The Paradox of How MCO's Decrease Quality of Health Care

The Kaiser Building, Portland, Oregon

In the early 70's, the Managed Care Organization model was introduced for the first time to the public as a promise to embody the future of improved care, a truth the public can welcome while covering the reality of managing costs (call a spade a spade: profit maximization.) In 1990, Oregon state adopted this care model but with several decades of using its methods, few health care providers & patients are satisfied with it. Here's why:

1.) Being funneled through a MCO's protocol violates patient ACCESSIBILITY.(1) Labor and Industry MCO's are an extreme example of this. (Up until a year ago, only medical doctors could be certified for overseeing a worker's comp case, and recently chiropractors were added to this.)
     a.) Let's say something fell on your big toe and broke it while you were at work. Past the initial visit to ER to reset the bone, you will spend time in a cast, on crutches and wearing a special boot that ruins your natural gait over the next 90+ days (giving you substantial back pain.)
     b.) Because MCO doctors are under a normalized pressure to minimize costs, this means the likely-hood of the patient getting a full scope of their injury and what it takes for full restoration is NOT the primary goal. The broken toe patient with a new onset of back problems has very low chances of being referred to a chiropractor and a massage therapist, yet L&I will cover those.

2.)  The medical system itself isn't functional yet. According to new research from the Commonwealth Fund, 85% of physicians from the top 10 industrialized nations agree that our health care system doesn't work. (2) And US doctors are the most dissatisfied compared to any other country. Here's an alternative take on why that is:
   a.) Medical costs are tripled in the US compared to most countries. The more you profit, the more corporate self interest drives down quality of care and turns your fellow man into a commodity. Translation: We're sustaining enormous emotional conflict over this, no socioeconomic level is exempt and it hurts all of us.
   b.) Patients desperate for results ultimately end up in independent alternative care clinics, where an unbiased, low overhead chiropractor or naturopath hears a common thread story all the time: My MD did this, referred me to this, that didn't work, now I'm here.
   c.) MD's are limited to a pharmaceutical protocol by their scope of licensing & malpractice insurance, and by default they are often legal scapegoats for side-effects of drugs and pressure to restrict care by insurers. Irony at its worst basically.

Morale of the story: We tried a managed-care-profit-based-health care model, and it didn't work 'Uh-merica. We turned a portion of our own people into medical-malfunction zombies, legal cases and medical bankruptcies soared and we're sorry for it. Let's stop and try the opposite now. Let's advocate a profitless model, close the gap of disconnect between physicians all kinds, and empower patients for their full potential of restoration.


 
(1) Hall, R. (n.d.). Ethical and Legal Implications of Managed Care. Ethical and Legal Implications of Managed Care. Retrieved June 23, 2014, from http://www.drrichardhall.com/ethical.htm

(2) Kliff, S. (2012, November 15). Six out of every seven doctors agree: Our health-care system doesn’t work. Washington Post. Retrieved June 23, 2014, from http://www.washingtonpost.com/blogs/wonkblog/wp/2012/11/15/six-out-of-every-seven-doctors-agree-our-health-care-system-doesnt-work/

Chiropractic Treatment for Low Back Disc Herniation

(A review of the latest studies by Dr. George Cluen)

This case study reviews a non-surgical treatment path for a 60-year-old-male who was reasonably active and had a previous low back pain case before returning 15 months later with severe LBP and pain radiating from his right glute to his calf.

His presenting symptoms were:

• A 73 out of 100 on the Oswestry Low Back Questionnaire
• Numerical pain scale a 6-10
• Inability to stand up straight
• Altered gait
• Difficulty standing from a sitting position

His treatment path included chiropractic adjustments, traction therapy, and physiotherapy to be followed up by at-home exercises. An MRI and surgical consult showed a lateral L5, S1 disc rupture with L5 nerve impingement, but improvements at this point were enough to avoid surgery. A week later a CT guided nerve root steroid injection was performed. Within three days, the patient reported sleeping better, was able to return to work and drive.

After another 4 weeks of physical therapy the patient reported a 0 of 10 on the numerical pain scale and after another month the patient reported being able to return to light exercising and reported zeros across all pain scales. 

It should be mentioned that this patient is fit for their age, motivated and compliant with treatment. Either way, this study demonstrates the effectiveness of a non-surgical therapy mix from chiropractic to physical therapy and the assistance of a steroid injection.

Erhard RE, Welch WC, Liu B, Vignovi M. Far-lateral disk herniation: case report, review of the literature, and a description of non-surgical management. Journal of Manipulative and Physiological Therapeutics 2004;27:e3.

Spinal Cord Canal Narrowing During Whiplash

(A review of the latest studies by Dr. George Cluen) 

The upper cervical spine is exposed to tremendous forces during rear end collision, even when speeds are under 10 miles an hour. Research shows that ligaments can be stretched or torn, the muscles can be strained, and a new study from Yale shows that the nerves and spinal canal may also be at risk.

