health insurance
This article explores how the sociological concept of trust, both externally and internally, presents challenges to the legitimacy and credibility of the chiropractic profession. This ethnographic study consisted of systematic observation and interviews of 40 chiropractors in South Carolina from Fall 2016 to Fall 2017. Additionally, interviews were conducted with staff members, patients, and other medical providers, such as physicians, physical therapists, massage therapists, and representatives from the insurance industry, about their understanding and experiences with chiropractic medicine. Phone interviews were also conducted with deans and provosts at seven chiropractic colleges around the country.
In total, over 100 interviews and informal conversations occurred during the course of the project. All identifiers of participants and chiropractic colleges in the study were removed to ensure anonymity. Instead, pseudonyms were created that were known only by the author of the study. Additionally, data from the South Carolina Department of Labor, Licensing and Regulation was obtained to document changes in the number of chiropractors who are no longer in practice in the state between 2016 and 2017.
The data from this study suggests that there may be a number of trust issues between the public and chiropractors, between chiropractors and physicians, and among chiropractors themselves. For example, comments and observations from respondent interviews suggests many patients do not fully trust their provider. Additionally, physicians claim the reason for the lack of trust is due to the absence of any meaningful accountability measures to control rogue chiropractors and the wide variance in types of treatment they offer. Among chiropractors themselves, there appears to be an absence of trust, as many providers see their colleagues as competitors and potential threats.
Trust is a key component to the success of any social relationship. Given the inability or unwillingness of the chiropractic profession to hold members accountable for questionable practices, along with the perception that chiropractic treatments may not be effective, the public, patients, and the medical profession will likely continue to view chiropractic medicine with suspicion.
In the paper, the author (Robert Hartmann McNamara, Ph.D. Department of Criminal Justice ) makes several further valuable points:
- The need for autonomy is a critical component to understanding why so many providers are unwilling to allow their profession to be regulated. It also seems apparent that there is no collective conscience, no real sense of solidarity, and there remain questions about the trustworthiness of chiropractors by patients, the public, the medical community and even among chiropractors themselves.
- Chiropractors point to some level of persecution by insurance companies—indicating that others in medicine engage in inappropriate billing and fraud, but that insurance companies target chiropractors because of their limited ability to stand up to them. While there may be some truth to these criticisms, there is also evidence to indicate that the identification of chiropractors for audits may be justified. For example, in a 2016 report by the Office of Inspector General, a division of the U.S. Department of Health and Human Services, the agency responsible for overseeing health programs like Medicare and Medicaid, of all the providers who were cited for fraud, abuse, and errors in Medicare billing, chiropractors were overwhelmingly the largest set of offenders. In fact, the report showed that for 2013, an estimated $359 million in Medicare payments for chiropractic services did not comply with Medicare requirements. Thus, one of the primary reasons for the creation of Medicare accountability teams is because the data indicated that chiropractors are at the center of the problem when it comes to inaccurate and fraudulent billing for treatment.
- The sociological literature points out that the development and enhancement of trust is a crucial component to establishing and sustaining social relationships, and thereby creating a sense of solidarity and morality. To the extent that chiropractors can better foster the development of trust, they will likely earn the respect of their colleagues in medicine and not be seen in a negative light by the public or their patients. This is accomplished, of course, by setting reasonable expectations of what chiropractors can legitimately do and holding the members of the profession accountable in adhering to those standards.
All of this ties in well with many of my previous posts on chiropractic. I might therefore just add this:
What can you expect from a profession that was founded by one of the most infamous snake oil salesmen in US history?
Mehmet Oz has featured regularly on this blog, e.g.:
- Donald Trump nominated SCAM promoter, Mehmet Oz, to lead the Centers for Medicare and Medicaid Services (CMS)
- Columbia University cut ties with Dr. Mehmet Oz … or did they?
- Quackery promoter, Dr. Mehmet Oz, is running for the U.S. Senate
- Trump, Kennedy and Oz just announced plenty of untruths about autism and its treatment
Currently, he serves in Trump’s administration as “Administrator of the Centers for Medicare & Medicaid Services” (CMS). He also is (or was?) a “Global Advisor & Stakeholder” for the company ‘iHerb’, and was appointed to that role in 2023. The company itself is a global e-commerce platform that was founded in 1996 and has its headquarters in California. iHerb specializes in health and wellness products. iHerb’s mission is to make health and wellness products accessible to everyone. The company operates as a direct-to-consumer retailer. iHerb sells a wide variety of products, including:
- Vitamins, minerals, and supplements (VMS)
- Sports nutrition
- Beauty and personal care products
- Grocery items
- Baby and pet care products
Crucially, iHerb sells several products with leucovorin, i.e. folinic acid, the drug that, even though unproven, is now officially used for autism in the US. As far as I can see, most of the products that Oz promotes are not based on sound evidence.
