The problems for homeopathy in Germany do not seem to stop. Recently, the German health minister announced that he will look at the issue of reimbursement of homeopathy. Now, an article in the Deutsche Apotheker Zeitung (German Journal for Pharmacists) critically discussed the question of the place of homeopathy in German pharmacies. At present, pharmacies are the only places that are allowed to sell homeopathic preparations. This undoubtedly gives them a veneer of respectability; many consumers seem to feel that, if homeopathic preparations are only available in pharmacies, they must be well-tested and effective.
But recently, more and more German pharmacists have been pointing out that homeopathy is ineffective nonsense. A journalist who had listened to the advanced training “Homeopathy Highlights” of the Westphalia-Lippe Chamber of Pharmacists, he subsequently confronted the Chamber with the controversial contents of this advanced training event. The Chamber then declared that it would “no longer offer any refresher seminars on the subject of homeopathy with immediate effect” and that the speaker would also no longer work for it.
And now, the Berlin Chamber of Pharmacists wants the pharmacy community to distance itself from homeopathy as a scientifically recognized and evidence-based drug therapy. With its motion, the Chamber wants to achieve that the title “Naturopathic Medicine and Homeopathy” of the training regulations is replaced by the title “Phytopharmacy and Naturopathy”. The justification states: “The permission to use the title ‘pharmacist for naturopathic treatment and homeopathy’ by the state chambers of pharmacists suggests that homeopathy is a scientifically recognized and evidence-based drug therapy”.
I think it is time that German pharmacists remind themselves that they are more than shopkeepers; they are healthcare professionals who have an ethical duty. I have discussed this issue often enough. If you are interested, here are a few of my posts on this subject:
- Pharmacists must advise customers that homeopathic remedies lack evidence
- “Pharmacists should not sell or dispense homeopathic products”
- German pharmacists fail their customers when advising them on homeopathy
- Pharmacists put themselves at risk by selling homeopathic remedies
- Pro and Contra: should UK community pharmacists sell homeopathic remedies?
- Pharmacists’ responsibilities vis a vis alternative medicine: the violation of healthcare ethics continues.
- It is “disappointing that some pharmacists are still stocking homeopathy products”
- Pharmacists: to sell quackery means you are quacks – or have I got that wrong?
- Pharmacists must use their professional judgement to prevent the supply of homeopathic remedies
It is high time that German pharmacists do the right thing!
If you go on Twitter you will find that chiropractors are keen like mustard to promote the idea that, after a car accident, you should consult a chiropractor. Here is just one Tweet that might stand for hundreds, perhaps even thousands:
Recovering from a car accident? If you have accident-related injuries such as whiplash, chiropractic care may provide relief. Treatments like spinal manipulation and soft tissue therapy can aid in your recovery.
In case you don’t like Twitter, you could also go on the Internet where you find hundreds of websites that promote the same idea. Here are just two examples:
A frequent injury arising from an automobile accident … is whiplash. After an accident, a chiropractor can help treat resulting issues and pain from the whiplash… Proceeding reduction in swelling and pain, treatment will then focus on manipulation of the spine and other areas.
The primary whiplash treatment for joint dysfunction, spinal manipulation involves the chiropractor gently moving the involved joint into the direction in which it is restricted.
There is no question, chiropractors earn much of their living by treating patients suffering from whiplash (neck injury caused by sudden back and forth movement of the neck often causing neck pain and stiffness, shoulder pain, and headache) after a car accident with spinal manipulation.
There are two not mutually exclusive possibilities:
- They think it is effective.
- It brings in good money.
I have no doubt about the latter notion, yet I think we should question the first. Is there really good evidence that chiropractic manipulations are effective for whiplash?
When I was head of the PMR department at the University of Vienna, treating whiplash was my team’s daily bread. At the time, our strategy was to treat each patient according to the whiplash stage and to his/her individual signs and symptoms. Manipulations were generally considered to be contra-indicated. But that was about 30 years ago. Perhaps the evidence has now changed. Perhaps manipulation therapy has been shown to be effective for certain types of whiplash injuries?
