COMPLAINT TO ARIZONA DEPARTMENT OF INSURANCE AND ARIZONA CHIROPRACTIC BOARD OF EXAMINERS 

TABLE OF CONTENTS

 

EXECUTIVE SUMMARY. 5

TALKING POINTS. 6

PATIENTS SPEAK! 8

PATIENT REVIEWS AT THE BETTER BUSINESS BUREAU (BBB) 8

YELP REVIEWS OF ASH. 11

ASH NOTICE OF TERMINATION. 22

LACK OF PEER REVIEW PRIVILEGE. 24

LaBROT GUILTY IN NEW JERSEY & KENTUCKY. 24

UNBLEMISHED RECORD. 26

FEDERAL BCBS BATTLE. 27

THE 3RD RAIL: POLITICAL RETRIBUTION. 29

JCS VITAE HIGHLIGHTS. 32

VIOLATIONS BY ASH. 34

REMOVING THE CHOKEHOLD TO BETTER CARE. 35

EVIDENCE-BASED GUIDELINES. 37

CLINICAL PRACTICE GUIDELINE: CHIROPRACTIC CARE FOR LOW BACK PAIN. 38

WHIPLASH GUIDELINES. 39

MEDICARE GUIDELINES ON IMAGING OF SUBLUXATIONS. 40

PROGRESSIVE WORKER COMP GUIDELINES. 41

BAD PRESS FOR ASH. 42

“A Victory Worth $11.75 Million”. 42

“ASH Dealt Another Blow”. 44

“Horizon BCBS Sues Physician Advocacy Group Over 'Smear Campaign'”. 45

DRACONIAN MANAGED CARE. 48

RESEARCH BIAS @ ASH. 49

COOKBOOK VS EVIDENCE-BASED GUIDELINES. 51

BAIT AND SWITCH. 53

PRACTICE TYRANNY. 56

FOLLOW THE MONEY, FOLLOW THE LIES. 57

FALLACIES AT ASH. 60

FALLACY OF SPINAL X-RAY PROHIBITION. 60

CHOOSING WISELY OR BLINDLY GUESSING. 63

THE KING OF IMAGING HAS SPOKEN! 68

THE FALLACY OF NONSPECIFIC / UNCOMPLICATED LBP. 74

FALLACY OF EVIDENCE-BASED CHIRO TECHNIQUES. 78

SUMMARY. 82

APPENDIX. 85

ASH LAWSUITS. 85

INEPT MDS. 86

JCS CURRICULUM VITAE. 89

 

 

 

 

 

August 10, 2020

TO:         Arizona Department of Insurance and Financial Institutions

Market Oversight Division

 

                   Arizona Board of Chiropractic Examiners

 

FROM:     Alan M. Immerman, DC (Ret.)

               President

               Arizona Chiropractic Society

              3515 East Carol Avenue

              Phoenix, AZ  85028

             

RE:         American Specialty Health and Dr. Thomas LaBrot, Chairperson, Quality Improvement Committee.

Since the Market Oversight Division works to resolve complex claims problems between health care providers and managed care insurers, and since the Arizona Board of Chiropractic Examiners protects the public from fraudulent acts, I hereby ask for an investigation by both bodies into ASH and Dr. Thomas LaBrot for malfeasance perpetrated upon patients and to my profession as a whole.

EXECUTIVE SUMMARY

American Specialty Health (ASH) is a managed care organization (MCO) in San Diego that has had its knee on the necks of thousands of patients and chiropractors for three decades by implementing draconian “cookbook” policies aimed to “squeeze care to expand profits.” According to its news release, ASH had a 94% overall revenue growth from 2014 ($255.90 million) through 2017 ($497.44 million). A private news article estimated ASH’s annual revenue of $854.9M.

 

ASH is one of the nation's leading specialty health benefit management companies currently administering benefit programs for over 46 million Americans and providing access to consumer-self pay programs for over 155 million people. "We're very pleased to see ASH once again recognized for our consistently high financial growth," said ASH co-founder, Chairman and CEO George DeVries.

However, ASH epitomizes what is terribly wrong with for-profit healthcare with its chokehold on the necks of patients and DCs alike with its motto, “Squeeze care to expand profits” that defrauds patients of their contractual rights to obtain reasonable chiropractic care and other complementary therapies. By implementing exhaustive administrative barriers and curtailing proper care by arbitrary criteria, ASH thereby drives patients away from chiropractic offices or forces them to risky and expensive medical spine care treatments (opioids, injections, surgery) that ASH is not responsible to cover.

ASH has also denied chiropractors their right to perform usual professional standards of care by denying standard diagnostic services such as a spinal x-ray analysis and limiting treatment plans to a fraction what standard guidelines recommend. In its defense, ASH gaslights the profession with misconstrued “evidence-based medicine” fallacies that have been disproven by reputable studies and denounced by many experts, authors, universities and associations, including the national American Chiropractic Association in 2012,  “ACA files class action lawsuit challenging ASHN's, CIGNA's improper practices.”

Fortunately, a legal precedent recently occurred with a $11.75 million settlement against ASH in a New Jersey lawsuit [High Street, et al v. Cigna, et al., No. 2:12-cv-07243-NIQA] that found ASH responsible for many nefarious actions similar to those DCs in Georgia experience daily. The New Jersey lawsuit aptly revealed  ASH’s corporate goal: “cutting benefits appears to be the business model of American Specialty Health.” The Arizona Market Oversight Division and the Board of Chiropractic Examiners must protect our citizens and chiropractic practitioners as New Jersey has done. It is time to take ASH’s boot off the necks of patients and DCs alike.

TALKING POINTS

There are a few main points I will challenge:

  1. Lack of proof of any reputable evidence-based guidelines supporting ASH’s position on many policies, such as its arbitrary definition of “medical necessity,” the inappropriate  short length of treatments allowed on acute, serious, or chronically-ill patients; routine denial of spinal x-rays, the cookbook procedures for patients, and the short-changing of patients in regard to their expected coverage.
  2. Jeff Randolph, Esq., summarized ASH’s violations that “improperly denied medically necessary care, carried out deceptive business practices and impeded patients' access to health care.”
  3. Dr. Lou Sportelli explains, “ASH and other MCOs seized an opportunity to provide a review service for a “piece of the action”. 
  4. Dr. Thomas LaBrot lost a case against him in Kentucky regarding his illegal peer review by lacking a Kentucky license. He was reprimanded and fined $1000 by the court.
  5. He and other ASH associates also fabricated a biased research study showing how ASH’s cookbook approach cuts costs by restricting care to patients and payments to DCs. However, the biased ASH study totally ignored the numerous patients and DCs complaints cited at the BBB and YELP websites who have also been victimized by ASH’s draconian managed care.
  6. ASH uses a smear campaign against those who oppose them as noted in a recent lawsuit (Horizon BCBS) in New Jersey in retaliation. Plaintiffs in Doctor-Patient Alliance said that "there could be a steep increase in improper claim denials"…"cutting benefits appears to be the business model" of American Specialty Health.  I also feel I am the target of ASH retaliation due to years of writing articles against them.

7. American Specialty Health has a history of denying care, improperly paying claims, and creating roadblocks to conservative care," said Amy Porchetta Boright, executive director of the association. Dr. Peter DeNoble, an orthopedic surgeon in Wayne who is president of the alliance, said “everything we put out there is based on fact. “When we go to court,” he said, “we will be able to present a trove of information”

  1. Spokesmen on medical ethics also disagree with ASH’s distorted use of evidenced-based medicine (EBM) to defend its draconian policies, such as the father of EBM, David L. Sackett, MD, author of Evidence-based medicine: what it is and what it isn't, who warns, “Evidence-based medicine is not ‘cookbook’ medicine,” which characterizes ASH’s policy with its inordinately stringent “medical necessity” criteria and clinical guidelines that are not reasonable and, according to Dr. Sackett, results in “slavish, cookbook approaches to individual patient care."
  2. A major method to cut costs and suppress clinical freedom occurs when ASH strongly discourages the use of spinal x-rays defending its policy on the unproven claim of the danger of “ionizing radiation”. However, many university department heads, chiropractic associations, technique instructors, and radiation experts disagree with ASH’s policy such as Jerry Cuttler, PhD, Nuclear Sciences and Engineering, past president of Canadian Nuclear Society, who said “There’s just no evidence of that.”

These are among many examples how ASH has failed to act in good faith to manage chiropractic benefits that the patients pay for and expect. Apparently, ASH did not learn its lesson from the recent New Jersey lawsuit settlement that fined ASH  $11.75 million for the same chokehold irregularities it continues to do to me and other Arizonan chiropractors.

Since ASH will not change itself, I believe it is time for the Market Oversight Division and the Arizona Board of Chiropractic Examiners to step into this case to stop ASH’s malfeasance here in Arizona.

PATIENTS SPEAK!

It is time to speak truth to power, so let me have the following patients and DCs figuratively speak in my behalf and every DC about the many unethical and illegal tactics taken by ASH by citing numerous complaints against ASH to warrant an investigation by the Insurance Commission and/or the Arizona Board of Chiropractic Examiners.

First of all, please note in the BBB heading that ASH is not BBB accredited and most importantly has a one-star rating for Customer Reviews.

 

 

PATIENT REVIEWS AT THE BETTER BUSINESS BUREAU (BBB)

Actual patients will bear witness to this national fight with ASH. The following speak volumes to the harm ASH brings to the healthcare table to both patients and chiropractors alike:

  1. American specialty Health Inc is a scam.
  2. If I could give ASH a big fat zero, I would. They are in the business of keeping insurance executives rich and denying people the medical care needed to stay well.
  3. I love ASH.  I love doing the best I can for my patients and getting reimbursed next to nothing.  I love checking my patients benefits to see they have 20 visits only to get denied further after 5 visits.  ASH is amazing at wasting my time submitting the most confusing treatment extension requests for absolutely no reason.  I wish I could give them more stars because really they are the best at being the worst company.  ASH is right up there with Comcast as the most hated company.  
  4. ASH is absolutely THE WORST Insurance Company out there.
  5. Management? You mean to tell me that they really have adults working in this place over their clinical customer service department? I had no clue. I guess my advice would be show your faces and stop using your customer service representatives for your dirty work.
  6. The Chiropractor literally LOSES money to work with ASH.
  7. They simply don't care, they're in business to deny claims and could care less about the person's health and wellbeing. Read all the other reviews, it's no wonder they have an average rating of 1 star, it's ridiculous.
  8. 100% of the time when submitting my chiropractic bills this company automatically declines them falsely. I am paying a very large premium for a PPO and they are not honoring the contract and something needs to be done. They are stealing as we are paying a premium for something they are not delivering on and I would like to join a class action lawsuit against them.
  9. This is the WORST company I have ever had to deal with. I really try to be fair, but there is something extremely shady going on with this company.

10. I have had to endure working with this company for 10+ years. Believe the overwhelmingly negative reviews and disregard the canned ASH responses trying to get your personal information and ignoring the actual complaints.

11. No stars. Horrific transactions with provider services and contracting.

12. This corporate entity should be investigated for fraud.

13. 100% of the time when submitting my chiropractic bills this company automatically declines them falsely. I am paying a very large premium for a PPO and they are not honoring the contract, and something needs to be done. They are stealing as we are paying a premium for something they are not delivering on and I would like to join a class action lawsuit against them.

14. The only reason they get a 1 Star is because there is not an option for zero.

15. ASH should be shut down. Truly awful.

16. ASH is contracted by healthcare providers when they want to get out from a fake coverage promise.

17. Worst company ever! Total crooks. I've been in healthcare over 16 years and never been treated so poorly and paid so low.

18. If I could put zero stars I would.

19. I can only have five visits before I must undergo a review. This is reckless and withholding accepted post-surgical revision protocol.

20. ASH is a total scam and the insurance companies that contract with them are getting ripped off.

21. I have been handling billing for a chiropractic office for the past 15 years.  NEVER have I dealt with a worse company then American Specialty Health.  

22. For more visits to be approved, ASHN requires my chiropractor to fill out six pages of documentation regarding my case.

23. This blatant abuse of the healthcare system by the ASH insurance company to try to make extra money for themselves is denying patients necessary care to live normal quality of life for the age group.

24. ASH also dropped my network status with Anthem and Aetna without any notice and it has caused a lot of loss to my business.

25. I have a PPO plan that is serviced by American Specialty Health.  I went to my usual Chiropractor and they submitted the claims with 19 pages of supporting documentation.  Of course, ASH denied the claim for insufficient documentation and sent me a separate notice for every single claim they denied.

26. ASH is contracted to provide rehabilitation coverage for our patients who have Cigna as their insurance company. Since ASH has taken over these services, our patients are being significantly restricted on the amount of care they receive even when it impacts their quality of life.

27. This blatant abuse of the healthcare system by the ASH insurance company to try to make extra money for themselves is denying patients necessary care to live normal quality of life for the age group.

28. All the comments are true. How this company is still in business is beyond finding out. They make it very difficult for the patient and the doctor. They restrict visits and say that I don't need any more treatments. My coverage says I have 30 but I could only use 5. The paperwork that these guys request from doctors is atrocious. Even though my doctor would send in the paperwork, they still wouldn't approve any more visits. I am in pain and there isn't anything I can do. From what I know their reimbursement rate to the doctors is mere peanuts as well. When I get the chance, even though I'm going to pay more, I'm going to switch from HMO to a PPO so that I won't have to deal with these scammers.

29. After being in-network for 2 years, we are leaving. Nothing good has come from working with ASH - not for us and not for our patients.