Based on available information from a financial disclosure analysis, Mehmet Oz’s work as an advisor for ‘iHerb’ has earned him as much as $25 million in company stock. The disclosure, which lists asset values in ranges rather than precise figures, shows that this stock was part of his overall financial portfolio.
Several experts have raised concerns that Oz’s financial interests in various healthcare and supplement companies, including iHerb, could create a conflict of interest. As the Administrator of the Centers for Medicare and Medicaid Services (CMS), a position that oversees a vast budget and a significant portion of the U.S. healthcare system, his past and present ties to the industry have been highlighted as potential issues. The concern is that a government official in such a powerful position could use their influence to benefit their own financial holdings or those of companies they are affiliated with. This is especially relevant given that Medicare Advantage, a program he would oversee, allows customers to use prepaid cards to buy over-the-counter medicines and supplements—a market that companies like iHerb are in.
Mehmet Oz has publicly disclosed his financial interests. A financial filing shows that his investments in ‘iHerb’ represented one of his largest financial holdings. In a filing with the Office of Government Ethics, Oz has committed to divesting his equity holdings in healthcare companies, including his iHerb stock, within 90 days of confirmation. He has also pledged to resign from his advisory role with ‘iHerb’. The Office of Government Ethics has stated that based on its review, it believes Oz is in compliance with applicable laws and regulations concerning conflicts of interest. The situation remains a point of public discussion and has drawn the attention of consumer advocacy groups. For example, the group Public Citizen has asked the Federal Trade Commission (FTC) to investigate whether Oz’s social media posts promoting iHerb violated FTC guidelines on undisclosed endorsements, as his posts did not always clearly state his financial connection to the company.
Based on current public information, there are serious questions and concerns about whether Mehmet Oz has divested all of his interests as pledged, particularly with respect to his holdings in ‘iHerb’. The latest publicly available filings detail his assets and his intent to divest, but do not show the final completed sale. iHerb itself has publicly stated that the company is no longer affiliated with Dr. Oz and is not working with him or the administration. However, this does not independently confirm the liquidation of his personal vested stock.
A failure to timely follow the pledge can and should trigger a chain of events that leads to serious civil and criminal penalties, as well as significant political repercussions.
As predicted in my post yesterday, Donald Trump, Mehmet Oz and Robert F Kennedy Jr made an announcement on Monday at the White House, advising pregnant women to avoid taking paracetamol and claiming that it heightens the risk of autism. As pointed out in yesterday’s post, this assertion is not based on reliable evidence.
Specifically, like a trio of charlatans, they misled the public by claiming that the use of paracetamol during pregnancy is linked to autism and that the US Food and Drug Administration (FDA) would be advising doctors to minimize its use. Also as predicted, they promoted leucovorin as an autism treatment, a claim equally not supported by reliable evidence. Finally, Trump repeated long-debunked claims that ingredients in vaccines or timing shots close together could contribute to rising rates of autism in the U.S., without providing any medical evidence.
Several medical organizations, including the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics, swiftly condemned these statements as “irresponsible” and not backed by sound scientific evidence. They emphasized that a causal link between paracetamol and autism has not been established. New York University bioethicist Art Caplan said it was “the saddest display of a lack of evidence, rumors, recycling old myths, lousy advice, outright lies, and dangerous advice I have ever witnessed by anyone in authority.” Health regulators in other countries, such as the UK and Australia, also reiterated their guidance that paracetamol is safe for use during pregnancy. The overwhelming consensus among the global scientific community is that paracetamol remains the safest pain relief option for pregnant women when used as directed. Untreated pain and fever during pregnancy can pose more significant risks to both the mother and the unborn baby.
Dr. Mehmet Oz, who is of course well-known for making millions by promoting every form of quackery on the planet, discussed the decision to have government health programs like Medicaid and the Children’s Health Insurance Program (CHIP) cover the cost of leucovorin, i.e. folinic acid, for the treatment of autism. He stated that this move would ensure access to the drug for millions of children and that he expected private insurance companies to follow suit. Yet, the use of leucovorin for autism is considered highly controversial, as pointed out in yesterday’s post. It is not widely accepted by the scientific community and, if effective at all, can work only for a small sub-set of autistic patients. Even for them, it is not a cure and would only be helpful for certain symptoms.
So, why mislead the public in this way?
