bin Reaction Any chiropractic work entitled "Best Practices" is going to face its fair share of challenge of the First Best Practice Chapter, red flags have been raised by a variety of groups in c vocal critics, Russ Leonard, from Wisconsin Chiropractic Assn., with a rebuttal by CCGF i such a diverse profession. Shortly after the release )practic. Here we hear from one of the most Drs. Wayne Whalen & Eugene Lewis. CCGPP: The Wrong Approach to Practice Parameters We commend the participants of the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) for their dedication and hard work. Their goal was to produce a "Best Practice" document after examining all existing guidelines, parameters, protocols and best practices in the United States and other nations. When they began their mission, they preached consensus. Mistakes of the past were to be avoided and they pledged to have a completely transparent process. They were fomied at the request of the Congress of Chiropractic State Associations (COCSA) and supported by the entire alphabet of national chiropractic organizations: ACA, ICA. FCER, ACC, CCE, FACS, NACA. NICR, and a host of vendors. The profession would, at last, have a document guiding chiropractors and third party payors that would avoid the perceived mistakes of the Mercy Guidelines. But, now that the document has been released for comment, questions abound about the process used to create the document and its clinical conclusions. CCGPP has all but abandoned transparency and consensus. The profession must now decide if there is anything worth salvaging from this document or to repudiate it if it is ultimately published. CCGPP and Worker's Compensation CCGPP has stated that requests from the worker's compensation systems of California and Texas were the major impetus for the creation of a best practices document. Chiropractic costs for providing worker's compensation care, according to the Worker's Compensation Research Institute (WCRI), are far higher in those states than others covered by their survey data. In the case of California, the state decided to adopt the American College of Occupational and Environmental Medicine (ACOEM) guidelines, which are detested by chiropractors, and to limit injured workers to no more than twenty-four chiropractic, twenty-four occupational therapy, and twenty-four physical therapy visits per industrial injury. Unfortunately, these visit limitations would not be altered by CCGPP's best practices document. The CCGPP document would, however, likely damage patients and chiropractors in the area of physical therapy services. The ACOEM guidelines state that physical therapy has "no proven efficacy." CCGPP replicates this biased system that poorly grades physical therapy, not because physical therapy is ineffective, but merely because insufficient research has been done to substantiate its effectiveness. Add CCGPP to ACOEM and you have disaster for injured workers. Instead of battling ACOEM or adopting reasonable WC treatment guidelines, as has been done in Wisconsin and Minnesota, CCGPP produced a best practices document that will not allow chiropractors in California to provide additional care, but will have a potential devastating impact on injured workers if they are denied physical therapy modalities. CCGPP's Impact on the Quality of Care CCGPP appears to have ignored the evolution of best practices guidelines (see the cover story in the May 29,2006, issue of Business Week) that were designed to help MD's determine the best treatment based on a plethora of well researched options. Instead of studying the applicability of this model to the entire spectrum of chiropractic treatment, it seems as if a judgment was made that, since the model would work well for chiropractic manipulation, which is well researched, it would be applied to all chiropractic services—regardless of the consequences. Now that the document has been released, the profession is beginning to understand the negative consequences for patients who need physical therapy, because this model was inappropriately applied to chiropractic. It was not reasonable for CCGPP to adopt an unreferenced grading scale for modalities when they knew the inherent bias in the grading system would negatively impact the quality of patient care. If an ABCD grading system is used, it is fair to expect there will be A and B choices. That was not possible for physi- Contimiecl on pg. 56 CCGPP: The Wrong Approach to Practice Parameters Continued from pg. 50 cal therapy modalities because, to have A or B choices, there has to be relevant research. And, by CCGPP's own admission, there is none. So what will happen if CCGPP's best practices guidelines are published? Patients will suffer, as it is likely that insurers and managed care companies will gradually eliminate reimbursement for any service that does not receive an A or B grade. After all, why should an insurer pay for something that received a C or D in a "Best Practice" document produced by the chiropractic profession itself? The consequences will be devastating. In the real world, if reimbursement is denied for modalities, patients will have to pay for these services out of their own pockets. The overwhelming majority of patients will not be able to do so and, as a result, will forgo the care. Their health will greatly suffer as a result. "Best Practices" Document or a "Guideline" It has been fascinating to watch as CCGPP struggles with the identity of this document. Is it a best practice document that will help chiropractors to select the optimal care for their patients? Or is it a guidelines document that will be used by insurers and managed care organizations to impose artificial limits on care? Throughout the national conference calls COCSA and CCGPP have held on this document, the words "best practices document" and "guidelines document" have been used almost interchangeably, except when a CCGPP member suddenly realized it was politically incorrect to do so. CCGPP has been trying to make the case that a "best practices" document does not lay out numeric parameters for care and, therefore, should not be misused. But a best practices document that assigns a C or D grade to commonly used services will absolutely be used as a guideline by some insurers or managed care companies. They won't just limit chiropractors to a few uses of physical therapy—they will refuse to pay for it at all. ACN has already written that they intend to create fee schedules based on best practice documents. CCGPP is hiding behind the words "best practices" when, in fact, they have created a guidelines document that will be used to deny needed chiropractic care, which will have a devastating clinical and economic impact on the profession. Consensus or Personal Opinion The best practices process was sold to the country as a completely transparent process that would be consensus driven at every step. Like some states, the Wisconsin Chiropractic Association invited Gene Lewis, DC, the then Chair of CCGPP, to make a presentation to our board where he stressed the importance of consensus. If you read Dr. Lewis' article on the CCGPP website, consensus is stressed over and over again. But that was then and this is now. In a conference call between CCGPP and the COCSA Board of Directors (available on CD from COCSA), COCSA was told, in no uncertain terms, by CCGPP that they have no rights to approve or disapprove the document. Chair Jay Triano, DC, stated, "It is not a matter of ratification and never has been." There is more. After all, if CCGPP does not intend for COCSA or the states to be allowed to approve the best practice document, can we trust in their judgment not to produce a document that will be harmful to the profession? Their response: "In nuts and bolts, that is what it really comes down to. If we think this is going to harm us, do we publish it anyway? And 1 think the only answer is, in an actually honest world, yes." The Path Ahead As of this writing, seventeen states have completed evaluations of the CCGPP document, many utilizing the AGREE Instrument which is specifically designed to assess documents of this type. Of the seventeen states, sixteen have requested that CCGPP withdraw the document. One state has determined the document should be published only if changes are made. More than a dozen states are still in the process of evaluating the document. These sixteen states go far beyond challenging the process used to create the document. They have significant clinical concerns about research that has been overlooked or misinterpreted and questions about its practice applications. Each of these clinical questions would, by themselves, need an entire article to explore. We are at a critical junction. While CCGPP says that states do not have the right to ratify this document, we believe they will change their minds if the majority of states take the position that the document should be withdrawn. For that to happen, many states need more information and time to respond. COCSA has scheduled a special meeting to discuss the best practice document on Nov. 11. If CCGPP is really interested in providing the information necessary for states to reach a conclusion and to reach true consensus, they should extend their comment period until after COCSA's special meeting. If they just want to publish a document based on the personal opinion of the ten people involved in its creation, then it should be disavowed. liu.sx Leonard can be reached by e-mail at [email protected] Russ Leonard is the Executive Director of the Wisconsin Chiropractic Association. Over the past seventeen years, Mr. Leonard has been involved in all aspects of policy work through his extensive involvement with legislative bodies, government agencies, and the insurance industry. Approximately 85% of practicing Wisconsin chiropractors belong to the WCA.