To find out, I did a few Medline searches. These did, however, not locate compelling evidence for spinal manipulation as a treatment of any stage of whiplash injuries. Here is an example of the evidence I found:
In 2008, the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders (Neck Pain Task Force) found limited evidence on the effectiveness of manual therapies, passive physical modalities, or acupuncture for the management of whiplash-associated disorders (WAD) or neck pain and associated disorders (NAD). This review aimed to update the findings of the Neck Pain Task Force, which examined the effectiveness of manual therapies, passive physical modalities, and acupuncture for the management of WAD or NAD. Its findings show the following: Evidence from 15 evaluation studies suggests that for recent neck pain and associated disorders grades I-II, cervical and thoracic manipulation provides no additional benefit to high-dose supervised exercises.
But this is most puzzling!
Why do chiropractors promote their manipulations for whiplash, if there is no compelling evidence that it does more good than harm? Again, there are two possibilities:
- They erroneously believe it to be effective.
- They don’t care but are in it purely for the money.
Whatever it is – and obviously not all chiropractors would have the same reason – I must point out that, in both cases, they behave unethically. Not being informed about the evidence related to the interventions used clearly violates healthcare ethics, and so does financially not informing and exploiting patients.
It has been reported that the US Insurer ‘State Farm’ is fighting a fraudulent scheme that has been exploiting New Jersey’s personal injury protection (PIP) benefits law since 2014. The insurer is seeking to recover $2.6 million in what it claims are fraudulent auto injury claims and a declaratory judgment that it need not pay any further claims submitted by the providers involved in the alleged scheme.
State Farm’s suit accuses 12 chiropractic and spine clinics and doctors of fraud, unjust enrichment, and violations of the New Jersey Insurance Fraud Prevention Act. The insurer alleges these providers used a “predetermined protocol” for all patients and a patient referral system for services that were either not performed or were not medically necessary for the individual patients. Instead, the services were carried out to enrich the defendants by exploiting the patients’ eligibility for PIP benefits, according to the complaint.
The suit accuses the providers of failing to legitimately evaluate patients to determine the true nature of their injuries and of reporting the same or similar findings for all patients to justify a predetermined course of treatment that was substantially the same for all patients. Part of the “predetermined protocol” for patients with soft-tissue injuries of the neck and back consisted of
- hot and cold packs,
- chiropractic manipulations,
- mechanical traction,
- physical medicine and rehabilitation,
- and manual therapy.
These treatments were administered to almost every patient on almost every visit, regardless of each patient’s unique circumstances and needs, according to the complaint. The chiropractors are also accused of referring patients to diagnostic clinics, some allegedly illegally owned by the chiropractors, for an “unnecessary and predetermined course of pain management and invasive treatments” including injections. State Farm says they would submit false documentation for each case representing that the treatments were legitimately performed and medically necessary.
The 80-page complaint details case after case where the patient’s responses to questions and tests were the same or similar, allegedly serving as a “pretext to justify” the chiropractors’ wide range of treatments. The defendants in the complaint filed in U.S. District Court for New Jersey are:
- Tri-County Chiropractic and Rehabilitation Center,
- Robert Matturro, D.C.,
- Advanced Spine and Pain Management,
- Varinder Dhillon, M.D.,
- Nicholas Rosania, D.C.,
- Bloomfield UAI,
- Dov Rand, M.D.,
- Primary Medical Services,
- Louis J. Citarelli, M.D.,
- Chiro Health Center P.C.,
- Marc Matturro, D.C.
- Marco Tartaglia, M.D.
This story made me wonder: which of the listed treatments
- hot and cold packs,
- chiropractic manipulations,
- mechanical traction,
- physical medicine and rehabilitation,
- and manual therapy
would ever be indicated for patients with soft-tissue injuries of the neck and back? Or more specifically, are chiropractic manipulations indicated or contra-indicated for such problems following a car accident? I fail to see any sound evidence that they are effective. If I am correct, should insurance companies not sue all chiropractors who routinely use manipulations for such cases? If the answer is YES, the sum of 2.6 million might need to be increased by several orders of magnitude.
In its homeland, Germany, homeopathy had a free ride for many decades. Only in the last 5 years or so, has a vocal opposition emerged of people who argue that disproven treatments should not be paid for by the public purse. Most political parties have been clever enough to pick up on the changed attitude of the German people and have thus joined more or less openly into the growing criticism of homeopathy. One noteable exception has been the German Green Party who have a long tradition of being in favour of all things alternative. Now this seems to have finally changed.