One reason could be that the company, “iHerb” for which Mehmet Oz is “Global Advisor & Stakeholder”, sells no less than 4 supplements with a version of leucovorin. The announcement from the White House and the administration’s push for the drug therefore raise serious questions and concerns about conflicts of interest and corruption.
- United States: $12,474 per capita
- Germany: $6,191 per capita
- Canada: $6,207 per capita
- Australia: $6,597 per capita
- France: $6,517 per capita
- Italy: $3,066 per capita
- United Kingdom: $5,139 per capita.
Extraordinary! The US spends 4 times more than Italy? Does that correlate with life expectancy? The short answer is NO! Here are the life expectancy averages for men and women (data from 2023/4):
- United States
- Men: 75.8 years
- Women: 81.1 years
- United Kingdom
- Men: 79.54 years
- Women: 83.33 years
- Canada
- Men: 80.74 years
- Women: 85.03 years
- Australia
- Men: 82.43 years
- Women: 85.97 years
- Germany
- Men: 79.21 years
- Women: 83.88 years
- France
- Men: 80.6 years
- Women: 86.2 years
- Italy
- Men: 81.75 years (or 81.94 years according to some sources)
- Women: 85.87 years (or 86.01 years according to some sources)
So, the United States have the highest per capita healthcare costs but ranks lowest in life expectancy. The UK has lower healthcare costs per capita while achieving higher life expectancies. Germany has higher healthcare costs per capita and relatively high life expectancies. France has moderate healthcare costs per capita ($6,400 and $6,600) and higher life expectancies.
How can this be? In the hope of getting a glimps of an answer, I searched the costs for a few specific interventions (where data were available for the listed countries). Here we go.
The estimated costs of a flu jab in various countries:
- United Kingdom:
Free for people aged 65 and over, pregnant women, those with certain long-term health conditions, and healthcare workers on the NHS.
Otherwise, costs range from £9.95 to £21.95 at pharmacies.
- United States:
Costs vary depending on the provider, insurance coverage, and type of flu vaccine.
Private sector costs per dose range from $19.48 to $32.45 for standard flu vaccines and $73.36 to $79.17 for high-dose vaccines for seniors.
CDC contract prices per dose range from $13.92 to $22.21 for standard flu vaccines and $56.40 to $56.45 for high-dose vaccines for seniors.
- Germany:
Statutory health insurance typically covers the cost of flu vaccinations for people 60 and older, certain chronic conditions, and some other risk groups.
Without insurance or for non-covered groups, prices can range from €15 to €35 per shot, but exact costs are not readily available.
- Canada:
Flu shots are often covered by provincial health plans for seniors and those with certain health conditions.
Without coverage, prices can range from $20 to $40 CAD per shot, but exact costs vary by province and provider.
- Australia:
Free flu vaccinations are available for people aged 65 and over, Aboriginal and Torres Strait Islander people aged 6 months and over, pregnant women, and people with certain medical conditions under the National Immunisation Program.
Otherwise, costs can range from $15 to $30 AUD per shot at some pharmacies and clinics.
- France:
Flu vaccinations are covered by the national health insurance for people 65 and older and those with certain health conditions.
For others not covered, prices can range from €10 to €25 per shot, but exact costs are not readily available.
- Italy:
Free flu vaccinations are offered to people 65 and older, pregnant women, and those with certain health conditions.
For others, costs can range from €15 to €30 per shot, but exact costs are not readily available.
The costs of a simple eye test in various countries:
- United Kingdom:
Basic Eye Test: £25-£30, depending on the optician.
Free Eye Test: Eligible for those under 16, over 60, with diabetes or glaucoma, or receiving certain benefits.
- United States:
Average Cost: around $100, but can range from $50 to $250.
- Canada:
Specsavers Canada: $99, including an OCT scan, at participating locations.
Free Eye Test: Eligible seniors have their eye exam costs covered by provincial healthcare.
The estimated costs for simple and surgical molar extractions:
- Germany
Simple extraction: around $113
Surgical extraction: costs may vary, but Germany has an average dental procedure cost of $210
- United Kingdom
Simple extraction: $495
Surgical extraction: $2,930
- USA
Simple extraction: $200
Surgical extraction: $4,000
- Canada
Simple extraction: $150-$198
Surgical extraction: $2,000
- Australia
Simple extraction: $160-$350
Surgical extraction: $2,500
- France
Simple extraction: around $126 (tooth extraction average cost)
Surgical extraction: costs may vary
- Italy
Simple extraction: $97
Surgical extraction: costs may vary, but Italy has an average dental procedure cost of $173.