30. This company is horrible. What they make patients go through is the saddest thing. It is obvious to patients and practitioners that this company is only out to make money while taking advantage of both sides of patient care....

31. Want to know the reason doctors' morale is at an all-time low, meaningless paperwork is abundant, and patients can't understand or use the benefits they pay for? It's because of companies like these sucking the life out of the once-great practice of health care. Get yours while you can, ASH, because your time is limited. Doctors and patients won't put up with this level of unfair bureaucratic torture forever. I look forward to your next class-action lawsuit.

Hold on because there are many more angry patients on the YELP website where there are 167 customers’ reviews on ASH. Here are a mere 92 complaints that reiterate the same offenses as the BBB reviews.

YELP REVIEWS OF ASH

  1. I called my insurance company to get a chiro referral and their prompt gave me AHS, so I called.  While on hold, I saw the 162 1-star yelp reviews. Yikes
  2. Ok, all my fellow chiropractors are right about Ash.  It is nothing but a scam.  If you have ASH for your chiropractic benefits, you might as well give up on getting the proper care from this company.  
  3. I agree, there should be a ZERO STARS option. ASH is awful!! Not only do they deny claims without cause, they send out so much paperwork to the patient and the chiro office that they could've essentially just paid the claim. They don't give the patient the benefits that their insurance company says they have from their plan!! All of the horrible reviews I read are completely true from my own dealings. It's as if they have a template on how to treat the patients and practitioners as horribly as possible. Don't even try to call them, it will just make your day worse. The customer service was rude and had no clue what they were talking about. Everything about this company is shady and awful!!! The CA insurance commissioner needs to get involved and shut them down!! Just thinking about ASH makes me fuming mad!!!
  4. Would give no stars if given the opportunity.  They evidently took over as a third-party administrator for Anthem Blue Cross PPO that we have, we have suffered heavily since them.  Nothing but paperwork, paperwork over a few chiropractic visits.  Still they haven't paid…   Such a scam, someone making money somewhere off this whole thing on the backs of people paying for Blue Cross Coverage.
  5. When purchasing health insurance for you or your family make sure to check if ASH is affiliated with the plan you are considering. If they are...DUMP THEM! Do not be fooled by their management's rhetoric about their role in controlling the "upward spiraling costs of healthcare." The sole purpose and corporate structure of this company is based on delivering more profits to the big insurance companies they contact with.....oh, and for them to take a sizable profit for their "service." Their arbitrary fee structures and medical review process are driving consumer costs up …SAY NO TO AMERICAN SPECIALTY HEALTH.
  6. This company is in the business of denying, or at the very least minimizing a person's access to care. The insured may have 24 visits per year, but will not get to use those benefits as the reviewer will find reasons to disapprove or approve a couple visits at a fee schedule of 1980's.
  7. WTF is that company?? Like all the reviews here, ASH declined pretty much every claims. Who the fuck are they to decide if I need treatment or not? Based on what? Statistics, moon phase? Who knows best if I'm in pain or not?
    I spend over $4k a year for Anthem, and still, they find a way not to spend a dime on me. This is beyond ridiculous, why there's no class action against those people? Health insurance companies are the cancer of this country.
  8. A building full of people being paid money every day to do nothing but deny coverage to people needing health care. Whole careers made out of saying no. I wonder if these employees have their own health coverage denied, too? To employees: How can you live with yourself working for a business that is just so cruel to people needing health care? Every piece of mail I get from them is full of "denied." This business is flat out sadistic.
  9. This has to be one of the most mismanaged companies in the US.  I've called them a dozen times and always get a different answer, all of which are wrong.  I don't know if they are trained to act stupid or if that's what ASH is all about.  I have to say, they're a special kind of stupid at ASH.  I won't get into the details, there's enough examples on Yelp to justify my opinion. I recently filed a complaint with the California Department of Insurance and I suggest everyone else here do the same. Maybe if the DoI receives enough complaints, they'll investigate this company.
  10. What a travesty! Criminal behavior in my opinion. Unfortunately all the companies on their networks  are to blame as well. ASH is a third party administrator of healthcare services that  saves insurance companies millions by effectively blocking access to care that we the insured pay for. It's nothing but a scam, and the State has yet to do anything about it. Total corporate scum.
  11. They deserve ZERO stars!  American Specialty health (ASH) is essentially a middle man between the  insurance companies and the patient. They are hired by insurance to "take care" of patients chiropractic and acupuncture visits. Instead they pocket the money from the insurance companies to supposedly "manage" the care of patients while denying patients the visits they are entitled to and the doctors the money that they should be paid.   It’s a total scam and the big insurance companies know it but they don't care as long as they are saving money which ASH clearly is able to do by their regular denial of benefits.  This is not a HEALTH company. This is a corporation that makes it money by denying people the healthcare they are entitled to.  I am sick of the run around that I get in order to get the care that I need and I hate that they make me and my doctor fill out endless paperwork for every visit. If your health insurance contracts with this company make sure and change it when you can. I have found out that Cigna, Aetna HMO, Anthem, and Kaiser contract with this terrible company. STAY AWAY!!!
  12. My only complaint with Kaiser Permanente after being with them some 40 years, is their association with this company.  I have never had a good experience with them.  Kaiser always says to contact them to pick a chiropractor, and when you call they always say to try again in a couple of weeks as they've no record "yet" of the authorization.  I usually just give up and don't get treatment, the pain notwithstanding.  And what's more, they just don't seem to care.
  13. These people  really suck. Kaiser needs to dump this company and handle their own claims before they loose members. If I could I give them a zero these people are very unprofessional and have no clue for people’s needs.
  14. Awful, Awful, AWFUL! I would give it negative stars if that was an option. I've worked as a medical biller for years, and this is the worst, most inefficient, pathetic excuse for a company that I've ever dealt with in my life! I HIGHLY advise anyone who needs reliable health insurance to steer clear of this company! Make sure the insurance you sign up for is in NO WAY, SHAPE OR FORM associated with ASH!
  15. I'm still in shock from the way their "customer representative" talked to me. Horrible, unprofessional tone of voice and service.
  16. This is one of the worst and most predatory companies in all of healthcare.  They force their doctors to do pages and pages of paperwork to get a few bucks.  Hopefully the new MLR rules cause this company to lose millions of dollars.
  17. ASH only pay 5 visits ( out-of-network provider, Cigna) . At the sixth visit, they ask for medical documents for review but ASH doesn't review out-of-network provider's documents. This is unreasonable if the patient has 20 visits benefit.
  18. Their terrible customer service wouldn't be too bad if they actually paid what their contract indicates. I highly recommend staying away from them!
  19. This is the worst run company I have ever had to deal with, George DeVries and Bob White are so unprofessional and their employees are so rude and NEVER return phone calls. I'm so glad I have other choices, and that I will never have to deal with this company ever again.
  20. My chiropractor hates to deal with ASH. He just takes the copay and never bills them. I guess total pay for a chiro visit is only $26 or $27. How can they do that and get away with it. We need to complain to the company itself and to our health insurance directly about Ash's practices. Which is what I did today, called anthem blue cross and complained. They told me I was not the first person. So people call your insurance company to make a change.
  21. I have been in practice for 20 years and this has got to be the worst insurance ever. They just don’t pay claims, don t answer the phone!!!!! Horrible Horrible, Horrible.
  22. Unbelievably bad company. Idiot employees, stupid operating procedures. Just a freaking joke! Run like a mini-mafia.
  23. I called American Specialty Health for my benefit coverage and was told all chiropractic services are fully covered but that is not the case.  This company expects the chiropractor to perform all chiropractic services and be paid under the adjustment fee, which is a small amount.  So basically, they expect the chiropractor to perform multiple expensive treatments and bill under one treatment.   I think the chiropractors and patients should file a class-action lawsuit together against this scam!
  24. American specialty health is the biggest scammer of all insurance company scams. They say they cover chiropractic services. They pay my doctor $5 a session. What a joke! They determine nothing is ever medically necessary and will not pay the bills owed. I pay my premiums and don't get my services covered.
    This company's goal is to scam patient out of premiums and scam doctors out of payment.
    Please avoid this insurance company at any and all cost. It will be hard to do however they have weaseled their way from HMO's to PPO's such as Cigna and Anthem Blue Cross and are denying all claims that are submitted.
  1. This company is so bogus and is why providers such as Blue Shield, Blue Cross, Kaiser, Health Net, Cigna, Aetna, etc., are pairing up your health insurance plan with ASH a third party.  It should be called Americas Shitty Healthcare!  I've been given a list of medical providers that accept the ASH from my insurance provider Blue Shield of CA and none of the medical providers listed will actually except the plan because ASH makes it hard for the medical provider to claim.  I've heard multiple complaints from ASH medical providers saying that even though they are able to accept patients that have ASH through their plan, that they still will not accept you if your coverage is with ASH.  It's just too much work and not enough payback for them.  They said that ASH limits the amount of visits provided to the patient even if they have more through their plan.  They make the medical provider fill out lengthy documents/paperwork to approve more visits for the patient.  The medical providers see less money back after ASH pays the claim and then on top of that will cut most patients off if it isn't an acute problem.  Chronic pain for joints & arthritis are not acute problems and something that many people see an acupuncture for.  Essentially ASH is making it impossible for people with health plans that offer alternative medicine, to actually find the doctors, that are supposed to be covered by your plan.  It's a bait and switch.  Make sure to check if your health care provider is using a 3rd party for the alternative health partners.  
    As another Yelp reviewer has noted please file a complaint/grievance with your health plan and let them know that ASH is not working for its members.  I have just formally sent my grievance with Blue Shield of CA and I hope you will to.
    I would highly encourage providers to drop all the ASH health plans and sign off from their network. For patients that have insurance that is a partner with ASH, please drop your health plan or file a complaint/grievance to your insurance to help to stop this medical provider and patients abuse.
  2. One star only because zero is not an option. THEY NEED TO BE INVESTIGATED FOR FRAUD!!! TOTAL CROOKS! NO WONDER THEY HAVE PAGES OF ONE STAR REVIEWS. I AM REPORTING THEM TO THE APPROPRIATE AGENCIES.
    WORST COMPANY EVER.
  3. How about negative 50 stars? These clowns are the WORST!  I'd love to know how much our "health" insurance companies pay them to be the gatekeepers. Probably WAY more than it would cost just to let us see our providers and pay a reasonable fee. Unfortunately, human resources is not interested in helping the company to maintain good loyal employees.
  4. All Providers who accept a medical plan that is managed by ASH should drop the plan(s) immediately. The contracted fee is very low, Limited visit(s), Multiple forms to be completed for authorization; to continue care, Ambiguous Peer review denials, Each patient is different; therefore ASH should not be able to determine that a patient can only be seen for a maximum of visits for Acupuncture and or Chiropractic treatments.
  5. ASH is the worst thing that's ever happened to my 26-year practice. They're a joke and the insurance industry should be ashamed to have any part in this corporation. I'm sure it's saving them money but at what expense. Doctors are not getting paid even after submitting a two-page report for each patient visit which means more expense or lack of necessary treatment for our patients. Shame on you ASH, shame on you.
  6. WHY isn't someone doing a class action lawsuit against these frauds!? Very smooth bait and switch American Specialty Health Incorporated -- minus 5 Stars needed.
  7. Great news what's goes around looks like has finally come back around!!! If you didn't believe the bad reviews about this horrible company, you had better believe it now!!!! This doesn't happen to good companies with good purposes it only happens to the worst and is ASH is an example of being the worst maybe in the history of 3rd party review and denial of claims that should have been paid!!!! This is a great day for patients and providers! Please read the following!!!! See all photos from Trent J. for American Specialty Health
  8. Many of the reviews I've read and the problems that I have faced regarding ASH are similar to many other people and could relate to the following:
    1. Unfair Insurance Claim Settlement Practices are generally defined as "if the Insurer knowingly commits or performs with such frequency as to indicate a general business practice" according to the following:
    2. Misrepresenting pertinent facts or insurance policy provisions relating to coverages at issue;
    3. Failing to acknowledge and act with reasonable promptness upon communications with respect to claims arising under insurance policies;
    4. Failing to adopt and implement reasonable standards for the prompt investigation of claims arising under insurance policies;
    5. Refusing to pay claims without conducting a reasonable investigation based upon all available information;
    6. Failing to affirm or deny coverage of claims within a reasonable time after proof of loss statements have been completed;
    7. Not attempting in good faith to effectuate prompt, fair and equitable settlements of claims in which liability has become reasonably clear;
    8. Compelling insureds to institute litigation to recover amounts due under an insurance policy by offering substantially less than the amounts ultimately recovered in actions brought by such insureds;
    9. Attempting to settle a claim for less than the amount to which a reasonable man would have believed he was entitled by reference to written or printed advertising material accompanying or made part of an application;
    10. Attempting to settle claims on the basis of an application which was altered without notice to, or knowledge or consent of the insured;
    11. Making claims payments to insureds or beneficiaries not accompanied by statements setting forth the coverage under which the payments are being made;
    12. Making known to insureds or claimants a policy of appealing from arbitration awards in favor of insureds or claimants for the purpose of compelling them to accept settlements or compromises less than the amount awarded in arbitration;
    13. Delaying the investigation or payment of claims by requiring an insured, claimant, or the physician of either to submit a preliminary claim report and then requiring the subsequent submission of formal proof of loss forms, both of which submissions contain substantially the same information;
    14. Failing to promptly settle claims, where liability has become reasonably clear, under one portion of the insurance policy coverage in order to influence settlements under other portions of the insurance policy coverage;
    15. Failing to promptly provide a reasonable explanation of the basis in the insurance policy in relation to the facts or applicable law for denial of a claim or for the offer of a compromise settlement;
    16. Using as a basis for cash settlement with a first party automobile insurance claimant an amount which is less than the amount which the insurer would pay if repairs were made unless such amount is agreed to by the insured or provided for by the insurance policy.
      Class Action: Class actions are a method for different persons to combine lawsuits because the facts and the defendant are similar whereby these individuals e.g. FBIC members of the proposed class, have similar claims and are by law able to be joined together to prosecute their claims in a more efficient manner. Class actions are designed to save Court time and allow one judge to hear all the cases at the same time and to make one decision that is binding to all parties.
      I am not an attorney but if there are enough people who feel the same maybe there is something that we can all do together?
    17. I have had never successfully had a claim paid...ever. Worst company I have ever dealt with.  Don't even bother trying to submit a claim just accept that you will never get paid and don't waste your time. I will however be submitting a complaint to the insurance commissioner of California. They need to be shut down. And no, I don't want to hear a reply from the poor girl that works their answering all these bad reviews. You should try to find another company that actually will process and pay claims.
    18. This company is a scam and is collecting and saving personal information in bad faith.  The ASH Customer service agent asked for my personal information under the guise of "verifying' then refused to delete my information after I directly requested they do so multiple times.  The agent also went through the process of collecting my information, all the while knowing they didn't offer the service I wanted, which I clearly stated at the beginning of the call.  I asked to speak to someone else and they hung up on me.  I'm not using their service, they claim they will not contact me, so why do they need to save my personal information?
    19. This company should be illegal to pay healthcare providers so low. It is a disrespect to the professions. I urge all healthcare provider to not accept this Company and put them out of business. Seriously why is this company not illegal and how are they allowed to set fees so low! Ugh!
    20. This is the worst company ever!  Sign up for insurance with BlueCross, then you very well may have to deal with this company that is paid to deny claims.  Using tactics like automatic denying of claims, delaying payments, lying about payments, requiring overly burdonsome documentation, making deposits of zero (no joke), not providing EOB documentation, this company is so shady.  Avoid at all costs, whether a doctor or insurance patient.
    21. Shithole company for one.  I have unlimited treatments according to my blue cross agreement.  ASH only approved 5 and we had to beg for 3 more treatments.  This is really cheesy and they should get sued for not honoring agreements.  I have a chronic problem which means it needs to be addressed constantly and since I can't take anymore drug due to liver and kidney damaged from the drug that I've been on for the past 30 years this is the only alternative. After reading all these post about ASH, I'm surprised they are in business.    
      They are cheesy and I want great care, which means better compensation to the providers and allowing us to actually continue our healing... Not all of us will get better  or cured and Chiropractic , PT and Acupuncture may all be the only thing that can help me for the rest of my life.  Who are they to take that from me?!
    22. Horrible, horrible company!  ASH will ruin the ability of acupuncturists to take insurance and force us to become cash only or concierge practitioners.  With a reimbursement rate of $40 this barely covers our overhead for rent, needles and other supplies.  It's degrading.  I have difficulty not giving my all to my patients, however, I have to limit the time I spend with them in order to run my business efficiently.  ASH cheats not only the practitioners but the patient.  It's wrong and unethical.  Furthermore, acupuncturist on staff at ASH oversee medical necessity reports and deny claims that should be approved.  I've needed to release patients before they were ready based on these denials.
    23. ASH is terrible to its practitioners that are contracted through them. They won’t pay them for proper evaluations of their patients. 
    24. This company needs to be removed from the insurance system. They will not address and issues from an honest standpoint.
    25. Much needed chiropractic services that I require in order to physically continue at my livelihood were disallowed. My chiropractic coverage was denied regarding a deductible that had been fulfilled (FACT) but was denied by ASH. My poor chiropractor was put through hoops. I am drafting a formal complaint with Kaiser Permanente although THAT health provider will probably blow off my claims as I am sure has happened with others. I need my chiropractor's services to the extent that I will try to manage paying for one visit a month.
    26. I would give minus 10 stars if I could for this company…The existence of ASH is the sign of narcotic drugs are still in great power in our medical system. If the majority of insurance companies are affiliated with ASH, their patients will be forced to turn to over the counter drugs or narcotics for pain management.
    27. So fellow yelpers, it has taken me a couple years but here is how you can possibly get reimbursed by ASH if you have blue cross PPO like I do:
      1. Expect the denial letters. Dont get mad. Go through the appeal and grievance protocol your insurance has. Expect their response to be ridiculous and not do anything about ASH.
      2. Make copies of these denials, get copies of your medical records clearly stating your condition and why it is medically necessary. Write a letter stating what you have had to go through up to this point.
      3. Fill out an Independent Medical Review form and submit your complaint to the Depattment of Managed Health Care. You need to make a strong case for yourself and back it up with medical records. They will review it and if they agree with you, they  will send a letter to ASH and/or your insurance company telling them they have to pay what the insurance policy says. 60% of the claims are approved by DMHC. IF ASH/Blue Cross refuses to pay at this point, take them to small claims court and you should win because the department of managed health care has already gotten involved. They are like the fraudulent insurance "police". At this point you have played by the rules, done everything they asked and a judge would clearly see how fraudulent they are.
      It took me almost 2 years but ASH finally reimbursed me closer to what the insurance policy says it should be. Now they are giving me issues with acupuncture but I will do the same thing again and am willing to go to court if they don’t honor what the insurance policy says. We pay a PPO monthly premium so it is not right to receive HMO care. This has literally been like a side job for me to figure out. I'm happy to answer questions and would recommend you all complain to your HR about their insurance options if they have anything to do with ASH! Anthem BC PPO is a good insurance except when it comes to paying for Chiropractic, PT and acupuncture visits. All other services they are good for in my personal experience. Keep at it until insurance companies stop partnering with ASH. SPEAK UP!
    28. I received a notice regarding a class action suit against this company. Seems like they got what was coming to them.
    29. Gaaaaaaarbage.
      I don't think I can overstate enough how terrible this company truly is. They incentivize poor quality care and dishonest documentation practices for chiropractors to get a maximum reimbursement of peanuts. I could go on and on about how worthless ASH is, and how horrible Cigna is for contracting this company, but ASH has, again, robbed enough of my time in compelling me to make this post warning people about the caliber of trash they are.
    30. FYI: ASH had Yelp delete my previous review from 2016, along with many other one star reviews that exposed their corrupt billing practices where they deny care patients need and pay doctors pennies to nothing.
      This company does not care for patients nor doctors.  Back when my claims were processed by ASH, even though I had 30 visits allowed a year, ASH denied my care (for low back pain) on the 8th visit.  My doc said ASH's response to the denial was that ASH felt that level 3 pain means I've reached a point where treatment are not needed anymore.  They're not the ones living with chronic pain, yet will dictate how much care they will allow you to receive despite the fact that you have a LOT more visits allowed in a year.  When my back pain eventually went up to 6 because ASH denied anymore visits early in the year, I went back to my doc and filled out ASH's medical necessity review to state why I needed 5 more visits.  ASH granted me 2 visits, saying that they felt the 2 visits were enough to get me where I don't need treatments anymore.  How can they justify that when they haven't examined me in person?
      The amount of money they reimburse doctors is a joke as well.  The max amount they allow a doctor to receive in a visit is $41, regardless of how many medically necessary services they do.  That $41 is my copay and what ASH will pay, combined.  Because of this, I have had to come back on separate days to get different treatments because one visit simply won't cover what I need.  Manicurists get paid way more than what ASH is paying doctors!
      I have switched insurance not long after, and am able to get my low back pain treated throughout the year without denials.  NOW I am able to regain quality of life.
    31. Stay away from this shady company. They act as a 3rd party claims processor for Cigna. My coverage with Cigna for Chiropractic care and massage therapy is 100%. ASH however invented a few "non-covered services" and refused to pay the chiropractor who then sent the bill to me. To be clear these "non-covered services" were 15-minute massages which Cigna confirmed were covered. Cigna is aware of ASH's illegal cost shifting and yet seem incapable and unwilling to intervene. This makes Cigna as dirty and shady as ASH and I just discovered that some lawsuits are already underway with similar story. Stay away from ASH.
    32. Steer clear. I am a doctor. I consistently witness patient care denial regardless of the nature of the patient's ailments or needs.  They are what is wrong with American health care.  I have had to raise my rates due to the excessive paperwork required by managed care companies like this one.  Absolutely disgusting.
    33. I'm wondering if Cigna/ASH better after two class-action suits?
    34. I am a health care provider as well as a consumer of heath care.  ASHN is the absolute worst third party administration insurance company.  They are a bottom line company that place profit over care.  They use a matrix of 5 visits.  After 5 visits you should be 50% better; if not then the care is "ineffective" and the patient should seek another form of care.  If the patients returns with an exacerbation they will only offer one visit and that is all.  They evaluate  exacerbations as the care was not "curative" in nature therefore ineffective.   They justify their existence and matrix as evidence based.  The only evidence that this is: they make more money   Ask providers they despise  ASHN!
    35. ASH is absolute garbage. Shame on Cigna and Kaiser for pairing with them.  As a medical provider, I can't afford to accept ASH patients anymore.  Not only are the reimbursements insultingly low but they make you crawl over broken glass to get paid.  The amount of paperwork demanded for such low reimbursement is untenable. I literally made more per hour as a cocktail server! I feel terrible for my patients, many of whom think they have "good insurance" only to find out what they really have is crappy ASH. It sucks that they will have to pay me cash or find a new provider, but running a business costs money and I have student loans to pay and a family to feed. Every colleague I have spoken to recently is planning to drop ASH (and all their affiliated plans) or has already done so. Pretty soon they won't have any providers left in network. #byefelicia
    36. They denied my insurance claim because they say my treatments were not medically necessary.  Listen, I don’t go to a chiropractor for fun.  I needed those treatments!  I will appeal!  This is ridiculous!
    37. You best change your insurance if ASH is involved.  the company was created to divert money away from patient care. it is an entity created solely to steal care and $$$ from insurance customers.
    38. I have been a practicing chiropractor for 30 years, and have never, ever dealt with a company like ASH.  If I request 12 visits for a patient, ASH gives us 8.  Request 10, you get 6.  Request 6, you get 2.  It has been that way year after year after year.  And now Horizon in NJ is going to contract with them.  When over 100,000 complaints went in to Dept of Banking and Insurance, Horizon sued the chiropractic state society as well a doctor and patient alliance group for a smear campaign.  It's like the big bully who finally gets punched in the nose and then goes running home to mommy.  ASH is evil incarnate.  Profits before patients.
    39. The only reason they get a 1 Star is because there is not an option for zero. This company has tons of complaints about ripping off customers, but businesses and practitioners that they work with are getting ripped off as well!
    40. Many patients of mine are receiving this "DENIAL" letter and cancelling their appointments. The letter is not a denial it's an adjustment to the number of visits granted to me through the Medical Necessity review form. I cannot see any other logical reason ASH would send these letters to my patients other than to discourage using their visits. You've stooped to a new low ASH!