The ‘Frankfurter Allgemeine Zeitung’ (FAZ) just reported that the German Green Party no longer backs homeopathy. After many years of supporting homeopathy and other so-called alternative medicines (SCAMs) and after years of agonising about it, the party has now decided to side with reason, science and evidence. Last Sunday, on their annual party conference, the Greens have voted to back a statement according to which the German health insurers should only reemburse treatments which are “medically reasonable and justifiable and which are supported by evidence of efficacy that is scientifically proven”. Even though they did not mention it in the text, it is understood that the they meant foremost homeopathy.
The Greens rejected a suggestion to go even further and would have stated that a treatment should not be covered, if “its efficacy has not been scientifically proven to be better than a placebo.” They also did not agree to an application by the homeopathy lobby to state that would have allowed the reembursement of homeopathy.
For those of my readers who read German, here is the short article from the FAZ.
Die Grünen haben in ihrem langwierigen Streit um die Homöopathie eine Lösung gefunden. Der Parteitag billigte am Sonntag eine Formulierung, derzufolge nur noch Leistungen von den gesetzlichen Krankenkassen übernommen werden sollten, „die medizinisch sinnvoll und gerechtfertigt sind und deren Wirksamkeit wissenschaftlich erwiesen ist“. Damit gehen die Grünen auf Distanz zu Homöopathie als Kassenleistung – auch wenn die umstrittene Heilmethode in dem Text nicht ausdrücklich genannt wird.
Eine noch weitergehende Formulierung, derzufolge Leistungen, deren Wirksamkeit über den Placeboeffekt hinaus nicht wissenschaftlich bewiesen sei, explizit als Kassenleistung ausgeschlossen werden sollten, fand aber keine Mehrheit.
Research by a reputable independent research company done for Securivita a German insurance company shows that those receiving homeopathic care were much better off. Over 15,700 patients were involved in the study which also used a comparison group.
The study showed that in a wide range of patients with various pathological problems that if they had homeopathic care they faired dramatically better than those just getting conventional medicine.
Children having homeopathy treatment from birth, were particularly healthier and with less problems. Over the three year study period, the number of children needing antibiotics decreased by 16.7 per cent in the homeopathy group, whereby it increased by 73.9 per cent in the conventional medical comparison group!
The number of hospitalizations in the comparison group increased by 32.6 per cent whereby in the homeopathy treatment group it decreased by 9.8 per cent!
Adults and children treated homoeopathically had dramatic improvements in allergies, dermatitis, asthma, just to name a few.
These are just a few examples of the remarkable benefits of homeopathic treatment outlined in the study by by the Leipzig Health Forum , an independent analytical institute specializing in health services conducted for Securvita Krankenkasse Insurer.
“We don’t need fewer, but more homeopathic doctors who will continue on this successful path,” says Götz Hachtmann , director of the health insurance company Securvita.
The study is in German and can be found here.
Blessed are those who don’t read German (at least in this instance)!
As I am not amongst the blessed, I ought to tell you a bit about the ‘massive’ study. The OHR, the ‘OFFICIAL HOMEOPATHIC RESOURCE’ (btw what makes the OHR ‘official’?) claims that the study can be found here. The OHR is evidently not well enough resourced for translating the German text into English; if they were, they would know that the link goes not to a ‘study’ but to some kind of a glossy marketing brochure about the ‘study’ (there is no actual published scientific paper on the ‘study’). It provides hardly any relevant information; all we learn is that 15 700 individuals who regularly consulted homeopathic physicians were compared over a three year period to an equally sized control group who did not consult homeopathic doctors… And that’s essentially it! No further relevant details are offered.
By contrast, quite a bit of information is offered about the findings, for instance:
- In the homeopathy group, the hospitalisation rate of depressive patients dropped by 10%, while it increased in controls by 33%.
- The days off work dropped by 17% vs an increase in controls of 17%.
- The use of antibiotics decreased by 17% vs an increase of 74%.
And how do they explain these differences?
Yes, you guessed it:
they are due to homeopathy!
