December 2004

A rose by any other name still stinks

by Dr. Terry A. Rondberg

Recently, the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) sent out a long apologia on their new guidelines ... oops, "Best Practices" document. Despite the name of their group, they went to great lengths to deny that they were developing guidelines at all.

I don't blame them for not wanting their new document to be associated with its predecessor, the Mercy Guidelines, which not only proved to be a dismal failure within the profession, but couldn't even qualify to remain listed in the National Guidelines Clearinghouse (NGC).

What we have here appears to be a case of "you say tom(ay)to, I say tom(ah)to" since there are so many obvious similarities between the two entities, and the way the final document will be used.

Some examples:

*** According to the CCGPP, the new initiative was formed at the behest of the Congress of Chiropractic State Organizations. That group also launched the Mercy Guidelines effort. In fact, the new group was formed to update the Mercy Guidelines or create a new set of guidelines. Only recently has the purported intent been to develop a "Best Practices" document.

*** The new group, its latest official statement notes, consists of a "steering organization comprised of 20 chiropractors with one in education, one in research, and one vendor representative, with 18 of the 20 chiropractors in full‑time private practice." Mercy had a panel of 35, supposedly a cross section of the profession. Later, one of the major criticisms of the Mercy Conference was that it failed to include all segments of the profession and was, in fact, a carefully hand‑picked and secretive assembly.

*** CCGPP says its "process for committee selection has been open and as transparent as possible." Really? How many of you knew about it while it was going on? How many of you were invited to participate? When will the open meetings be held and how much input are they accepting from the entire profession? It's true that, if an organization pays for travel expenses, a member of the group will "answer questions" about the CCGPP (and, no doubt, ask for donations). But this is quite different from asking for input.

*** The CCGPP informed us that "members of the Commission include well‑known individuals: Dr. John Triano, Dr. William Meeker, Dr. Cheryl Hawk, Dr. Alan Adams, Dr. Donald Murphy, Dr. Robert Mootz, Dr. Warren Hammer, and many others." Five of these seven names were associated with the Mercy Guidelines, either as members of the Commission or as consultants.

Furthermore, the CCGPP has said that it "serves all stakeholders that we either impact on or who have an impact on our profession." I find little evidence of this. In fact, the makeup of the CCGPP is decidedly slanted in favor of the ACA and its allies. There is little or no representation of subluxation‑centered schools or organizations and very few actively practicing doctors.

I've carefully reviewed the rest of the list of participants and can find no one except Dr. Ashley Cleveland clearly identified with the subluxation‑based chiropractic community. The members of the "Wellness and non‑musculoskeletal disorders" workgroup (which, I assume may actually include vertebral subluxation) are:

> Dr. Cheryl Hawk, a National College graduate with a PhD in preventive medicine from the University of Iowa. Now a researcher at Palmer, she has not been in private practice since 1988. She is a member of the ACA's "Wellness Committee" formed just last year.

> Dr. Jacqueline Bougie, who has teamed up with Dr. Triano for research with the Texas Back Institute, is a Diplomate, American Board of Chiropractic Orthopedists.

> Dr. John Hyland, DACBR, DABCO, is author of a book on Biomechanics and a member of the ACA's "Wellness Committee."

> Dr. Randy Ferrance, a DC/MD whose presentation for this year's American College of Chiropractic Consultants conference was "Manual Treatment and Management of the Pediatric Patient."

> Dr. Ashley Cleveland, an associate dean at Cleveland College who also serves on the ACA's Wellness Committee.

> Dr. Meridel Gatterman chairs a subcommittee of the ACA's Wellness Committee's.

> Dr. Thomas Davis is associate professor for the chiropractic program at Northwestern.

Can this really be considered a fair representation of all "stockholders?" If this new document is forced on us the way Mercy was, we will all be affected. Yet, this is clearly similar to "taxation without representation" ‑‑ we will pay the price, without having input in the process.

*** The final document will be published and distributed by the Work Loss Data Institute, a private database development company. Dr. John Triano is one of just three DCs on its advisory board. The second DC is listed only as a "Certified Insurance Consultant." The third is the president and CEO of the National Board of Forensic Chiropractors.

*** In trying to explain the differences between guidelines and best practice documents, the CCGPP states: "a guideline contains numbers/suggested therapy time frames that are often mistakenly applied as arbitrary limits. Best Practice (BP) is a process/document that reviews the evidence and provides interpretation consistent with the chiropractic perspective as the providers involved in treating these cases, using chiropractic methods (Triano). BP is more of an ongoing dynamic process and initiative rather than just a document." That's an interesting, if subtle, distinction but one that apparently makes little difference to insurance companies.

For instance, Mutual of Omaha notes that its "Medical Necessity Criteria" are based on "official consensus statements from medical specialty organizations, federal health agencies, academic institutions, technology research firms, and/or a physicians committee determination of "best practice" (emphasis added).

Please understand, I'm not arguing about the relative benefits of Best Practice documents. I'm saying that the CCGPP's new "Best Practice" document is being developed by many of the same people, in much the same way. If the resulting document is comparable to the Mercy Guidelines (and why would we assume it will not be?), it will probably be used to cut chiropractic claims just as the Mercy document was.

In the words of that noted "Star Trek" philosopher, Mr. Spock, "A difference that makes no difference is no difference."

Additionally, the CCGPP is hoping to get the profession to pay more than a million dollars to come up with this document! It lists a 2004 budget of $475,000 and projects that its 2005 budget should be similar.

While giving no estimate of the overall cost, the CCGPP says only: "Document development expenses are the most significant portion of the budget. Meetings, accounting expenses, clerical expenses, research honorariums, travel and stakeholder communications are the principal remaining budgetary items." You have to specifically request a more detailed budget (although the website doesn't include any specific information about how or from whom you're to make this request).

The CCGPP claims to have raised about $135,000 in donations and pledges. "Another $80,000 gain was achieved by investing the majority of potential future royalties in the research process," they explain on their website.

That leaves a mere $785,000 that we're supposed to donate so the same people who brought us the Mercy Guidelines can develop another document and send it to the insurance companies.

If this isn't your idea of a smart way to spend your money, I have a suggestion. Make a donation instead to the Council on Chiropractic Practice (CCP), whose evidence‑based guidelines help support subluxation‑centered practices and are included in the National Guidelines Clearinghouse.

The entire CCP effort was open and included input from all interested parties. The CCP document has been used successfully to defend chiropractors in court and to substantiate insurance claims. It has been endorsed by numerous organizations and is distributed free on the Internet! (www.ccp‑guidelines.org)