  1. I wish I could give them negative stars.  They are incredibly unhelpful. I called to check my benefits, was told what I qualified for. Then my chiropractor called to double check my benefits, she was told the same. So I proceed to get the medically advised treatment. And then they denied my claim.
  2. Just shocked that Yelp has hidden over 66 negative reviews.  There is something very corrupt about ASH and I'm starting to think they are paying Yelp to protect their already horrible reputation from further damage.
  3. Who oversees this corrupt company's practices?  They need to be investigated!  Can we all go to the media to expose what they are doing to patients and providers?  I'm with you all in giving them zero stars.  How can they have 45 one-star reviews on BBB and all these reviews on Yelp and still have an A+ rating!??  Seem their legal dept is working overtime to prevent a class action lawsuit, but their practices are truly unscrupulous and deceptive.  They "win" every time and rip off the patient and medical providers.  It's just so wrong!  
  4. As so many others have noted, ASH is a scam company fronting as a third-party payment provider.  I am allowed 20 acupuncture sessions under my Anthem Blue Cross plan. I have submitted 10 claims, totaling $1000 and all of them have  been denied. I called to complain and was told flat out by a customer representative that they always deny claims for acupuncture,
  5. If there was a zero star option, I would have picked it.
  6. They lie. They will do anything to refuse coverage. They will waste your time. They will run you in circles. And they will simply deny your benefit.
  7. Worst insurance company EVER!  I have been forced to deal with them for 8 years now because BCBS in Arizona has been using them.  Now Cigna and Banner use them as well.  They simply are in the business to deny claims.  They allow 6 on average that pay $6-18 dollars per visit.  They have caused several practitioners to go out of business!  With that low reimbursement you cannot afford to treat those patients. The year after ASH took over BCBS claims, my reimbursements  went down 98% for the entire year.  It is unbelievable that they are allowed to do what they do.
  8. Does ASH need another 1 star review? Damn straight they do.
  9. Criminal behavior! Received a denial letter from them that  basically states that I don't have the condition my doctor and physical therapists have been treating me for 2 years! How can they “undiagnosed” a patient? They need to be sued already!
  10. There are no words that adequately capture how horrible this company is. They intentionally structure their organization in a way that makes it next to impossible for families and providers to receive timely and honest clinical reviews. 
  11. Add mine to the rest of the stories. I have Cigna as my provider but these guys act as a middle man with sole purpose of denying claims.
  12. All the comments are true. How this company is still in business is beyond finding out. They make it very difficult for the patient and the doctor. They restrict visits and say that I don't need any more treatments. My coverage says I have 30 but I could only use 5. The paperwork that these guys request from doctors is atrocious. Even though my doctor would send in the paper works, they still wouldn't approve any more visits. I am in pain and there isn't anything I can do. From what I know their reimbursement rate to the doctors is mere peanuts as well. When I get the chance, even though I'm going to pay more, I'm going to swtich from HMO to a PPO so that I won't have to deal with these scammers.
  13. I have never dealt with a more Dishonest insurance company in my life.
  14. This is the WORST company I have ever had to deal with. I really try to be fair, but there is something extremely shady going on with this company.
  15. I have a PPO plan that is serviced by American Specialty Health.  I went to my usual Chiropractor and they submitted the claims with 19 pages of supporting documentation.  Of course, ASH denied the claim for insufficient documentation and sent me a separate notice for every single claim they denied.
    This example of how they work leads me to the conclusion that they are in the business of denying claims, not providing a valid health insurance.
  16. I have had to endure working with this company for 10+ years. Believe the overwhelmingly negative reviews and disregard the canned ASH responses trying to get your personal information and ignoring the actual  complaints.
  17. I have Anthem Blue Cross and am thoroughly disgusted by the relationship that Anthem has created with ASH. My husband and I as well as our 2 kids have insurance PPO through Anthem. We are each supposed to receive up to 30 chiropractic visits per year under our plan. After 7 visits ASH has decided I am no longer in need of chiropractic care. It is not considered a medical necessity, even though I have had to change my profession because of the injury I am carrying around from lack of chiropractic care. Thanks for nothing! Total scam artists. What they are doing should be illegal. My pain is real and they get their payments but I don't get the care I pay for. If I could give no stars I would.
  18. This company is horrible. What they make patients go through is the saddest thing. It is obvious to patients and practitioners that this company is only out to make money while taking advantage of both sides of patient care....
  19. If I could give ASH a big fat zero, I would. They are in the business of keeping insurance executives rich and denying people the medical care needed to stay well. It's mind boggling that I'm paying for the highest health insurance option through my employer yet I'm denied claims left and right once they get handed to the ASH.
  20. BEWARE BEWARE BEWARE BEWARE
    If there was a ZERO STARS option I would be giving them -100. I thought I was the only one that was dealing with this ASH company and having the hardest time but looking through these comments I can see I am not alone.
  21. This company is like a canker. A sore that won't go away. I would rather kiss a slug than have to call this company. A putrescent mass, a walking vomit. A spineless little worm deserving nothing but the profoundest contempt. This company is a monument to stupidity. A stench, a revulsion, a big suck on a sour lemon.
  22. It doesn't matter how much you need the service, ASH will deny the claim. They are probably one of the most corrupt, illegitimate health care contractors in the US. We've had some of the top
    physicians in my area write and call them directly, petitioning on my behalf. And, yet, their "doctors" always say "not medically necessary". When asked what background and criteria the use, you'll often find out the physician reviewing your case has no background in that area.
  23. American Specialty Health is money making machine. They are not in this because they want to make sure your benefits are administered correctly. They are taking over services that the large insurance companies don't want to deal with - presumably because they are often ongoing - and have rigged a system that works against the policy holder and physicians.
  24. This place is a crock. They treat their employees like they are 8-year olds that misbehaves. There's no means of advancement here. The employees are just innocent pawns or puppets where management and executives make them "dance" to their liking. Like greedy whores, they turn away the best employees to make room for their upcoming bonuses.
  25. I would give ZERO stars if I could!!!!!!!!!!!!!!
  26. American Specialty is - hands down - the single WORST firm that I have EVER been forced to deal with!  They simply do NOT listen to the consumer, and do NOT send or process medical treatment requests and authorizations in a timely manner.  
  27. This company is paid to "review" and systematically deny claims.  It's cheaper for Cigna and Blue Cross small group to pay ASH to deny them than to just pay the claims.  Funny how they can never lay eyes on a person and make a better determination than the attending doctor.  It's illegal in California, but done so en-mass that they get away with it. If you do get something, it takes 6-9 months and is some pittance.
    I've NEVER seen consistent 1 Star ratings like this anywhere else on Yelp. They deserve every one- in droves.
  28. If there was a ZERO star rating, I'd go with that.  As a health care practitioner, I find ASH a despicable company for their practices of denying care and requiring documentation that is beyond unreasonable, robbing from the quality time that should be spent between a doctor and patient.  As a result of their denying claims that are legitimate and very necessary, my practice has decided to cut ties with Cigna and any other company that elects to associate themselves with ASH.  Deplorable is an understatement.
  29. Wish I could post zero stars. Worst experience with any business I've ever had. Terrible at getting back, doing what they say they've already done, communication with our insurance company... Truly terrible.
  30. They continue to leave me in tears.  I've tried to get answers, tried to get my chiropractic claims straightened out.  I'm getting delayed and denied.  I wish I'd known more before I utilized these benefits.    I'm not trying to rip anybody off, here.  They can't understand I've met my deductible through my actual insurer, they never tell me where I stand financially. This is all such a mess. And, I'm always getting their letters in my Saturday mail so I can wait two anxious days to find out how to deal with the next issue.  I've resorted to paying cash to the provider so I can STILL get treatment on my own terms.  Defeats the purpose of having insurance but oh well.
  31. If I could give this company no stars I would. I can't believe Cigna (which I've heard is a pretty good insurance company) would collaborate with such a horrendous company. This company was only made to deny claims on NO basis.
  32. Not sure why there aren't hundreds of reviews for this Awful Company. First of all, we pay high premiums to our insurance company to be able to choose who we want to see and to find out that they go through a third party company which in this case is ASH to determine if my care is medically necessary. Really? who are Anthem Blue Cross and ASH to decide if i really need it or not. I went to see a PT and Chiropractic after an accident and was denied treatment for visits because it wasn't serious enough according to ASH standards or they just pay pennies to the provider. Now most places that I want to go to does not take Anthem because they have to go through all these hoops to get visits.  Really!! Ugh. Now I have no other choice but to switch to a better quality insurance that does not deal with this ASH.
    Plus, customer service is worst than comcast. Got transferred to 4 different people that don't know what they are doing or saying when i just have one simple question about coverages. Keep getting the run around with these scums!!
  33. I would give this company 0 stars. I hope they are prepared for a class action. My son who has always has a brain condition that requires therapy and has never been an issue now, these people have made him regress and develop complications because they pushed us off on therapy.
  34. American Specialty Health denies 85% of my family's claims.  We are not overly ill. We are not seeking unnecessary medical treatments. We are not seeking narcotics. I have had whiplash four times in my life and I need chiropractic treatment from time to time to help me with pain and mobility but American Specialty Health finds a way to deny nearly all of my visits.  What good are they? If they are not serving the patients or the providers, who are they serving?
  35. Probably one of the worst companies I have ever dealt with.   They have taken over much of the claim processing for chiropractic care claim processing for Cigna, Blue Cross etc.   All is ok after 5 visits but after that, it gets flagged even though the insurance plan covers up to 30.  They were rude to my wife. Also, you should look at the law suits (google it) to see what this company is up to.  
    Also, the person who gave a 5-star rating Rating (Rachel F) is actually is the Social Media Coordinator at American Specialty Health.... Yelp is about independent reviews, not tooting the horn of the company you work for.
  36. Worst insurance company ever. Can't pay claims even if they are approved. Spend hours on the phone getting them to pay claims. AND their payout is incredibly low and insulting.