One does not need to have a perfumer’s nose to smell a few badly decomposing rats here, for example:
- We do not learn how many variables were tested in this ‘study’. Therefore, it is likely that the ‘results’ provided are the positive ones, while the not so positive potential effects of homeopathy remained unmentioned. Perhaps the death rate was higher in the homeopathy group? Perhaps they suffered more heart attacks? Perhaps they had a lower quality of life? Perhaps they caused more costs? Perhaps they committed more suicides? etc. etc.
- Even more obvious is the stench of selection bias. The individuals in the homeopathy group were clearly different from the controls to start with. They might have been more health conscious. They clearly were more cautious about antibiotics. They might have been of better general health. They might have been younger. They could have contained more women. They might have been more afraid of going into a hospital. They might have been keener to attend work. In fact, the only variable in which the two groups were comparable is sample size.
Even if we eventually we see this ‘study’ published in a peer-reviewed journal with full methodological details etc., it will not allow even the smartest spin-doctor to establish cause and effect. Its findings would not be more conclusive than those of previously discussed attempts to produce positive evidence for homeopathy. The ‘positive’ findings could have been the result of hundreds of causes, none of which are related to homeopathy.
In a nutshell: this new German ‘study’ is a textbook example for arguing in favour of conducting proper research rather that rampant pseudo-research.
But I must not always be so negative!!!
So, let me try to point out the positive sides of this ‘study’:
The ‘massive independent study’ is a true masterpiece of advertising and marketing for both Securivita and homeopathy.
Well done guys!
I am proud of you!
- That’s exactly the stuff needed for successfully misleading the public.
- That’s precisely the info required to increase your cash flow.
- That’s helpful ‘research’ for convincing politicians.
- That’s definitely the type of baloney to impresses the Ullmanns of this world.
- That’s even the sort of ‘science’ which the ‘OFFICIAL HOMEOPATHIC RESOURCE’ cannot recognise for what it truly is:
This is a somewhat unusual post.
I do not normally dwell on personal anecdotes or experiences – but this one might be relevant, and it is absolutely true.
About 7 or 8 years ago (we had just published our book Trick or Treatment), I was invited to a meeting of health insurers. Not just any old meeting, but a top-notch conference where many of the world’s most influential executives of large insurance companies were gathered. It took place in one of the most luxurious hotels of Istanbul. The most prominent speaker was the brother of France’s president Sarkozy (who flew in by helicopter and came with two body-guards). He began his lecture by stating “You of course all know me because I have a famous sister in law.”
I did not have such a witty opening phrase for my talk. My task was to review the evidence for and against the major alternative therapies (at the time, I did such lectures regularly). My audience of about 300 people listened politely to what I had to say and, during, question time, they made some relevant comments. Altogether, it was a good and well-received lecture.
But the interesting bit came later.
Over coffee, I was surrounded by people who came to me and said something like this: “We know the evidence, of course, and we know how flimsy it is, particularly for homeopathy. But we still pay for it, because the competition does it too. We cannot be seen to offer less than they do. This is purely a commercial decision about being seen to be competitive.”
Such honesty came as a surprise to me. I had expected that they were well-informed about the evidence; after all, they were in charge of huge companies selling health insurances. Not knowing about the evidence would have been negligent. But I had not expected they would volunteer their motives quite so openly. I got the impression that they were trying to justify their nonsensical actions without seeming irrational. In a way, they seemed to say: ‘Such treatments might not work for the patient, but they do work for us’.
I remember suggesting to some of these executives that they could even be more competitive, progressive and ethical by telling their customers that they took better care of their money that the competition by NOT paying for ineffective treatments. Such remarks resulted in blank faces or vague smiles. I felt my audience had not really understood the opportunity. Being honest, transparent and evidence-based was evidently not understood as a viable marketing tool.
As I said, this was almost a decade ago
… lots has happened since.
I wonder whether the message might be more attractive today.
Chiropractors (and other alternative practitioners) tend to treat their patients for unnecessarily long periods of time. This, of course, costs money, and even if the treatment in question ever was indicated (which, according to the best evidence, is more than doubtful), this phenomenon would significantly inflate healthcare expenditure.
This sounds perfectly logical to me, but is there any evidence for it? Yes, there is!