The estimated costs of an acupuncture session in different countries:
- United States: $60-$150, with initial visits ranging from $100-$150 and cosmetic acupuncture sessions costing $120-$200. Community acupuncture clinics offer more affordable options at $25-$50 per session.
- Canada: $95-$135, with prices higher in cities like Toronto and Vancouver.
- United Kingdom: £40-£70 per session, with first sessions potentially costing $88-$100 due to consultations.
- Australia: AUD 75-AUD 120 per session, depending on location and practitioner experience.
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Do these data make sense?
I am not sure.
If anything, they seem to suggest that the US is very poor value for money when it comes to healthcare. Of course, this is all going to change now that Trump and Kennedy are in charge …
… SADLY, NOT FOR THE BETTER, I’M AFRAID!
he German press reported yesterday that the country’s Health Minister Karl Lauterbach plans to remove homeopathic treatments from the benefits catalog of statutory health insurance companies. “Services that have no medically verifiable benefit should not be financed from contribution funds,” states a recommendation paper by the minister. “For this reason, we will remove the option for health insurance companies to include homeopathic and anthroposophic services in their statutes, thereby avoiding unnecessary expenditure by health insurance companies.” However, private supplementary insurance should still be possible.
Lauterbach had already announced last year that he would review the funding of homeopathic treatments. “Although homeopathy is not significant in terms of expenditure, it has no place in a science-based healthcare policy,” the SPD politician told “Der Spiegel” last October. The measure would save merely a maximum of ten million Euros. This is because firstly not all health insurance companies offer the option to reimburse homeopathy, and secondly, because not that many Germans use homeopathy.
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Before I was joined about a decade ago by a group of excellent and effective skeptics, I seemed to be a lone, lost voice in Germany cautioning against the misunderstanding that homeopathy and anthroposophical medicine were backed by evidence. Thus, you probably think that I am rejoicing at this spectacular success. At first glance, it does indeed seem to be great news for those who support evidence-based medicine. But sadly, I also have second thoughts.
We should, I think, be concerned that Lauterbach intends to leave homeopathic and anthroposophical remedies reimbursible via private supplementary insurance. Most Germans have such insurance which means that, despite Lauterbach’s grand announcement, very little will probably change. Homeopathy and anthroposophic medicine, both pure placebo therapies, will still be able to pretend to be real medicine.
Moreover, we should be concerned about Lauterbach’s reasoning. It is, of course, laudable to point out that homeopathic and anthroposophic remedies are not demonstrably effective. But clearly, this is only half of the truth. The full truth is that they are based on totally ridiculous assumptions, that, in other words, they fly in the face of science. Only if we manage to get this message across, will we inform the public responsibly, in my view.
A total ban then? No, personally, I don’t want to ban homeopathic or anthroposophical remedies. If someone loves esoteric nonsense or placebos, he/she should, in my view, be able to buy them. But he/she should use their own money for the purchase. We should remember that wasting notoriously scarce public funds from either statutory or private health insurances is not just uneconomical but foremost unethical.
The U.S. Department of Health and Human Services alleges that Jason James of the James Healthcare & Associates clinic in Iowa, USA — along with his wife, Deanna James, the clinic’s co-owner and office manager — filed dozens of claims with Medicare for a disposable acupuncture device, which is not covered by Medicare, as if it were a surgically implanted device for which Medicare can be billed. According to the lawsuit, more than 180 such claims were filed. Beginning in 2016, the lawsuit alleges, the clinic began offering an electro-acupuncture device referred to as a “P-Stim.” When used as designed, the P-Stim device is affixed behind a patient’s ear using an adhesive. The device delivers intermittent electrical pulses through a single-use, battery-powered attachment for several days until the battery runs out and the device is thrown away.
Because Medicare does not reimburse medical providers for the use of such devices, DHHS alleges that some doctors and clinics have billed Medicare for the P-Stim device using a code number that only applies to a surgically implanted neurostimulator. The use of an actual neurostimulator is reimbursed by Medicare at approximately $6,000 per claim, while P-Stim devices were purchased by the Keokuk clinic for just $667, DHHS alleges. The department alleges James knew his billings were fraudulent as the P-Stim device is “nowhere close to even resembling genuine implantable neurostimulators” and does not require surgery.
The lawsuit alleges that on June 15, 2016, when Jason James was contemplating the use of P-Stim devices at the Keokuk clinic, he sent a text message to P-Stim sales representative Mark Kaiser, asking, “Is there a limit on how many Neurostims can be done on one day? Don’t wanna do so many that gives Medicare a red flag on first day. Thanks.” After realizing the “large profit windfall” that could result from the billing practice, DHHS’s lawsuit alleges, James “told Mark Kaiser not to mention the Medicare reimbursement rate to his nurse practitioner or staff – only his office manager and biller needed that information.” James then pressured clinic employees to heavily market the P-Stim devices to patients, even if those patients were not agreeable or, after trying it, were reluctant to continue the treatment, the lawsuit claims.