These complaints about ASH are real people expressing their anger and disappointment that need to be heard by the Insurance Commissioner’s office and the Board of Chiropractic Examiners. Obviously, by its inaction to create an ethical organization aimed on helping sick people, ASH has no interest to stop squeezing care with its unethical if not illegal measures that I will further elaborate.

ASH NOTICE OF TERMINATION

Dr. Thomas LaBrot, in a letter dated April 8, 2020, set in motion an effort to ban me, James C. Smith, DC, from ASH’s managed care program based on frivolous clerical errors. Please note there were no accusations of anything injurious to patient care, insurance fraud, or sexual harassment charges. It had nothing to do with my treatment plans or clinical techniques; it is simply a case of minor clerical errors.

Let me address the misguided accusations in the ASH NOTICE OF TERMINATION to show how petty, confusing, and unsupported its allegations are:

  • Regional X-Ray Protocol; CAP 06-2094 for X-Ray Protocol CAP 1027925-3 for X-Ray Protocol, X-Ray Quality:
    • JCS RESPONSE: We know the basic ASH protocol discourages x-rays no matter the case so we no longer send any imaging report knowing it will be rejected anyway.
    • Failure to Perform and/or Document Appropriate Patient Evaluations,
      • JCS: We document every office visit and spinal evaluations with ChiroTouch software.
      • Failure to Perform/Document Established Patient Evaluations At Appropriate Intervals to Assess Progress:
        • JCS: Most of our patients are given a re-exam on every 10th visit to assess progress with an eventual Progress Report to ascertain patients’ prognosis as per Medicare. However, these services are never done on any ASH patient because it terminates care on an average of 6.5 visits. I find this especially ironic considering ASH automatically reviews every patient on the 5th visit no matter what our treatment plan involves. If I were to assess patients on every 5th visit, I would be accused of over-utilization.
        • Failure to Document Objective Findings in Daily Treatment Notes That Support the Services Provided:
          • JCS: This is untrue as our SOAP notes are done at every visit with ChiroTouch
          • Failure to Initial or Sign Medical Record Entries:
            • JCS: This is automatically done by ChiroTouch software.
            • Failure to Utilize Adequate Patient Entry Forms:
              • JCS: We use the standard ChiroTouch software program, plus we have never had any other MCO, Medicare, DVA, or insurance carrier make this claim.
              • Billing for Services Not Supported by the Medical Records:
                • JCS: This is totally untrue and alleges we have committed insurance fraud; never has any other MCO or insurance carrier made this claim with my office. We utilize the standard musculoskeletal services on nearly every patient without problems from any other third-party payer.
                • Health and Safety Concern in Failing to Document Appropriate Management of Patients with High Blood Pressure Readings Upon Examination and No Record of Medical Management:
                  • JCS: We do not manage any patients solely with HBP; this is a totally fabricated issue showing how ASH is desperately searching for far-fetch accusations of mistreatment.
                  • ASH denial code 962 states in part, "They (the patient's complaints) may require co-treatment with a medical doctor or specialist":
                    •  JCS: My patients with HBP are already under the care of their local primary care physician and have no need of me to duplicate services.

As you can read, Dr. LaBrot is groping for any picayune issue he can find to accuse me of malpractice. None of these bogus charges have anything to do with serious violations such as improper patient care, insurance fraud, sexual abuse, or clinical iatrogenesis. This is a prime example of his chokehold on the necks of practitioners.

LaBROT GUILTY IN NEW JERSEY & KENTUCKY

In the New Jersey lawsuit, Dr. LaBrot was found guilty of:

  • Making utilization management determinations on chiropractic care by non-New Jersey licensed chiropractors in direct violation of N.J.S.A. §45:9-14.5 (2010).

In 2018, Dr. Thomas LaBrot also was found guilty in Kentucky of similar actions and I now contend he has done the same here in Georgia in my case:

In August 2012, Dr. LaBrot entered into an agreed order with the Kentucky Board, admitting violating statutory and administrative provisions related to his chiropractic license. Specifically, Dr. LaBrot admitted reviewing a patient’s chiropractic file without:

(1) having registered with the Kentucky Board to perform peer reviews in violation of Kentucky statutory law (Ky. Rev. Stat. Ann. § 312.200(3) (2014)), and (2) meeting the Kentucky requirements for performance of peer reviews (201 Ky. Admin. Regs. 21:095, § 1 (2014)). The Kentucky Board reprimanded Dr. LaBrot’s license for the violation and imposed a $1000 fine.

¶ 19 On May 29, 2015, the Administrative Law Judge (ALJ) issued her findings and recommendations. Among these findings was the ALJ’s conclusion regarding aggravating factors. The ALJ concluded “the primary statutory aggravated factor” to be Dr. LaBrot’s lack of contrition for the offense. The ALJ reasoned Dr. LaBrot, during his testimony, “denied any wrongdoing and consistently attempted to minimize the violation of Kentucky law.” According to the ALJ, Dr. LaBrot, as medical director, was responsible for overseeing the peer-review process and the credentialing of his staff. The peer reviews at ASH looked at the patient’s specific information, such as age, history, and clinical findings to determine the appropriate care based on those demographics and clinical findings. Not only did Dr. LaBrot fail to comply with Kentucky law but so did his entire staff. The ALJ rejected Dr. LaBrot’s assertions he merely violated registration requirements. Kentucky required peer-review training and maintained its own set of standards and protocols for the reviews and record keeping.

¶ 20 The ALJ found additional aggravating factors, including Dr. LaBrot’s testimony he was unaware of the Kentucky statute for registration and, concerning to the ALJ, the protocols for the peer-review process. Dr. LaBrot, upon entering the agreed order, admitted reviewing a chiropractic file: “Respondent reviewed a chiropractic file on Patient R.D. of Kentucky chiropractor D.P. and possible others.” But, during testimony, he repeatedly denied performing any peer reviews. The ALJ further concluded the fact the discipline was “recent” to be another aggravating factor.

