or practice indicators, you will ensure your success for years to come IF you are willing to adapt based on the trends and indicators and IF you are willing to take the action steps required.
These changes have nothing to do with how you practice. You can be a "far-right conservatist" practicing in a pure "Tic" environment or a "far-left liberal" using every modality, treating extremities, using nutrition and every other avenue your scope allows, or somewhere in the middle like the majority of us. The rules are the same for all. Trends dictate how we triage, document, bill and collect our fees, not how we deliver chiropractic care to our patients.
When looking for trends in a professional setting, we must examine what the carriers, chiropractic boards, courts and legislators are dictating through rulings and legislation. First, we cannot be Pollyannaish and think that the carriers are outside influencing any of the above entities, as their profit base is purely derived from rules, regulations and laws. When looking at trends, we look for bellwethers nationally, and currently there are 2 states that are leading the pack, New York and, to a greater degree, New Jersey.
The First Trend Is Evidence-Based:
In December, 2010 New York revamped its workers’ compensation guidelines, mandating evidence in the form of peer-reviewed literature to expand the amount of reimbursable care. New York also forbade treating workers’ compensation patients in a fee-for-service scenario outside of the workers’ compensation system. This changed the historical usual and customary amount of care based upon a doctor’s findings to that centered on the literature. Although this was limited to workers’ compensation, it laid the foundation for future legislation.
On January 4, 2013 New Jersey enacted regulation that says:
N.J.S.A. 39:6A-4a provides that the Commissioner, in consultation with the Commissioner of the Department of Health and Human Services and the applicable licensing boards, may reject the use of protocols, standards and practices or lists of diagnostic tests set by any organization deemed not to have standing or general recognition by the provider community or applicable licensing boards. Although the Department is not adding to the list of rejected protocols, the Department is proposing to add a definition of standard professional treatment protocols to guide the acceptable evidence of standing or general recognition for a specific medical procedure or test. These are defined as evidence-based, clinical guidelines published in peer-reviewed journals. The Department has become aware that the medical necessity of a procedure or test is being supported by articles, books and practice or treatment guidelines that are published by the proponents of the treatment or test in journals that are not peer-reviewed and where the evidence supporting the treatment or test is anecdotal. These types of treatment protocols and guidelines cannot be used as evidence that a treatment or test is medically necessary.
Evidence-based practice is NOT the trend. A perversion of what evidence-based practice was intended to be has become the trend and is here for the foreseeable future. In order to understand the trend, we must understand evidenced-based practice as it was intended. "The most common definition of evidence-based practice (EBP) is taken from Dr. David Sackett, a pioneer in evidence-based practice. EBP is 'the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research'"
(Schardt & Mayer, 2010, http://www.hsl.unc.edu/services/tutorials/ebm/whatis.htm
EBP is the integration of:
- Clinical expertise: The clinician's cumulated experience, education and clinical skills.
- Patient values: The patient's own personal and unique concerns, expectations, and value.
- The best research evidence into the decision making process for patient care: The best evidence is usually found in clinically-relevant research that has been conducted using sound methodology (Schardt & Mayer, 2010, http://www.hsl.unc.edu/services/tutorials/ebm/whatis.htm).
"The evidence, by itself, does not make a decision for you, but it can help support the patient care process. The full integration of these three components into clinical decisions enhances the opportunity for optimal clinical outcomes and quality of life. The practice of EBP is usually triggered by patient encounters which generate questions about the effects of therapy, the utility of diagnostic tests, the prognosis of diseases, or the etiology of disorders. Evidence-based practice requires new skills of the clinician, including efficient literature searching, and the application of formal rules of evidence in evaluating the clinical literature"
(Schardt & Mayer, 2010, http://www.hsl.unc.edu/services/tutorials/ebm/whatis.htm
There are a myriad of articles published on the cons related to a purely evidence-based "published only" approach and its potential to be used to deny care. In a recent article by Carr (2008), published in the Journal of Regional Anesthesia and Pain Medicine, he writes, “Yet even as I was preparing that talk, the climate of pain medicine was changing. It was already clear that powerful stakeholders in the healthcare enterprise were looking to evidence-based medicine (EBM) for answers about effectiveness, cost effectiveness, appropriateness, and even efficacy beyond what EBM could reasonably provide. Since then, over- and mis-application of EBM to support health policies such as 'pay for performance' and to restrict payment has created a crisis. This ongoing crisis threatens the survival of important forms of pain therapy, restricting health care offered..." (Carr, 2008, p. 229). The biggest concern in his article and among healthcare providers is clarified when he states, “…I realized that the practice of EBM dates to antiquity, but what is new today is that EBM is being used as a rationale to restrict physician payment and/or autonomy" (Carr, 2008, p. 229).