In this study, the author studied the biomechanics of a cadaver's cervical spine during a simulated whiplash motion. The spine was subjected to three types of tests: A crash of 7 mph with no head restraint, an active head restraint, and a modern whiplash protection system (like that of the Mercedes Benz M class models 2005 and newer.) The cervical canal houses the spinal cord, this area and the foraminal space was computed during each impact while researchers looked for evidence of spinal canal narrowing.

The study found that "Average peak canal and foramen narrowing could not be statistically differentiated" between the three types of tests.

The study concludes:

"While lower cervical spine cord compression during a rear crash is unlikely, our results demonstrated foraminal kinematics sufficient to compress spinal ganglia and nerve roots. Future anti-whiplash systems designed to reduce cervical injury may reduce radicular symptoms in whiplash patients."

Non-Scientist Translation: 

7 mph is enough to compromise the space around the spinal cord and the connecting nerves momentarily, damage can be done.

This study shows that further seat design developments are needed and even with advanced head restraint technology, injury from rear end collisions is still possible.



Ivanic PC. Cervical neural space narrowing during simulated rear crashes with anti-whiplash systems. European Spine Journal 2012; January 24; Epub before print.

Physical Therapy VS. Self Care for Whiplash

(A review of the latest studies from Dr. George Cluen.)

Up to half of all whiplash patients are plagued with chronic symptoms, and ongoing research seeks to identify affordable, effective methods of preventing chronic pain. The standard treatment for whiplash often includes comprenhensive, long term physical therapy. While these treatments have been shown to be beneficial, researchers from the University of Australia wondered if patients could get some of the same benefits with more minimal visits and an at-home exercise program.

What they discovered was, patient education coupled with at-home exercise programs, can be equally as effective as longer, more intensive physical therapy treatments are needed. The results showed that healthcare costs could potentially be reduced and those in chronic pain could reduce their appointment load.

The study included 172 patients suffering from whiplash after an auto accident who were randomly assigned to either a physiotherapy or an advice-only group. The patients in a professional treatment path were given 20 one-hour physical therapy sessions over the course of 12 weeks. The second group received a single 30 minute session of patient education and physiotherapy, along with the at-home exercise program. After 14 weeks of care, there were no clinically significant differences between the two groups. (Note that emotional burden or any other adaptive benefits were not measured. Let's not completely discount in person physical therapy.)

What we see a lot of within our industry that patients reflect back to us within initial appointments, is that a path of drugging and physical therapy typically sums up the corrective steps before a surgery is recommended. At Auto and Work Injury Center, we educate patients about the full spectrum of alternatives and how they compliment each other. Research shows that when you combine chiropractic with physiotherapy, recovery takes on a new momentum. Chiropractic can reduce symptoms for 93% of whiplash patients, and research also shows that patients receiving chiropractic adjustments for neck pain have lower medical costs and speedier recovery compared to patients seeing only a physician or physiotherapist alone. 



References

MichaleffZA, et al. Comprehensive physiotherapy exercise programme or advice for chronic whiplash (PROMISE): a pragmatic randomized controlled trial. The Lancet 2014; pii S0140-6736(14)60457-8. doi:10.1016/S0140-6736(14)60457-8.http://www.ncbi.nlm.nih.gov/pubmed/24703832

Woodward MN, Cook JCH, Gargan MF, Bannister GC, Chiropractic Treatment of chronic 'whiplash' injuries. Injury: International Journal of Care of the Injured 1996;27(9):643-645

Korthals-de Bos IB, et al. Cost Effectiveness of physiotherapy, manual therapy, and general practitioner. British Medical Journal 2003. doi: http://dx.doi.org/10.1136/bmj.326.7395.911. 

PTSD Tied to Chronic Pain After Auto Injury

 (A review of the latest studies from Dr. George Cluen)

Post traumatic stress disorder, although typically conjuring images of soldiers in shell shock, is becoming an increasingly documented concern after auto accidents. Unfortunately, it doesn't take a major car crash to forever alter a patient's psychological health. Research shows that even patients with mild injuries can show signs of PTSD. Now, a new study from the journal of Rheumatology indicates that PTSD is the biggest predictor of poor quality of life after an auto collision.

Prior to adjusting for socio-demographic characteristics, these results showed that 56% of whiplash patients reported non-recovery one year after the accident, compared to 43% of patients with other mild injuries. Whiplash patients were also more likely to report their symptoms negatively impacted their occupation status (31% versus 23%). These differences were not considered significant however after adjusting for socio-demographics such as gender, family, age, and education level.

What did hold true after adjusting for other stress factors, was the effect PTSD has on chronic pain. Patients with PTSD reported a two-fold increase in residual pain 12 months after the accident and a subsequent reduced quality of life.

These findings demonstrate that identifying and treating PTSD in auto injury patients is vital for preventing persistent pain. Finding healthcare providers that are both sensitive to the emotional needs as much as the physical needs is imperative for relief. At Auto & Work Injury Center we strive to educate our patients about approaching healing in way that addresses all three planes of the injury (the physical, emotional and energetic plane) and we offer supportive programs for this.



Reference

Hours M, et al. One Year After Mild Injury: Comparison of Health Status and Quality of Life between Patients with Whiplash Versus Other Injuries. Journal of Rheumatology 2013.10.3899/jrheum.130406