In his appeal is noted:

 “Dr. LaBrot maintains he was accused of violating a purely administrative rule, having nothing to do with patient care, and the letter appears to align with his position he should not be further disciplined.”

¶ 47 On appeal, Dr. LaBrot maintains the sanction is overly harsh given the mitigating circumstances. Dr. LaBrot emphasizes in his 36-year career as a licensed Illinois chiropractor he had not been accused of misconduct involving patient treatment, had his privileges to practice restricted or modified, or been the subject of a professional negligence lawsuit. Apart from the Kentucky reprimand, Dr. LaBrot had not been investigated for any wrongdoing. Dr. LaBrot points to his community service, the fact the Kentucky violation was inadvertent, and no harm to a patient was alleged. Dr. LaBrot further points to the fact he and ASH acted quickly and responsibly to cure the registration requirements and comply with the agreed order. Dr. LaBrot, maintains the “aggravating factors” do not support the imposed discipline in light of the mitigating factors.

UNBLEMISHED RECORD

It appears the Appellate Court was gracious to acknowledge Dr. LaBrot’s “unblemished record” and mitigating circumstances to pardon his offenses and fine of $1000.00. May I suggest the same leniency is due in my case to show the same civility to our parallel situation.

Let me illustrate the similarities:

  • Dr. LaBrot [Dr. Smith] maintains he was accused of violating a purely administrative rule, having nothing to do with patient care.
  • Dr. LaBrot [Dr. Smith] emphasizes in his 36-year [40-year] career as a licensed Illinois [Georgia] chiropractor he had not been accused of misconduct involving patient treatment, had his privileges to practice restricted or modified, or been the subject of a professional negligence lawsuit.
  • Apart from the Kentucky [ASH] reprimand, Dr. LaBrot [Smith] had not been investigated for any wrongdoing.
  • Dr. LaBrot [Smith] points to his community service [Dawg Jawg[1]], the fact the Kentucky [ASH] violation was inadvertent, and no harm to a patient was alleged.
  • Dr. LaBrot [Smith] further points to the fact he and ASH [Smith’s office staff] acted quickly and responsibly to cure the registration [insurance paperwork] requirements and comply with the agreed order.
  • Dr. LaBrot [Smith] maintains the “aggravating factors” do not support the imposed discipline in light of the mitigating factors…violating a purely administrative rule, having nothing to do with patient care.”
  • “Given the mitigating factors, including Dr. LaBrot’s [Smith’s]previously lengthy and unblemished record, Dr. LaBrot’s [Smith’s] prompt action in correcting the problem, and the lack of any alleged harm to a patient, the sanction is overly harsh.”
  • Dr. LaBrot [Smith] maintains the “aggravating factors” do not support the imposed discipline in light of the mitigating factors.
  • On appeal, Dr. LaBrot [Dr. Smith] maintains the sanction is overly harsh given the mitigating circumstances.

In summary, the ASH punishment of my office does not fit the crime, just as Dr. LaBrot stated in his appeal to the Kentucky charges. The similarity of the mitigating circumstances is remarkable between Dr. LaBrot’s sanction and my sanction by ASH. In this light, I contend the ASH sanction against me is also “overly harsh” with the potential impact to deny patient access to my office and to impair my reputation and livelihood is unjust and based on spurious and unfounded charges. This ASH sanction must be prohibited.

My investigation into this episode will show Dr. LaBrot has lost any semblance of objectivity toward evidence-based guidelines for patient care evident by his double-standard that I will discuss in regard to his own book, Standard of Care. We see the conflict between his financial motivation and professional politics. He should not be involved in any case due to his conflict of interest nor has he revealed full disclosure with my case.

FEDERAL BCBS BATTLE

After years of fighting with ASH on other picayune issues, in disgust I finally voluntarily resigned in August 2019 after reading Dr. Rick Cole’s article, The Moral Dimension of Network Participation: Let's Stop the Abuse. Little did I realize that would lead to a new set of problems that continue to this day.

My share of ASH problems in the past led me to stop accepting assignment on ASH patients by either switching them to private pay status or regrettably not accepting them as patients to avoid the inevitable problems with ASH. Another retaliatory tactic by ASH when patients complained about cutting their benefits is to make the provider the scapegoat suggesting to disgruntled patients their DC did something wrong, never ASH. This policy, of course, plays into the hands of ASH by saving them more money when patients drop out or when providers refuse to accept ASH programs—the ultimate “squeeze” to “expand profits.”

Nonetheless, little did I know of an unexpected twist that leaving ASH would deny me access to the lucrative Federal BCBS programs that do not follow ASH’s clinical or administrative criteria. I have never read anything nor was I forewarned by ASH that leaving ASH’s draconian program would automatically eliminate my office’s preferred provider participation in the lucrative Federal BCBS programs at Robins AFB that do not follow ASH’s draconian guidelines, which is by far the largest chiro market on base.

It also subjected me to unwarranted public humiliation impugning my reputation when ASH sent a letter to every BCBS policy holder at Robins AFB stating I was no longer a “preferred provider” implying I had done something immoral, illegal, or unethical. ASH sent a letter to all Federal BCBS members even those who were not my patients that I was no longer an in-network preferred provider as of Sept. 21, 2019, branding me as some sort of outcast.

Reluctantly, I swallowed my pride and sought reinstatement upon appeal but lost many patients due to its letter that soiled my brand. Now months later over the confusion in the administration of a mere 5 patients, Dr. LaBrot has decided to expel me from this marketplace again on spurious reasons that had nothing to do with patient care.

As Dr. Louis Sportelli revealed, “DCs were automatically enrolled in many silent networks often without their knowledge or actual permission.” Conversely, it appears DCs can be automatically removed from programs as well.

Seeking clarification why resigning from ASH also removed me from the Federal BCBS programs, I wrote to Danielle Walton, regional director for Anthem BCBS about this conflict, but she could not explain to me why leaving ASH would automatically eliminate our preferred provider participation in the Federal BCBS programs at Robins AFB that do not follow ASH’s guidelines.

Here is the main scam: ASH uses the lucrative Federal BCBS programs as leverage to keep chiropractors in the stringent programs it controls such as Anthem BCBS, Aetna, and Cigna, which was a co-defendant in the New Jersey lawsuit. Apparently ASH has DCs over a barrel, another example of a chokehold.

As you can see from the federal BCBS plans below, patients in the Standard Option (#104/#105) expect 12 visits annually whereas the Basic Option (#111, #112, #113) offers 20 chiropractic visits annually. None of these programs follow the draconian ASH guidelines whatsoever. They are not exposed to arbitrary “medical necessity” that limits the number of office visits nor are we denied using spinal x-rays for diagnostic analysis.

 

THE 3RD RAIL: POLITICAL RETRIBUTION

Let me also note I have practiced for 40 years without any insurance problems with any other payer until ASH came into the picture—a common scenario for many DCs. I have reason to believe this reprimand has more to do with a 3rd rail — my outspoken political opposition to ASH as a journalist rather than any significant clerical issues or practice malfeasance as a practitioner.

I believe this accusation by Dr. LaBrot has nothing to do with my so-called “non-compliance” with “best practices guidelines” as much as it has to do with retaliation by a vindictive staff at ASH. I believe Dr. LaBrot has a political ax to grind with me considering I have a long outspoken professional conflict with Dr. LaBrot and the ASH policy for years. I have been a frank critic of ASH’s draconian policy and have written recent articles on my blog at Chiropractors for Fair Journalism such as The Ignoble Experiment and The Chiropractic Waterloo.

My fight with ASH began in the early 2000s with Kurt Hegetschweiler, DC, former ACA president before he sold-out and went to the dark side to become an executive vice president at ASH. I had written on my blog about the stringent policy at ASH. Since he and I were friendly while members in the ACA, he paid a visit to my office here in middle Georgia to placate my complaints knowing I had a voice in the profession as an author and blogger. At lunch he explained to me how ruthless the MCO business was and, apparently, he was right since he was fired from ASH in 2007.

Dr. LaBrot’s attack upon me is clouded by a political vendetta considering he is a partisan in a group of “anti-vertebral subluxation” extremists, philosophical / academic agnostics, and pro-medical naysayers within chiropractic who hate classic chiropractic concepts, such as the profession’s mainstay cornerstones — the concepts of vertebral subluxation, vitalistic philosophy, and the Palmer concept of clinical analysis and neuroscience in general, aka, the Big Idea.

In full disclosure, I graduated from Life University, another Palmer-oriented chiropractic college. While a student I worked as a writer for Dr. Sid Williams, founder and first president at Life, and more recently I worked for the current president, Dr. Rob Scott, as a research assistant.

I daresay Dr. LaBrot’s political partisanship was evident in a shocking public display at the ACC-RAC educational/research conference in 2012 in Las Vegas when I witnessed a verbal assault by LaBrot when he shouted out in a Q&A session that  Dr. Rob Scott, who had just finished his plenary speech on vitalism to the audience, was a “threat to humanity.” I kid you not!

After his obnoxious outburst at the conference, I posted an article on my blog about LaBrot’s unprofessional behavior that was sent to my list of leading chiropractic politicians, educators, and researchers. I also sent a copy to Dr. LaBrot; no doubt he still bristles from my story of his unprofessional outburst that illustrated his depth of resentment.

The gall of LaBrot’s accusation was shocking at a professional meeting, not only by his wrath, but also by the irony coming from an officer of the leading MCO company using draconian policies with bogus guidelines that “squeeze care to expand profits” that are truly a real “threat to humanity” by denying proper care to thousands of patients and depriving a fair livelihood to thousands of DCs.

I also occasionally communicate with the ASH Advisory Committee to discuss its draconian policy. Here is the list of “advisors”:

On occasion I have emailed every member of the ASH Advisory Committee including Dr. LaBrot to share with them my critical viewpoint of ASH. Of course, such admonition falls on deaf ears.

No doubt I have been a thorn under Dr. LaBrot’s saddle to openly criticize his draconian leadership. I believe this reprimand by ASH to my office is partially in retaliation for being forthright about speaking truth to power. This over-reaction by ASH in my case consisting of a mere five cases with clerical errors to which we had already corrected is clearly a small issue but used as a hidden political agenda by Dr. LaBrot to cast a wider net.

In his letter of denial he clearly stated a threat to me:

ASH Group may have a contractual obligation to report the adverse action against you to the following bodies:

a)              National Practitioner Data Bank

b)              State Board of Chiropractic Examiners

Dr. LaBrot has embellished five minor clerical errors into “high crimes and misdemeanors” that he thinks require notification to the GBCE. This scare tactic was part and parcel of the smear campaign when ASH sent thousands of letters to all Federal BCBS policy holders to defame my reputation after I resigned from ASH last year. Now it appears Dr. LaBrot is ready to defame me again on these minor clerical mistakes.

It is obvious I cannot receive a fair hearing from ASH; therefore, I suggest Dr. LaBrot recuse himself from my case. Indeed, it might be best if the Arizona Board of Chiropractic Examiners were to stand in judgment of this case since Dr. LaBrot now acts both as a false accuser and a biased judge. Indeed, it might be best to have another court case in Arizona to investigate the same illegal policies as the New Jersey and Kentucky lawsuits broached.

JCS VITAE HIGHLIGHTS

Since ASH has a way to dehumanize patients and providers, in my own defense let me first introduce myself as a DC who is more than ASH Provider Number: 1027925. I have practiced for over 40 years without incidence, adhered to the best chiropractic science, clinical guidelines, spinal rehab techniques, and am active in the chiropractic profession on many levels.

  • I’ve taught for years a continuing ed class, Research Trends in Chiropractic, at many chiropractic colleges (Life U, Cleveland, National, Western States, LACC, NYCC, Palmer, and the British Chiro Assn) so I am well aware of the current evidence-based research and political issues in our profession.
  • In 1991 my office was certified by the Chiropractic Rehabilitation Association as a recognized Nationally Certified Chiropractic Rehabilitation Facility.
  • Presently I used the best in classic chiropractic care with the Pettibone method, Pierce-Stillwagon technique, the Cox Flexion-Distraction Technic, the Nonsurgical Spinal Decompression method, numerous extremity adjusting techniques, to name a few of the leading-edge technology utilized in my office.
  • I was presented in 2002 the ACA Chairman’s Award for Outstanding Service to the Chiropractic Community for my role investigating the dubious deeds of Sid Williams and Terry Rondberg.
  • I have written nearly 600 articles and 5 books on chiropractic issues, namely the medical and media wars against chiropractors. You can read these articles at Chiropractors For Fair Journalism.

Let me reiterate in my 40-year practice I have never had a single malpractice lawsuit, nor have I been sanctioned by the Georgia Board of Chiropractic Examiners. Now for ASH to suggest I am in violation of evidence-based guidelines to the level requiring my banishment is certainly ridiculous. I do not choose to be a participant in ASH, but it has me “over a barrel” and helpless by controlling the lucrative federal programs at Robins AFB that do not adhere to ASH’s draconian guidelines. Nevertheless, I have learned ASH has the power to remove me from the federal BCBS programs when I violate its state level programs.

I will show the ASH model of care is not “best practices” by any stretch of the imagination. In fact, ASH can be accused of creating its own Frankenstein chiropractic  “cookbook” that terrorizes and exploits patients and the chiropractic profession alike as the New Jersey lawsuit suggested: "cutting benefits appears to be the business model of American Specialty Health.”  