In October 2016, the clinic’s supplier of P-Stim devices sent the clinic an email stating the company had “no position on what the proper coding might be for this device if billed to a third-party payer” such as an insurer or Medicare, according to the lawsuit. The company advised the clinic to “consult a certified biller/coder and/or attorney to ensure compliance.” According to the lawsuit, James then sent Kaiser a text message asking, “Should we be concerned?”
DHHS alleges the clinic’s initial reimbursement claims were submitted to Medicare through a nurse practitioner and were denied for payment due to the lack of a trained physician’s involvement. In response, the clinic hired Dr. Robert Schneider, an Iowa-licensed physician, to work at the clinic for the sole purpose of enabling James Healthcare & Associates to bill Medicare for the P-Stim devices, the lawsuit claims. James then informed Kaiser he had a goal of billing Medicare for 20 devices per month, which would generate roughly $125,573 of monthly income, the lawsuit alleges. The lawsuit also alleges Dr. Schneider rarely saw clinic patients in person, consulting with them instead through Facebook Live.
In April 2017, Medicare allegedly initiated a review of the clinic’s medical records, triggering additional communications between James and Kaiser. At one point, James allegedly wrote to Kaiser and said he had figured out why Medicare was auditing the clinic. “Anything over $7,500 is automatically audited for my area,” he wrote, according to the lawsuit. “We are now charging $7,450 to remove the audit.”
The clinic ultimately submitted 188 false claims to Medicare seeking reimbursement for the P-Stim devices, DHHS alleges, with Medicare paying out $4,100 and $6,300 per claim, for a total loss of $1,028,800. DHHS is suing the clinic under the federal False Claims Act and is seeking trebled damages of more than $3 million, plus a civil penalty of up to $4.2 million.
An attorney for the clinic, Michael Khouri, said Wednesday he believe the federal government’s lawsuit was filed in error because a settlement in the case had already been reached. However, the assistant U.S. attorney handling the case said no settlement in the case had been finalized and the lawsuit was not filed in error.
Previous legal cases
In 2015, the Iowa Board of Chiropractic charged Jason James with knowingly making fraudulent or untrue representations in connection with his practice, engaging in conduct that was harmful or detrimental to the public, and making untruthful statements in advertising. The board alleged James told patients they would be able to stop taking diabetes medication through the use of a diet and nutrition program, and that he had claimed to be providing extensive laboratory tests when not all of the tests for which he billed were ever conducted. The board also claimed James referred patients to a medical professional who was not licensed to practice in Iowa. The case was resolved with a settlement agreement in which James agreed to pay a $500 penalty and complete 10 hours of education in marketing and ethics.
In 2019, Schneider sued the clinic for failing to comply with the terms of his employment agreement. Court exhibits indicate the agreement stipulated that Schneider was to work no more than two days per month and would collect $2,000 for each day worked, plus $250 per month for consulting, plus “$250 per device over six per calendar month.” In March 2020, a jury ruled in favor of the clinic and found that it had not breached its employment agreement with Schneider.
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Before some chiropractors now claim that such cases represent just a few rotten apples in a big basket of essentially honest chiropractors, let me remind them of a few previous posts:
- A $2.6M Insurance Fraud by Chiropractors and Doctors?
- Fraud and sex offences by chiropractors
- Chiropractic therapy for gastrointestinal diseases. Evidence of scientific misconduct?
- Twenty Things Most Chiropractors Won’t Tell You
- The Dark Side of Chiropractic Care
- Chiropractic subluxation: the myth must be kept alive
- CHIROPRACTIC: an early and delightful critique
- Students of chiropractic condemn the ‘unacceptable behaviour’ of some chiropractors and their professional organisations
- Far too many chiropractors believe that vaccinations do not have a positive effect on public health
- Chiropractor is in the dock for not wearing a mask
- “The uncensored truth” about COVID-19 vaccines” … as told by some chiro loons
To put it bluntly: chiropractic was founded by a crook on a bunch of lies and unethical behavior, so it is hardly surprising that today the profession has a problem with ethics and honesty.
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:
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.
Why?
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,
- massage,
- 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.
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This story made me wonder: which of the listed treatments
- hot and cold packs,
- chiropractic manipulations,
- massage,
- 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.