The WSJ recently reported that over 80% of the money that Medicare paid to US chiropractors in 2013 went for medically unnecessary procedures. The federal insurance program for senior citizens spent roughly $359 million on unnecessary chiropractic care that year, a review by the Department of Health and Human Services’ Office of Inspector General (OIG) found.
The OIG report was based on a random sample of Medicare spending for 105 chiropractic services in 2013. It included bills submitted to CMS through June 2014. Medicare audit contractors reviewed medical records for patients to determine whether treatment was medically necessary. The OIG called on the Centers for Medicare and Medicaid Services (CMS) to tighten oversight of the payments, noting its analysis was one of several in recent years to find questionable Medicare spending on chiropractic care. “Unless CMS implements strong controls, it is likely to continue to make improper payments to chiropractors,” the OIG said.
Medicare should determine whether there should be a cut-off in visits, the OIG said. Medicare does not pay for “supportive” care, or maintenance therapy. Patients who received more than a dozen treatments are more likely to get medically unnecessary care, the OIG found, and all chiropractic care after the first 30 treatment sessions was unnecessary, the review found. However, a spokesperson for US chiropractors disagreed: “Every patient is different,” he said. “Some patients may require two visits; some may require more.”
I have repeatedly written about the fact that chiropractic is not nearly as cost-effective as chiropractors want us to believe (see for instance here and here). It seems that this evidence is being systematically ignored by them; in fact, the evidence gets in the way of their aim – which often is not to help patients but to maximise their cash-flow.
According to Wikipedia, Swiss state insurance funding of homeopathy and four other alternative therapies had been withdrawn after a review in 2005, and a 2009 referendum vote called for state backed health insurance to once more pay for these therapies. In 2012 the Swiss government reinstated them for a trial period until 2017, pending an independent investigation of the efficacy and cost-effectiveness of the therapies. The rules for the registration of homeopathic remedies without a concrete field of application are more liberal in Switzerland than they are in member countries of the EU. For homeopathic medicines based on well-known low-risk substances, Swissmedic, the regulatory authority, offers inexpensive registration by means of a simplified electronic registration procedure.
Several weeks ago, I have commented on the remarkable position of alternative medicine in Switzerland. Now this website offers further information specifically on homeopathy in Switzerland:
According to a report jointly issued by the Swiss Federal Health Office and the Swiss State Secretariat for Economic Affairs (SECO), the annual expenses for homeopathic treatments and medications in Switzerland amount to roughly CHF 50 million and CHF 31 million, respectively. These numbers seem impressive, particularly if we consider how little each homeopathic remedy costs and how ineffective it is.
But the argument that homeopathy somehow defies scientific testing does not seem to die. For instance, SantéSuisse, the umbrella organisation of health insurers, argues that standardised methods used to test conventional treatments cannot be applied to homeopathy. “It would be unfair to homeopathy if we borrowed the methodologies from conventional therapeutic options when evaluating its effectiveness. The potential risk is that these systematic and internationally accepted methods of biomedical science go against the underlying principles of homeopathy,” said SantéSuisse spokesman Christophe Kämpf. I am afraid, he is talking complete tosh – and he should, of course, know better.
The Swiss Federal Health Office admitted in its press release at the end of March that “no evidence has so far been found to prove that complementary and alternative therapies”, including homeopathy, meet the standard criteria for “effectiveness, appropriateness, and costs.” And a Swiss health office spokesman, Daniel Dauwalder, explained that the decision “reflected the will of the people” in a 2009 referendum. “The health insurance system will cover the cost of alternative therapies according to the principle of trust,” Dauwalder explained. He added that, if the standards of effectiveness, suitability and economy are called into question, SantéSuisse have the right to deny payment.
The core of the issue centres on the questions
- How to ensure that the physical conditions of patients will not be compromised by unqualified, self-proclaimed clinicians?
- How can health insurers deal with the potential challenges?
The truth is, alternative treatments will not be unconditionally covered by the basic insurance policies which every Swiss resident must have. Only the costs of treatments administered by certified medical doctors will be considered. Otherwise, the costs incurred can only be reimbursed, if the person insured has purchased supplementary health coverage.
END OF QUOTE
That, however, does not mean that only doctors can practice homeopathy in Switzerland. Lay-homeopaths do exist in the form of Heilpraktiker. While it is true that the national health insurance only covers the treatment by medical doctors, some private health insurances also cover homeopathy by Heilpraktiker.