VIOLATIONS BY ASH

Undoubtedly, these harsh patient criticisms of ASH resonate around the nation. Numerous experts and chiropractic groups concur that ASH is a danger to the welfare of patients who are denied their contracted chiropractic services and demeaning DCs’ ability to  offer quality care evident by its unsupported justification to limit spinal imaging and to ridiculously reduce the length of care that are shown to be baseless in reputable guidelines.

Indeed, ASH has become a pariah in the healthcare MCO industry that needs to be investigated by every state government as we recently witnessed in New Jersey where ASH was fined $11.75 million for the same dirty tricks as these BBB and YELP reviewers indicated and as I have experienced.

Under the guise of evidence-based medicine (EBM) and its chokehold excuse of “medical necessity” to limit care, ASH gives itself license to interfere with the doctor-patient relationship, arbitrarily curtails care, denies essential services such as plain film x-rays, and short-changes the patient’s expectations to the length of care and contracted services.

In its own defense, spokesman Dr. Thomas LaBrot at ASH stands behind ASH’s skewed shield of EBM to justify its draconian measures and his absurd accusation against my office for taking x-rays on new patients:

“…non-compliance with evidence-based best-clinical practice guidelines may be considered a pattern of performance that is unacceptable to ASH Group…”

The irony of ASH’s statement regarding “evidence-based best-clinical practice guidelines” is surprising coming from an MCO that promotes  the most egregious sub-optimal level of professional acumen (truncated treatment plans, no x-rays, no active rehab, no maintenance care, no progress exams/reports) and has been the subject of lawsuits condemning its harsh cookbook policies.

Indeed, I find it quite offensive and unfounded that ASH has the temerity to suggest standard classic chiropractic clinical procedures such as a diagnostic x-ray exam and my customary “practices are not in accordance with professionally recognized standards of practice.”

ASH also states I have “a pattern of performance that is unacceptable to ASH Group…” Indeed, ASH’s hidden hand is its desire to deny x-rays and put a chokehold on the number of office visits solely in order to “squeeze care to expand its profits” that has nothing to do with safety or clinical efficacy.

This intimidation occurs I believe because in their own defense few DCs and regulators understand the current raging debate concerning EBM. Nor do they know of the many EBM experts who oppose the defense used by ASH. Gaslighting DCs seems to be the tactic used by ASH to confuse and intimidate unwary patients and providers. This is beyond calling the kettle black — it is delusional but has gone unchallenged here in Georgia.

This ASH claim that I and all other classic chiropractors who do comprehensive exams and treatment plans are in “non-compliance with evidence-based best-clinical practice guidelines” is nonsense considering I will show there are more evidence-based guidelines supporting our brand of comprehensive care than the draconian measures used by the ASH guidelines.

I will also show Dr. LaBrot flipped on the standards of care as the Arizona Chiropractic Society revealed.

In effect, ASH has its boot on the neck of every DC in its MCO thereby strangling the care of every patient and driving them to the dire world of medical spine care awaiting them with possible opioid addiction, ineffective spinal injections, and risky, expensive spine surgery that has a nearly 50% failure rate. This is not by accident, but by design by ASH to divert expenses to  medical insurances away from its MCO services..

As I have experienced, DCs are forced to submit to ASH’s harsh policy or else be denied access to better markets that do not follow its sup-optimal standards but are still administered by ASH such as the Federal BCBS programs at Robins AFB near my office. This trickery occurred, according to Dr. Louis Sportelli, because “DCs were automatically enrolled in many silent networks often without their knowledge or actual permission.” When providers like me attempt to quit the draconian ASH program, they are also automatically removed from the more lucrative Federal BCBS programs that do not follow ASH’s unreasonable measures. Indeed, ASH has us “over the barrel” or, more aptly, ASH has its “boot on our necks.”

REMOVING THE CHOKEHOLD TO BETTER CARE

It is past time for the Market Oversight Division to investigate this malicious group of unethical and greedy ASH employees just as New Jersey did recently. If not, ASH will continue to prevent more patients from getting adequate chiropractic care as patient testimonials from the Better Business Bureau clearly state. It is past time to remove ASH’s boot from the necks of patients and chiropractic professionals alike.

This ASH pandemic in our profession is widespread, not merely isolated to my case. Richard L. Cole, DC, DACNB, FIACN, DAAPM, filed a lawsuit against ASH in Tennessee in October 2011 revealing its perverse motivation to make profits by cutting claims:

“MCOs like ASH are not attempting to improve patient care. They are only concerned with lowering the cost of the care and attacking the expense by lowering the fees, lowering the access, and limiting the number of approved procedures.

“Plus, we need to remember that the managed care companies earn a financial bonus for not paying claims. They are paid a set dollar figure per member, per month. With these dollars, they pay your bill and get to keep the difference.”

Jeff Randolph, Esq., summarized ASH’s violations of many statutes:

“The [New Jersey] case was originally filed in 2012, and the recent settlement ends a six-year legal battle in which out-of-network chiropractors nationwide claimed Cigna and ASH, its utilization management company, improperly denied medically necessary care, carried out deceptive business practices and impeded patients' access to health care.”

ASH’s draconian policies recently litigated in New Jersey were found to be in violation of many statutes. Regrettably, the same violations occur in Georgia and need to be investigated to protect the public and DCs from ASH’s exploitive control of chiropractic services.

  • In effect, ASH is conducting “institutional looting” by denying the contracted services patients pay for and expect to receive. This “bait-and-switch” situation is clear when the average office visit is limited to 6.5 rather than the 12, 24 or 30 visits patients expect.
  • As well, ASH’s draconian clinical policy has restricted practitioners to sub-optimal practices such as its spinal x-ray prohibition unsupported by evidence-based research as many chiropractic experts such as Dr. Terry Yochum, author of the leading text on radiology now states.
  • Dr. Lou Sportelli explains, “ASH and other MCOs seized an opportunity to provide a review service for a “piece of the action,” a perverse motivation to deny claims to increase profits.
  • Richard L. Cole, DC, DACNB, FIACN, DAAPM, filed a lawsuit against ASH in Tennessee in October 2011 revealing its perverse motivation to make profits by cutting claims: “MCOs like ASH are not attempting to improve patient care… managed care companies earn a financial bonus for not paying claims.” 

EVIDENCE-BASED GUIDELINES

Anyone familiar with evidence-based guidelines (EBM) realizes ASH’s stance is on thin ice.

The founder of EBM, David L. Sackett, MD, would disagree with ASH’s interpretation of evidence-based practices. He wrote that “best practices” constitutes more than just evidence-based information gleaned from the scientific literature”, the strategy used by ASH to cut costs. Indeed, Sackett warned of efforts to cut services as we now see with ASH that tyrannize our patients and profession:

 “Some fear that evidence-based medicine will be hijacked by purchasers and managers to cut the costs of health care. Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough. Without clinical expertise, practice risks becoming tyrannized by evidence.” [2]

Dr. Sackett is spot-on with his warning that EBM will be “hijacked by purchaser and managers to cut the costs of health care.” In this regard chiropractic care continues to be tyrannized by ASH cost-cutters as I have experienced for years.

Dr. Rick Cole also explains this tyranny:

ASHN controls cost by several mechanisms. First, they have a significantly lower fee schedule. Chiropractors are reimbursed on average 30% of what medical doctors are reimbursed for the same services. Secondly, they limit the amount and types of services that can be reimbursed by contract. While the best medical evidence supports simultaneous interventions for the treatment of musculoskeletal conditions, chiropractors can only use one therapeutic intervention per visit. So, the chiropractic physician must choose between therapeutic interventions like electric stimulation, ultrasound, myofascial release, or exercise while a multimodal approach is most effective.

Finally, they require chiropractors and their patients to fill out several pages of paperwork every few visits to allow for authorization of care that ASHN determines is appropriate. This paperwork requirement tends to frustrate the patients and certainly is a hassle for the chiropractic physicians and staff. As the frustration and hassle of seeing a provider goes up, utilization goes down. ASHN makes it clear in provider notifications that chiropractic physicians with more than a 6.5 visit average per year per patient will be required to submit more forms and will be under greater scrutiny.

In light of the scholarly comments by Dr. Sackett and empirical expertise by Dr. Cole, I have requested ASH provide any evidence-based guideline (other than its own) that requires pre-authorization of “medical necessity” via the requirement of re-evaluation on the 5th visit, the justification for its average of 6.5 office visits, and the prohibition of spinal x-rays for “nonspecific” back pain (which I will show is a misapplied medical misnomer, not a chiropractic term).

Since the Consumer Services Division – Managed Care is empowered to protect consumers’ welfare from unscrupulous actors, I urge the insurance commissioner to investigate this sordid situation to stop ASH’s looting both patients and our profession under false claims of EBM just as New Jersey did recently.

As the facts will show and the patients’ testimonials revealed, ASH epitomizes what is terribly wrong with for-profit healthcare whose corporate goal is to “squeeze care to expand profits.” As the New Jersey lawsuit stated, “cutting benefits appears to be the business model of American Specialty Health.” 

Here are evidence-based clinical practice guidelines that are commonly used in the chiropractic profession but ignored by ASH:

CLINICAL PRACTICE GUIDELINE: CHIROPRACTIC CARE FOR LOW BACK PAIN

Gary Globe, PhD, MBA, DC, Ronald J. Farabaugh, DC, Cheryl Hawk, DC, PhD, Craig E. Morris, DC, Greg Baker, DC, Wayne M. Whalen, DC, Sheryl Walters, MLS, Martha Kaeser, DC, MA, Mark Dehen, DC, and Thomas Augat, DC

J Manipulative Physiol Ther. 2016 Jan;39(1):1-22.

This consensus was more realistic in its clinical program that averaged 2-3 visits for 2-4 weeks for acute and sub-acute cases.

WHIPLASH GUIDELINES

Adapted from Arthur Croft, DC, MS, MPH, FACO, FACFE, FAAIM: Treatment paradigm for cervical acceleration/deceleration injuries (whiplash).   Am Chiro Assoc J Chiro 30(1):   41-45, 1993.

MEDICARE GUIDELINES ON IMAGING OF SUBLUXATIONS

Despite ASH’s refusal to acknowledge the routine use of spinal x-rays to develop a specific chiropractic diagnosis to detect vertebral subluxations, Medicare Services is very keen on this neuromusculoskeletal diagnosis, in fact, it demands it.

As you can read for yourself, the documentation of subluxation via spinal x-rays is an accepted method per Medicare Services. “The patient must have a subluxation of the spine, as demonstrated by x-ray or physical exam.” For ASH to deny this diagnostic x-ray tool, perhaps the most scientific in our arsenal, is an affront to practitioner professionalism, adequate diagnosis, and proper patient care.

PROGRESSIVE WORKER COMP GUIDELINES

A good example of implementing chiropractic care is already available at Chiropractic Physicians’ Guide to Oregon On-the-Job Injuries. Two notable items are a far cry from the ASH policy:

  • Pre-authorization

Generally, insurers do not have to issue pre-authorization for any treatment. An exception is for imaging studies other than plain film X-rays.

As a chiropractic physician you may, from the first visit on the initial claim do both of the following:

  • Provide treatment up to 60 consecutive days or 18 visits, whichever comes first

New York State has used the American College of Occupational and Environmental Medicine to develop Medical Treatment Guidelines for spinal manipulation. As you can see, this guideline also contradicts ASH’s policy of treatment:

D.10.a.i Manipulation is recommended for treatment of acute back pain when tied to objective measures of improvement.

Frequency: Up to 3 times per week for the first 4 weeks as indicated by the severity of involvement and the desired effect, then up to 2 treatments per week for the next 4 weeks with re-evaluation for evidence of functional improvement or need for further workup. Continuance of treatment will depend upon functional improvement.

 Optimum Duration: 8 to 12 weeks.

 Maximum Duration: 3 months. Extended durations of care beyond what is considered “maximum” may be necessary in cases of re-injury, interrupted continuity of care, exacerbation of symptoms, and in those patients with co-morbidities.

D.10.a.ii A maintenance program of spinal manipulation (by a physician (MD/DO), chiropractor or physical therapist) may be indicated in certain situations, after the determination of MMI, when tied to maintenance of functional status. (See Section D.11, Therapy: Ongoing Maintenance Care.)

The new protocol was developed from evidence-based medical guidelines that show most back strains and sprains resolve within six weeks with conservative nondrug, nonsurgical treatments. Some of these mandatory guidelines effectively create a waiting period for surgery even where not explicitly stated.

 

Unfortunately, the Georgia State Workers’ Compensation program cannot be used as an example of a progressive state regarding injured workers’ right to seek chiropractic care although a legal benefit. I submitted an extensive analysis about this racketeering to the State Inspector General’s office but have not heard back. You can view this fascinating account at Reforming Georgia’s Workers’ Compensation Program Through Choice, Competition, & Chiropractic Care.

 

BAD PRESS FOR ASH

There are many examples how ASH has failed to act in good faith to manage chiropractic benefits as the patients and providers expect. My complaint about ASH is not limited to Georgia, but a systemic problem across the country.

Apparently, ASH did not learn its lesson from the recent New Jersey lawsuit settlement that fined ASH  $11.75 million for the same irregularities it is now doing to me and other Georgian chiropractors.

This case was mentioned recently in two articles in Dynamic Chiropractic, a professional journal. Please take time to read these short articles that explain how ASH has been short-changing both patients and chiropractic providers. Here are excerpts:

A Victory Worth $11.75 Million

Dynamic Chiropractic, November 2019
By Jeff Randolph, Esq.