Proponents of evidence-based, clinical guidelines published in peer-reviewed journals argue that it would eliminate waste and reduce costs while providing patients with the most up-to-date care available. That is a dangerous partial truth. Those currently practicing don't argue, but understand, through daily patient care, that this is too limiting and would eliminate many procedures that fall under this narrow definition and remove clinical decision making and professional experience from the equation. What would be left is denial of valid and often critical therapies with the concurrent stifling of innovation, since the process of establishing a research study, following its participants and publishing those findings can take many years. This delay could eventually cost lives and/or severely diminish the quality of life for those who could have been helped during the research and publication processes.
With the understanding of EBP, the legislation in New Jersey has set forth a path that ONLY therapies and diagnostic testing that have been published are reimbursable with far-reaching effects. The trial lawyers’ concerns are that non-published tests or treatments will be barred as evidence in the courts with further implications not yet illuminated, as future court rulings will further define this regulation.
Although managed care companies and workers’ compensation carriers are not regulated, within weeks of the regulation becoming effective, denials were being rendered quoting these standards. The carriers took it to the next step and cited "standard of care" as a result. These same types of denials are being reported in multiple other states because the carriers realize that the rationale has been clearly defined and, in the end, many courts will uphold their reasoning, again citing "standard of care". Therefore, the first significant megatrend in chiropractic is to utilize peer-reviewed evidence.
The second trend is credentials and certifications:
In the Fall of 2012, a trial court in New Jersey ruled that the chiropractor for the plaintiff was not allowed to testify on MRIs for his patient because of his insufficient certification (and credentials) in the "eyes of the court" on MRI interpretation. During direct and cross-examination, the specifics of this doctor's MRI education were clearly detailed and the judge went further and ruled that ALL chiropractors in New Jersey couldn't testify on MRIs based upon this one doctor's account of his training.
Therefore, the second significant megatrend in chiropractic is to be prepared with the appropriate credentials and certifications. MRI spine interpretation is only one example.
This ruling, which is being challenged in the appellate division and has amicus briefs by both the Association of New Jersey Chiropractors and the New Jersey Association for Justice (Trial Lawyers Association in New Jersey), has far-reaching negative implications for our profession, both locally and nationally, should it be both upheld and followed blindly by other judges. This judge cited how this one doctor's MRI course was structured and monitored along with the content and institutions accrediting the certification in his ruling. Understanding the needs of the courts and the power of credentials, 3 different doctors during the week of February 17, 2013 testified in 3 different courts, and in each instance the same qualifying questions were asked as in the case where the one doctor was ruled against. In all 3 recent cases, the DCs were qualified as experts and allowed to testify on MRI. These 3 doctors understood that it is no longer "business as usual" and although their treatment protocols haven't changed, they have chosen to ensure that they are qualified as expert. These doctors were certified by the Federation of Chiropractic Licensing Boards, the University of Bridgeport College for Chiropractic and the State University of New York at Buffalo School of Medicine and Biomedical Sciences for CE and AMA Category 1 PRA credits in MRI spine interpretation. These credentials were ruled by the courts as acceptable for DCs to be expert in interpreting MRI. These credentials, unlike those obtained by the other doctor, have met not only New Jersey court standards, but those of every other state where they have been challenged in court.