All this is very different from what some enthusiasts report about homeopathy in Switzerland. Probably the best example for someone obscuring the truth is (yet again) Dana Ullman who stated that “the Swiss government has determined that the very small doses commonly used in homeopathic medicine are both effective and cost-effective.” Little wonder, I might add, because Dana Ullman also keeps on referring to “a remarkable report on homeopathic medicine conducted by and for the government of Switzerland”. He does so despite having been told over and over again that the report in question is firstly utterly unreliable and secondly not by the Swiss government.
Why this odd insistence on disseminating wrong information? Is it because it is good for business, or because homeopaths are not capable of learning (otherwise they would not be homeopaths), or both?
The Subject of the German ‘Heilpraktiker’ has recently been the topic of one of my blog-posts. In Germany, it has been a taboo for decades, but now the ‘Frankfurter Allgemeine Zeitung’ (FAZ) have courageously addressed the problem. In today’s article, the FAZ reports that, Josef Hecken, the chair of the an organisation called ‘Selbstverwaltung im Gesundheitswesen’ (self-administration in healthcare), demands that “health-insurers should be forbidden to pay for treatments that are not supported by evidence.” Hecken, is also the chair of the Gemeinsamen Bundesausschusses, an umbrella organisation of doctors, insurers and hospitals which determines which services are paid for and which not. He stated that even paying for homeopathy out of your own pocket when treating diseases like cancer must be forbidden and stressed that “this is not about well-being but human lives.”
Hecken’s views are partly supported by Rudolf Henke, the chair of both a German doctor’s union and of the Marburger Bund, a union of hospitals: “the regulations regarding the Heilpraktiker have to be re-considered entirely… I do not believe it to be acceptable that Heilpraktiker are able to treat cancer patients.”
These remarks relate to the deaths that recently occurred in a clinic led by a Heilpraktiker. About two thirds of all German health insurers seem to pay for consultations with a Heilpraktiker. Vis a vis the fact that most of their treatments are not evidence-based, this situation seems intolerable and deeply unethical.
Hecken’s stance seems clear, rational and, in view of the popularity of homeopathy in Germany, even courageous: “The government should charge the ‘Gemeinsamen Bundesausschuss’ or another organisation with the task of conducting a meta-analysis on the evidence of homeopathy and then draw the appropriate conclusions… We have reached a point where we need a public discussion, and I am prepared to take the flack.”
Several investigations have suggested that chiropractic care can be cost-effective. A recent review of 25 studies, for instance, concluded that cost comparison studies suggest that health care costs were generally lower among patients whose spine pain was managed with chiropractic care. However, its authors cautioned that the studies reviewed had many methodological limitations. Better research is needed to determine if these differences in health care costs were attributable to the type of HCP managing their care.
Better research might come from the US ‘Centers for Medicaid and Medicare Services’ (CMS); they conduced a two-year demonstration of expanded Medicare coverage for chiropractic services in the treatment of beneficiaries with neuromusculoskeletal (NMS) conditions affecting the back, limbs, neck, or head.
The demonstration was conducted in 2005–2007 in selected counties of Illinois, Iowa, and Virginia and the entire states of Maine and New Mexico. Medicare claims were compiled for the preceding year and two demonstration years for the demonstration areas and matched comparison areas. The impact of the demonstration was analyzed through multivariate regression analysis with a difference-in-difference framework.
Expanded coverage increased Medicare expenditures by $50 million or 28.5% in users of chiropractic services and by $114 million or 10.4% in all patients treated for NMS conditions in demonstration areas during the two-year period. Results varied widely among demonstration areas ranging from increased costs per user of $485 in Northern Illinois and Chicago counties to decreases in costs per user of $59 in New Mexico and $178 in Scott County, Iowa.
The authors concluded that the demonstration did not assess possible decreases in costs to other insurers, out-of-pocket payments by patients, the need for and costs of pain medications, or longer term clinical benefits such as avoidance of orthopedic surgical procedures beyond the two-year period of the demonstration. It is possible that other payers or beneficiaries saved money during the demonstration while costs to Medicare were increased.
In view of such results, I believe chiropractors should stop claiming that chiropractic care is cost-effective.