United States District Court Judge Nitza I. Quiñones Alejandro, who sits in the Eastern District of Pennsylvania, has approved an $11.75 million settlement of a class-action lawsuit filed by chiropractors against Cigna Insurance and American Specialty Health Networks (ASH), which was contracted by Cigna to administer chiropractic claims for its subscribers.

The case was originally filed in 2012, and the recent settlement ends a six-year legal battle in which out-of-network chiropractors nationwide claimed Cigna and ASH, its utilization management company, improperly denied medically necessary care, carried out deceptive business practices and impeded patients' access to health care. In particular, the class-action suit claimed that Cigna / ASH engaged in a business practice and pattern of:

  • Issuing false and misleading reports relating to chiropractic claims including Explanations of Benefits ("EOB") informing subscribers of how their chiropractic claims have been processed. These falsified reports misrepresented the amount insureds owed for health care services, leading to greater out-of-pocket costs than were properly charged under their plans, while also interfering with the doctor-patient relationship because they mischaracterized the administrative fee owed to ASH as a medical cost.
  • Reporting inaccurate Medical Loss Ratio ("MLR") due to the inaccurate EOBs above which allowed them to misrepresent the ASH administrative fee as a medical expense, thereby minimizing the potential for paying rebates to insureds required by the federal Patient Protection and Affordable Care Act ("PPACA").
  • Adopting utilization review and pre-certification requirements which imposed restrictions on coverage that were not included in the subscriber's insurance plans.
  • Making utilization management determinations on chiropractic care by non-New Jersey licensed chiropractors in direct violation of N.J.S.A. §45:9-14.5 (2010).

The class-action lawsuit in New Jersey arose, in part, from a Market Conduct Study of ASH conducted by the New Jersey Department of Banking and Insurance in 2012. As a result of the study, NJDOBI inspectors found that "the Company's practices did not accord fully with various provisions of New Jersey insurance statutes or regulations ... where the frequency of error was such as to constitute an improper general business practice" (NJDOBI Market Conduct Study Consent Order E12-101). The NJDOBI inspectors found error ratios of 56 percent on electronic claims and 55 percent of paper claim for a total error ratio of 56 percent for random files. The examiners found significant errors in the following claim adjudication areas:

  • § Failure to adjudicate claims in accordance with the provider contract and fee schedule
  • § Failure to adjudicate CPT 98941 (3-4 regional spinal adjustment) and improperly denying the benefits for these chiropractic claims
  • § Failure to adjudicate CPT 97140 (manual therapy, aka, massage therapy) and under-paying the benefit
  • § Unfair denials due to failure to comply with Treatment Form Waiver Program
  • § Systemic claim settlement delays
  • § Improper copayment assessment
  • § Failure to provide reasonable Explanation of Benefits and utilization of misleading statements on Provider Remittance Advices (improper General Business Practice)

The NJDOBI noted that American Specialty Health misrepresented pertinent facts or insurance policy provisions on its EOBs by including its administrative compensation in the amount billed section of the form. The NJDOBI examiners concluded: "Accordingly, the EOB is untrue and misrepresents pertinent facts, contrary to N.J.S.A. §17B:30-13.1a."

Below are a few excerpts about this case from articles published in Dynamic Chiropractic:

The case was originally filed in 2012, and the recent settlement ends a six-year legal battle in which out-of-network chiropractors nationwide claimed Cigna and ASH, its utilization management company, improperly denied medically necessary care, carried out deceptive business practices and impeded patients' access to health care. In particular, the class-action suit claimed that Cigna / ASH engaged in a business practice and pattern of:

  • Issuing false and misleading reports relating to chiropractic claims including Explanations of Benefits ("EOB") informing subscribers of how their chiropractic claims have been processed. These falsified reports misrepresented the amount insureds owed for health care services, leading to greater out-of-pocket costs than were properly charged under their plans, while also interfering with the doctor-patient relationship because they mischaracterized the administrative fee owed to ASH as a medical cost.
  • Reporting inaccurate Medical Loss Ratio ("MLR") due to the inaccurate EOBs above which allowed them to misrepresent the ASH administrative fee as a medical expense, thereby minimizing the potential for paying rebates to insureds required by the federal Patient Protection and Affordable Care Act ("PPACA").
  • Adopting utilization review and pre-certification requirements which imposed restrictions on coverage that were not included in the subscriber's insurance plans.
  • Making utilization management determinations on chiropractic care by non-New Jersey licensed chiropractors in direct violation of N.J.S.A. §45:9-14.5 (2010).

Here is the follow-up article about the legal woes of ASH.

ASH Dealt Another Blow

Dynamic Chiropractic, Dec. 2019

American Specialty Health, which recently agreed to an $11.75 million settlement, along with Cigna, in a chiropractor-initiated class-action suit filed against the two, has been dealt another blow. The New Jersey Department of Banking and Insurance has disapproved a proposed partnership between ASH and Blue Cross Blue Shield of New Jersey, as revealed in an Oct. 16, 2019 letter from N.J. DOBI Office of the Commissioner to Amy Boright, executive director of the Association of New Jersey Chiropractors:

"On Aug. 16, 2019, the Department received a contract for its review regarding a possible partnership between Horizon Blue Cross Blue Shield of New Jersey and ASH for the Horizon BCBSNJ Chiropractic & Physical Medicine Services Program. The department reviewed it and, on Oct. 11, 2019, disapproved the contract. Horizon and ASH may resubmit a new contract for the department's review."

This legal trouble for ASH is certainly not its first, but now includes retaliation against provider groups who oppose its poor behavior such as indicated in another case in New Jersey. In this case, ASH and Horizon BCBS claimed it was smeared by disgruntled medical providers, a similar tactic used by Brown & Williamson Tobacco against Jeffery Wigand, the whistleblower who appeared on “60 Minutes”.

Horizon BCBS Sues Physician Advocacy Group Over 'Smear Campaign'

Morgan Haefner - Tuesday, September 3rd, 2019

Horizon Blue Cross Blue Shield of New Jersey sued a physician advocacy group after the group urged patients to fight the insurer's new claim oversight contract, according to the New Jersey Record.

Horizon filed a lawsuit in U.S. District Court against the New Jersey Doctor-Patient Alliance. The 350-member group represents independent physicians and other medical professionals like chiropractors and physical therapists. Horizon claimed the group launched a "smear campaign" against the insurer after it decided to sign a contract with American Specialty Health to review claims and determine medical necessity for Horizon members.

In its criticism of the contract, the Doctor-Patient Alliance said that "there could be a steep increase in improper claim denials" due to the change, according to the New Jersey Record. The alliance called the contract "bad news" for Horizon patients and claimed "cutting benefits appears to be the business model" of American Specialty Health.

Horizon requests in its lawsuit that the alliance take down any ads and petitions opposing the contract. The insurer also wants the alliance to post "corrective advertising" and reimburse Horizon for any economic losses incurred by what it deems false and misleading advertising. The provider advocacy group rebutted, saying the lawsuit aimed to quiet free speech among its members and their patients.

Read the full report here.

American Specialty Health also filed a similar, but separate, lawsuit in federal court against the Doctor-Patient Alliance and the Association of New Jersey Chiropractors, which has waged a parallel campaign against the Horizon partnership.

"We believe that there have been many false and misleading statements, and we are committed to getting truthful information out to the public," Lisa Freeman, a spokeswoman for American Specialty, said of the lawsuit. The company is "committed to setting the record straight," and "to implementing the Horizon program and serving New Jersey residents," she said.

In response, the head of the chiropractors' association accused American Specialty of "attempting to stifle the free speech and expression rights of our members and, more importantly, their patients," by filing the lawsuit.

"In our opinion, [American Specialty Health] has a history of denying care, improperly paying claims, and creating roadblocks to conservative care," said Amy Porchetta Boright, executive director of the association. "We will not be silenced when trying to educate the public. ... New Jersey residents should be allowed to voice their opinion to legislators regarding concerns they have with their benefits,"  

Horizon’s plan, announced in August, has generated a flood of opposition from the providers affected. They and their patients had sent more than 170,000 emails to legislators and insurance regulators by last week, according to the chiropractors' association.

Dr. Peter DeNoble, an orthopedic surgeon in Wayne who is president of the alliance, said “everything we put out there is based on fact. “When we go to court,” he said, “we will be able to present a trove of information” about the experience of the group's members with American Specialty Health through another insurer, Cigna, with which American Specialty has a contract. 

The alliance has about 350 members, DeNoble said. They are physicians and other providers who are "on the ground, seeing patients at the working end of [American Specialty Health’s] denials.” 

American Specialty Health has said it will review some claims after the patient has visited the provider five times, to see if they are medically necessary. This will increase the paperwork burden on providers and could delay or interfere with treatment, critics of the plan said.

If Horizon members cannot make full use of the 30 visits most plans cover, it may also cause financial harm to independent chiropractors and physical therapists, DeNoble said. That will “hurt the small business, the mom-and-pop shop, that provides the higher-quality, more personal care,” he said.  

 

Attorney Jeff Randolph, Esq., revealed ASH as managers of Anthem BCBS and other programs was guilty of “Adopting utilization review and pre-certification requirements which imposed restrictions on coverage that were not included in the subscriber's insurance plans.”

This is exactly the point I am making with the Federal BCBS program at Robins AFB that ASH administers but do not follow the draconian ASH guidelines. Indeed, there is no mention in the Federal BCBS patient recruitment brochures that patients are subjected to:

  • pre-authorization requirements,
  • a prohibition of spinal x-rays,
    • an automatic 5th visit reevaluation for “medical necessity” that is used to arbitrarily curtail further care, thus
    • denying patients’ access to their full benefits,
      • nor is there any mention that resigning from ASH automatically removes a provider from the Federal BCBS programs at Robins AFB.

After reviewing the evidence I will present against ASH, any impartial observer will agree ASH has “tyrannized” patients and DCs alike driven by “top-down directives” aimed to “squeeze care to expand profits” that should call for ASH’s brand of managed care as an example calling for the “rejection of evidence-based medicine as a failed model”.

Dr. Rick Cole mentioned the ruse of managed care promoting itself as “oversight to improve care and contain unnecessary costs” in his article, The Moral Dimension of Network Participation: Let's Stop the Abuse:

  “… some managed care organizations (MCOs) are now injecting themselves directly in patient care decisions by approving or disallowing certain diagnostic and therapeutic procedures. In some cases, the reimbursement for certain procedures is so low that the procedure is paid below our cost. Visits are limited by frequency and duration, and per contract, the MCOs will not allow you to bill the patients for non-covered expenses.

   “Injection into the doctor-patient relationship by the carrier in this manner is a violation that cannot be tolerated. They call it "oversight" for improved care, but it really is just cutting the bill. In attempting to work with these managed care organizations in the past, I have never received a call recommending that I take more X-rays, provide more care or add rehab (evidence informed care) to a patient's regimen.

“MCOs are not attempting to improve patient care. They are only concerned with lowering the cost of the care and attacking the expense by lowering the fees, lowering the access, and limiting the number of approved procedures. Plus, we need to remember that the managed care companies earn a financial bonus for not paying claims. They are paid a set dollar figure per member, per month. With these dollars, they pay your bill and get to keep the difference.

 “Staying in networks that will not allow us to properly serve our patients has an ethical dimension. We are supporting companies that abuse our patients. We are working for a fee and compromising our principles on patient care.

“Many have heard the old Winston Churchill story about a man who asks a woman if she would sleep with him for a million dollars. "Sure," she says. He then asks if she'd do it for $20. "What do you think I am?" she retorted. To which the man responded: "We've already determined what you are. Now we are merely negotiating price."

“If we stay in a network for the few dollars we can generate, knowing full well that our patients cannot get the care they need and deserve, we truly have prostituted ourselves. We no longer serve the needs of our patients; we serve the desires of the MCO.”

Indeed, under the guise of EBM and “medical necessity,” ASH gives itself license to interfere with the doctor-patient relationship, arbitrarily curtails care, denies essential exam services, and short-changes the patient’s expectations to the length of care and contracted services.

The onerous “medical necessity” rule occurs when ASH arbitrarily denies further patient costs and providers subsequently by ASH guidelines are not allowed to bill the patient as we do for all other insurance coverage. For example, presently I have 5 cases where my charges amounting to $1,510.00 were denied that I will never collect.

Too often insurance verification is also a pain in the neck for my staff because the ASH clerks are foreign agents who speak improperly taking an inordinate amount of time, often give incorrect information about coverage, and do not know if ASH is the administrator. Instead of admitting its mistake, ASH penalizes the practitioner by not paying the bill and then telling the patients it was the practitioner’s office fault, not their fault.

Due to this stringent clerical issue, ASH has decided to exclude me from its entire program as punishment including the lucrative Federal BCBS programs that do not adhere to ASH’s clinical model.

The questionable issue in my case is the role to determine clinical standards by ASH to police at Robins AFB Federal BCBS plans in the Standard Option (#104, #105) and Basic Option (#111, #112, #113) that have never followed its draconian measures. I believe this is an overreach ASH uses in its administrative role to browbeat DCs to adhere to their senseless rules even when the Federal BCBS programs do not use the same regs, nor do other private health insurance companies; indeed, no reputable plan follows the severe ASH restrictions.

DRACONIAN MANAGED CARE

For non-practitioners unaware of the chiropractic healthcare marketplace, it is difficult to discern the ethical MCOs from the worst of the lot like ASH. Behind the slick PR promotions and price differences rests different motivations in the present for-profit healthcare system. As chiropractic professionals and their patients have learned, there are at play “evidence biases and the hidden hand of vested interests,” most notably by American Specialty Health.

