Why were chiropractors overlooked in spine care article, and other letters

The article "Rethinking spine care" was certainly timely. But I found it interesting that nowhere in the article was mention made of chiropractic care in addressing the current boondoggle of spine management in this country, even though it's highly recommended as a first-line treatment by both national and international guidelines, as well as prestigious scientific journals. Of the 56 million Americans who have back pain, only 5% need surgery, says Dr. Charles Rosen, an orthopedic surgeon and co-founder of the Association for Medical Ethics. Yet there are nearly 1.2 million unsuspecting patients undergoing surgery for spinal problems every year who face a failure rate approaching 74% (Spine, Feb 15, 2011). Thus, even in the face of evidence-based research, spine surgery rates continue to escalate, leaving a wake of impairment and disability, as well as opioid dependency and huge costs. Enter the solution: conservative care. In the wake of the Patient Protection and Affordable Care Act and its mandate to reimburse providers for evidence-based care only, systems are turning to conservative providers to treat that 95% cohort of spine pain patients who might otherwise undergo an unnecessary surgical procedure. The most recent, better-designed studies strongly suggest that chiropractic care can not only reduce the immediate cost of an episode of care, but reduce spine pain recidivism. Two representative studies worth noting are: Consumer Reports (May 2009), surveyed more than 14,000 consumers and found that 88% of those who tried chiropractic manipulation said it “helped a lot,” and 59% were “completely” or “very” satisfied; the Journal of Occupational and Environmental Medicine (April 2011) published a joint study from the Center for Disability Research at the Liberty Mutual Research Institute, the University of Massachusetts Lowell and the Center for Health Economics, Epidemiology and Science Policy of United Biosource Corp., that concluded that there is a two-to-one chance of disability under a physical therapist's care rather than care under a doctor of chiropractic (D.C.), and a 60% chance of disability under M.D. care, rather D.C. care. The study recommended chiropractic as a first-line treatment. The major savings from chiropractic management come from fewer and lower costs of auxiliary services, far fewer hospitalizations and a highly significant reduction in recurrence and chronicity of spine problems, as well as disability. All major research in the field of spine care now recommends chiropractic care prior to advanced imaging and/or a surgical consult. Yet chiropractic is systematically overlooked—why?

Peter Furno, D.C. Indianapolis

Regarding “Getting to the root of the problem: Systems tackle social conditions to improve outcomes despite the financial risks,”—excellent article! At my company, we've actually seen some great interest from insurers (Medicaid managed care) willing to pay for our solution to help connect patients to relevant social services and in-network behavioral health providers. The issue we've been having is that each payer we chat with has a remarkably different infrastructure, making the integration of a technology solution quite difficult.

Manik Bhat Healthify, New York

Regarding "CMS will try offering hospice patients palliative, curative treatments", this makes a mockery of hospice philosophy. Hospice is not a place or a logistical matter; it is a presence of mind. It is mutually exclusive to simultaneously attempt cure and pursue end-of-life care. Those who attempt both do both poorly, and risk greater toxicity from aggressive therapies taken less seriously. The quality of an individual's remaining life will suffer as a result. These “experts” clearly have little hands-on experience. I am frankly appalled that Sen. Ron Wyden would consider the choice between hospice and curative care to be a false one. That is the defense of an uneducated person.

Dr. John Rochat Mendocino Coast Hospital District Fort Bragg, Calif.

Regarding the article "CMS hospice plans draw mixed reactions," the upcoming CMS hospice demonstration is a critical step in the evolution of end-of-life care. I experienced this situation firsthand two years ago, when my mother died from advanced lung cancer. It was incomprehensible to me at the time that we had to navigate a complex web of coordination from multiple providers and time her transition to a disassociated in-home hospice provider in a way that maximized her quality of life. The situation was exacerbated by her multiple comorbidities and the subpar quality of care by her hospice team that prompted investigations after her death by both the CMS and state officials. Suffice it to say, I firmly believe we all have the right to die with the best quality of life that aligns with our personal beliefs (i.e., do not resuscitate/do not intubate). By establishing dual coverage, the CMS would go a long way toward creating the bridge care that's necessary for complex cases. In my mother's case, it would have eliminated a vast amount of coordination and advocacy that I found myself doing at a time when all I wanted to focus on was her every waking minute. Though I would do it all again in a heartbeat, I do hope the demonstration prompts a necessary evolution in treatment protocols that more specifically define “curative” and “hospice,” in order to cover care that comfortably extends life.

Kelly Stein Frisco, Texas