October 2006

CCGPP and WLDI make strange bedfellows

by Dr. Terry A. Rondberg

In an ideal world, health care standards of care guidelines should be produced solely to ensure the welfare of patients and assist practitioners in making the most appropriate decisions about the care they provide.

But this is the real world, and we all recognize that another "purpose" for guidelines (and this includes "best practices" documents) is to give the third party payers a way to determine what services are reimbursable.

However, we have to draw the line when accommodating the insurance industry becomes the primary motivation behind a guidelines effort.

An article in the New England Journal of Medicine, pointed out: "In the United States there has been a radical shift in the power to determine when health care is medically necessary and therefore covered by insurance. From the 1950s through the late 1970s, physicians' medical opinions largely dictated coverage and were rarely challenged by insurers. Physicians no longer have this extraordinary level of autonomy. Insurers now routinely make treatment decisions by determining what goods and services they will pay for. The line between clinical decisions about necessary medical care and decisions about insurance coverage is particularly blurred in managed‑care plans. The power of insurers to determine coverage potentially gives them the power to dictate professional standards of care for all but the wealthiest patients." (Newcomer, L. N., et. al., "Who Should Determine When Health Care is Medically Necessary?" NEJM 341: 58‑60)

This appears to be the case with the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) and is one of the reasons why that group's first effort, the low‑back draft, is being so resoundingly rejected by the profession.

According to an article by CCGPP Board member Ronald J. Farabaugh, DC, the CCGPP contracted with a company called Work Loss Data Institute (WLDI) to publish and distribute the final document. Dr. Farabaugh says that "WLDI was chosen because of their wide experience in this area and ability to get this type of document into many hands."

Interesting spin, but the WLDI offered a different perspective. In its 2004 brochure, the WLDI noted: "Development by WLDI and the Council on Chiropractic Guidelines and Practice Parameters is underway, and this joint protocol for frequency and duration of effective chiropractic treatment is expected later in the year." The role of the WLDI is obviously more than simply publishing and distributing the final document. It appears to have been involved in the development of the document itself. Keep in mind that the WLDI has an intimate relationship with the insurance industry, which uses its documents to cut costs and minimize reimbursements for "inappropriate" care.

In addition, Dr. Farabaugh failed to note that John Triano, DC, CCGPP's Research Commission Chairman, was a member of the WLDI Advisory Panel, at least since 2003, according to information on the WLDI website. At first, Dr. Triano claimed "I never did contribute to WLDI but there was a publishing lag which prevented withdrawal of my name." He didn't explain how there could be such a publishing lag with an online document. Later, Dr. Farabaugh stated in a mass mailed e‑mail message that Dr. Triano "is not an official advisor for WLDI, and never has been ... period." Either he didn't know about Dr. Triano's relationship with the WLDI or was trying to cover up that relationship. Fortunately, several doctors had saved the relevant documents before they mysteriously disappeared from the WLDI website in August of this year.

It's also likely that Dr. Triano ‑‑ possibly working on behalf of the WLDI ‑‑ was instrumental in instigating the CCGPP efforts. It has been reported that the minutes of a COCSA meeting indicate that when asked who suggested the formation of CCGPP, Dr. Triano noted that two states requested guidelines: Texas and California. Not coincidentally, WLDI's offices are in Corpus Christi, Texas and San Diego, California.

What has angered most doctors about Dr. Triano's relationship with WLDI is the fact that the WLDI's previous guidelines ‑‑ marketed to the insurance industry ‑‑ generally limited chiropractic to six visits in two weeks for low back pain. Although Dr. Triano may not have been personally responsible for writing those guidelines, I can find absolutely no evidence that he ever protested them or tried to have them changed. He continued his relationship with WLDI despite such ridiculously anti‑chiropractic recommendations.

The WLDI's involvement in the CCGPP process is underlined by the fact its brochure already boasts that it will be offering the CCGPP document ‑‑ even though the vast majority of chiropractic organizations have rejected it and asked the CCGPP to withdraw it. Apparently, this is a "done deal" and receiving input from the profession was merely for show.

As pointed out in the NEJM article, "The need to control costs and generate profits also brings into question the reliability and soundness of decision making by insurers. The sine qua non of scientific research is the production of objective results, and objectivity is ensured through a process of open and vigorous debate among persons who have no financial stake in the outcome."

It's clear that the WLDI has a significant financial stake in the outcome of the CCGPP guidelines and its involvement taints the entire process. This factor, together with Dr. Triano's well‑known and documented antagonism to subluxation‑centered chiropractic, adds one more reason that the CCGPP effort should be discontinued immediately and the low‑back draft deep‑sixed before it causes the same type of problems generated by its predecessor, the Mercy guidelines.