This, too, has far-reaching implications for the chiropractic profession. The limited reach is being able to treat personal injury patients, with both lawyers and patients not fearing the loss of cases as a result of involvement by a chiropractor because the doctor of chiropractic will not be able to represent them in court. The long-term implication is the courts will now view chiropractors as well-credentialed experts on par with all other specialists, and when future utilization issues are considered, we will not be considered subservient. Therefore, the second significant megatrend in chiropractic is to be prepared with the appropriate credentials and certifications. MRI spine interpretation is only one example.
In order to meet the trends for today and the future, we all must meet the "highest standard" in the nation regardless of our individual state's requirements. Do the New York or New Jersey laws affect you in your state? Maybe or maybe not, but, given time, some form of these standards WILL affect you and your practice, whether it be today, tomorrow, next week, next month or next year. These are the indicators of today and demonstrate that you must be prepared.
To accomplish this, your choices are either to go to Google Scholar, Pubmed or Ovid and hunt for each citation or use a service that provides you with those citations.
When documenting care in your records, you should strongly consider adding peer-reviewed evidence in your reports to support your recommendations. To automate the process, your EMR (electronic medical records) program should have macros to add those citations. To accomplish this, your choices are either to go to Google Scholar, Pubmed or Ovid and hunt for each citation or use a service that provides you with those citations (Historically, the latter has not been an expensive option.). Either way, this is a trend that cannot be overlooked and gives you a much deeper appreciation for the research community and what it provides to the chiropractic profession.
Credentials are important, but the right credentials are critical, and whether you get cross-credentialed with another profession or a diplomate within chiropractic shouldn't matter. The only criteria should be learning the material and having credentials that are legally defensible. Learning how to perform an EMG, interpret an MRI or rehabilitate the paraspinal musculature, although integral to the practice of chiropractic, is not knowledge exclusive to chiropractic. However, the credentials and subsequent certifications are crucial for the DC to be able to function in today's economy and the trends of the courts that we currently see in most states dictate that a continuing education course lasting a few hours, given by your state organization in a hotel, is often nothing but a great start.
New Jersey is a prime example and, thankfully, those 3 doctors (with many more to come) who were in court last week chose to go beyond the few hours in a hotel room and instead got certified. Over time, more and more New Jersey (and other states') courts will recognize that chiropractors are qualified to render expert opinion on MRI and overcome the negative opinion of this one judge, protecting chiropractic and your right to represent your patients and your profession. As a result of this case being an Allstate case, it is one that is significant, as this is one of the wealthiest carriers in the world, literally, who has the ability to leverage this lower court ruling nationally. Having DCs in other courts in New Jersey recognized as experts after the fact of this ruling minimizes the impact of this one judge's ruling and essentially limits the negative influence of that case only to its specific facts and circumstances, and not to the entire profession as viewed by that one New Jersey court.
With these 3 doctors, was it necessary to get credentialed through a chiropractic university and earn category 1 AMA PRA credits through a medical school in addition to the chiropractic state board for the doctor's chiropractic license? No. However, the judge saw these credentials and the work that was required for the certification as meeting much more stringent standards and qualified the doctor of chiropractic as expert. That is meeting the standard at the highest level and winning as a profession through clinical excellence.
No matter your philosophy, politics or manner of practice, this is where the profession is trending today and the near future. You need to meet the highest standard in the nation and let everyone else wonder why you are always doing well while THEY continue to struggle.
- New Jersey Department of Banking and Insurance, Retrieved from: http://www.state.nj.us/dobi/proposed/prn11_163.pdf
- Schardt , C., & Mayer, J. (2010, July). What is evidence-based practice (EBP)? Retrieved from http://www.hsl.unc.edu/services/tutorials/ebm/whatis.htm
- Carr. D. B. (2008). When bad evidence happens to good treatments. Regional Anesthesia and Pain Medicine, 33(3), 229-240.
- Sackett, D. L., Rosenberg, W. M., Gray, J. A., Haynes, R. B., & Richardson, W. S. (1996). Evidence based medicine: What it is and what it isn't. British Medical Journal, 312(7023), 71-72.
- Lamb v Allstate Ins. Co., Docket No: ESX-L-5830-09, Sup. Ct NJ, Essex Cty (2012).
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