As I and others have discovered, ASH and Dr. LaBrot have misconstrued evidence-based studies with fake guidelines of its own to support its hidden hand of vested interests.

According to Dr. Rick Cole:

ASHN's Lack of Scientific Basis for Denials

“ASHN claims to be using the best medical evidence in the process of evaluating treatment recommendations. However, ASHN uses their independent interpretation of the evidence, "cherry-picking" information in a manner to justify the denial of care. There is no respected organization within the chiropractic profession that would agree with such interpretations.”

Lack of Professionalism

“While not illegal, the lack of professional behavior by ASHN employees borders upon literal obnoxiousness. It has frustrated Cigna enrollees to the point that they wish to discontinue their chiropractic care based solely upon the trouble caused them by ASHN. Some statements by ASHN appear to be designed to scare patients out of chiropractic offices, and what is worse, they are using clinical information to do this. Other behaviors seem to be designed to frustrate patients, such as the requirement that they fill out paperwork on almost every visit after the 8th treatment.”

The irony of ASH’s statement regarding “evidence-based best-clinical practice guidelines” is odd coming from an MCO that promotes  most egregious sub-optimal level of professional acumen (truncated treatment plans, no x-rays, no active rehab, no maintenance care, no progress exams/reports) and has been the subject of lawsuits condemning its harsh cookbook policies.

RESEARCH BIAS @ ASH

In order to support its “cherry-picking” policy, the masterminds of research at ASH, Craig Nelson, RD Metz, and Thomas LaBrot, configured its data to appear as an evidence-based guideline that lowers cost to sell its managed care program to payers. At the worst, this research is the basis to justify its perverse motivation.

Research bias, also called experimenter bias, “is a process where the scientists performing the research influence the results in order to portray a certain outcome.”

Plus, nowhere in this report is mentioned their bias / conflict of interest as employees of ASH. Nor does this study have any feedback from enrollees to give a truer picture of its effectiveness in terms of patient care.

J Manipulative Physiol Ther. 2005 Oct;28(8):564-9.

Effects of a managed chiropractic benefit on the use of specific diagnostic and therapeutic procedures in the treatment of low back and neck pain.

Nelson CF1Metz RDLaBrot T.

Author information

1 Health Services Research, American Specialty Health, San Diego, CA 92101, USA. craign@ashn.com

Abstract

OBJECTIVE: The aim of this study was to measure the effects of a managed chiropractic benefit on the rates of specific diagnostic and therapeutic procedures for the treatment of back pain and neck pain.

DESIGN: This study is a retrospective analysis of claims data from a managed-care health plan over a 4-year period. The use rates of advanced imaging, surgery, inpatient care, and plain-film radiographs were compared between employer groups with and without a chiropractic benefit.

RESULTS: For patients with low back pain, the use rates of all 4 studied procedures were lower in the group with chiropractic coverage. On a per-episode basis, the rates in the group with coverage were reduced by the following: surgery (-32.1%); computed tomography (CT)/magnetic resonance imaging (MRI) (-37.2%); plain-film radiography (-23.1%); and inpatient care (-40.1%). On a per-patient basis, the rates were reduced by the following: surgery (-13.7%); CT/MRI (-20.3%); plain-film radiography (-2.2%); and inpatient care (-24.8%). For patients with neck pain, the use rates were reduced per episode in the group with chiropractic coverage as follows: surgery (-49.4%); CT/MRI (-45.6%); plain-film radiography (-36.0%); and inpatient care (-49.5%). Per patient, the rates were surgery (-31.1%); CT/MRI (-25.7%); plain-film radiography (-12.5%); and inpatient care (31.1%). All group differences were statistically significant.

CONCLUSION: For the treatment of low back and neck pain, the inclusion of a chiropractic benefit resulted in a reduction in the rates of surgery, advanced imaging, inpatient care, and plain-film radiographs. This effect was greater on a per-episode basis than on a per-patient basis.

Although many comparative studies have found chiropractic care results in reduction in usual medical spine care, the primary point to this ASH study was to show their draconian clinical measures resulted in lower costs for chiropractic care in their managed care plan. Of course, this “bait and switch” outcome would occur since that is the main point of its managed care to squeeze care to increase profit via “medical necessity” that always states the key conditional words “up to” to allow them to cut care.

On the average, this study:

  • allowed 6.5 visits per patient
  • no spinal imaging
  • reviews at the 5th visit to determine the need for medical necessity
  • no active rehab,
  • no maintenance or palliative care for chronic problems,
  • short-changing the time of service (15 minutes instead of the usual 60 minutes) and fees for manual/massage therapy.

The largest omission in this ASH study was the lack of data on either patient or provider satisfaction rates with the ASH treatment procedures. It should be noted the BBB and YELP reviews are honest indications of patients’ dissatisfaction of ASH’s austere program. You need to read them to get the full frustration of these disgruntled enrollees who are getting ripped-off by ASH. Apparently patient and provider dissatisfaction as noted by these reviews are not important to MCOs like ASH that lack a social ethic to provide good benefits for its enrollees.

COOKBOOK VS EVIDENCE-BASED GUIDELINES

Many have likened ASH’s program to “cookbook” medicine, a rather lean one at that. The father of EBM, David L. Sackett, MD, author of Evidence-based medicine: what it is and what it isn't, warns, “Evidence-based medicine is not ‘cookbook’ medicine,” which characterizes ASH’s draconian policy with its inordinately stringent “medical necessity” criteria and clinical guidelines that according to Dr. Sackett results in “slavish, cookbook approaches to individual patient care."

While this may be fine for those DCs working at high-volume low-service “clinic mills” such as the ignoble “The Joint” franchise clinics that market primarily discount prices and do the lowest level of chiropractic care. They make no x-ray spinal imaging analysis of the spine nor do they exam in the spine via standard orthopedic or bio-mechanics motion palpation to detect the vertebral subluxations. They simply “pop and pray” the patients improve.

Plus, without the use of spinal x-rays these cookbook chiropractors are unable to detect pathoanatomical issues such as spondylolisthesis, disk degeneration, scoliosis, or any structural abnormalities. Nor do they develop a treatment plan to correct and stabilize the spine with active rehab / palliative methods as do comprehensive DCs. They are putting patients at risk as well as their own careers when a rare catastrophic accident occurs. Moreover, they have demeaned chiropractors to superficial therapists rather than conservative (nondrug, nonsurgical) spine specialists.

By virtue of its draconian clinical format, the minimalist ASH and Joint programs prohibit quality analysis, diagnosis, and treatment plans to manage both the most serious cases or the common chronic degenerative problems we see in most middle-age or senior patients who have never seen a chiropractor in their lives.

Dr. Rick Cole mentioned this point in his complaint:

“As we have analyzed ASHN's approval criteria it has become clear that only patients with simple problems will have an opportunity to improve. Patients with complicated cases or with comorbidities that will require extended treatment programs will not be approved for the care they need.”

As I mentioned, instead of following comprehensive treatment protocols, ASH favors the cookbook model like “The Joint” franchises. This is definitely not evidence-based “best practices”, but a regressive cookbook approach featuring a stomach-curdling recipe of inadequate care that makes reputable DCs sick to their stomachs.

Dr. Cole in his complaint against ASH echoes the cookbook gatekeeper via stringent “medical necessity” criteria allowing only 6.5 visits that results in patients fleeing to the medical world where medical bills are not the responsibility of ASH:

“ASHN is a management organization that drastically limits access to chiropractic services, effectively lowering the cost for the total of chiropractic services… As patients are not allowed full access to chiropractic services, they will seek services elsewhere. These resultant services may be less clinically effective and more expensive. While this is in the best interest of ASHN, it is not in the best interest of FedEx and their employees.

Dr. Cole also speaks of ASH’s Overreliance upon Statistics:

“They have also threatened to downgrade our status to a "lower tier", which would require yet more paperwork on our part if we were to treat patients at more than a 6-visit average. This average is not related to the severity of the patients, the patient's age, diagnosis or any other factor related to the patient's presentation. This downgrade is just based on an average of care utilization. Based upon this simplistic analysis, it is clear that they are motivated and incentivized by profit, and this places our patients' care at risk. Patients who present with a risk factor ranking warranting the need for more than 6 visits should have access to the number of visits their plan allows, provided the treatment is medically necessary.

“Besides not being supported by any industry standard or research studies, arbitrary limits set by statistical "evidence" has been thrown out of court in national class actions as leaving out the human component in utilization review and as overreliance upon electronic rankings.”

This also summarizes the opinion of Dr. Sackett who spoke of “slavish cookbook approaches to individual patient care.” This is exactly how ASH places both patients and DCs at risk by its conflicted so-called “standard of practice” evidence that is debatable at best and dangerous at its worst. As Dr. Cole mentioned, ASH’s model of care is “not supported by any industry standard or research studies, arbitrary limits set by statistical "evidence" has been thrown out of court…”

Dr. Cole continues about the discrepancy between medical and chiropractic care:

“Our observation is that the services are not allowed past about 10 visits regardless of the patient's diagnosis, clinical status or response to treatment. Visits to medical doctors do not require this level of scrutiny or paperwork. The hassle factor and uncertainty of insurance coverage alone is enough to drive patients to medical providers.

“Cigna insured employees currently being treated in our clinic have been very frustrated with the ASHN system. Many have 25 to 30 contracted covered visits to a chiropractor's office each year, but they cannot get access to those visits unless ASHN approves the visits, and ASHN has extremely limited approval criteria. As we have analyzed ASHN's approval criteria it has become clear that only patients with simple problems will have an opportunity to improve.

“Patients with complicated cases or with comorbidities that will require extended treatment programs will not be approved for the care they need.”

ASH denies patient care based on spurious or non-existent guidelines in order to drive complicated, acute, or chronically-impaired patients to the medical professionals because ASH is not responsible for that expense. This is the hidden agenda with ASH — to deny care thereby railroading patients to PTs or MDs escaping costs and increasing profits.

BAIT AND SWITCH

This ASH tactic is a classical “bait and switch” ploy where ASH offers the same benefits/amount as competitive programs but at a lower price. The gullible patients assume the will have access to the 12, 24, or 30 visits only to discover later they will get on the average only 6.5 visits due to the ASH gatekeeper who cuts benefits with the excuse of “medical necessity.”

I might add ASH has added one more component to its fraud — a “bait and switch with a good boot” to rid themselves of complicated cases that require more expenses.

Dr. Cole filed a lawsuit against ASH in October 2011 that echoes the same unethical ASH practices I’ve encountered:

ASH controls cost by several mechanisms. First, they have a significantly lower fee schedule. Chiropractors are reimbursed on average 30% of what medical doctors are reimbursed for the same services. Secondly, they limit the amount and types of services that can be reimbursed by contract. While the best medical evidence supports simultaneous interventions for the treatment of musculoskeletal conditions, chiropractors can only use one therapeutic intervention per visit. So, the chiropractic physician must choose between therapeutic interventions like electric stimulation, ultrasound, myofascial release, or exercise while a multimodal approach is most effective.

Finally, they require chiropractors and their patients to fill out several pages of paperwork every few visits to allow for authorization of care that ASH determines is appropriate. This paperwork requirement tends to frustrate the patients and certainly is a hassle for the chiropractic physicians and staff. As the frustration and hassle of seeing a provider goes up, utilization goes down. ASH makes it clear in provider notifications that chiropractic physicians with more than a 6.5 visit average per year per patient will be required to submit more forms and will be under greater scrutiny.

Other chiropractic experts agree with Dr. Cole and the New Jersey statement about “cutting benefits.”

Dr. Louis Sportelli explains:

“ASH and other MCOs seized an opportunity to provide a review service for a “piece of the action”.  These groups organized chiropractors who were not included in a plan, got them to sign contracts which often permitted the doctors to be automatically enrolled in silent networks often without their knowledge or actual permission.  These phantom networks then used the billing and pricing services to limit the # of DCs in the network, # of visits per DC,  and onerous reporting mechanisms to discourage the DC's to bill for more than the minimum # of visits.  This then enabled ASH and others to report to new employers or insurance companies that their network only utilized X # of visits and could save money by their monitoring the system.”

The hidden hand of ASH to sway insurance companies to its miserly MCO was the goal of its flawed study explained at  Research Bias @ ASH. Although some were convinced, many saw ASH’s program for what it really is—a “dangerous innovation.”

Mark Studin, DC, FASBE(C), DAAPM, DAAMLP, Adjunct Associate Professor of Chiropractic, University of Bridgeport, reported in his paper, Evidence-Based Practice vs. Best Practice, that this brand of “evidence-based” medicine is actually “…a dangerous innovation, perpetrated by the arrogant to serve cost cutters and suppress clinical freedom." In a nutshell, he accurately described the present situation at ASH.

The facts will show ASH follows no reputable guideline whatsoever. Indeed, the ASH staff concocted its own study replete with research bias to justify its draconian policy to get a large “piece of the action” as Dr. Sportelli said and “cutting  benefits” as the New Jersey court mentioned. This is not “best practices” but an “institutional looting” by short-changing both patients and providers.

The CONSUMER SERVICES DIVISION – MANAGED CARE  needs to discover what guideline(s) does ASH follow. Dr. Cole mentions that ASH makes up its own guideline “cherry picked” from unknown entities when he filed a similar complaint against ASH in Tennessee in October 2011.

Indeed, I have not seen any evidence-based guideline that mirrors the same unethical sub-optimal ASH practices on patient care that literally cuts patients’ benefits of their contracted services for a “piece of the action” and denies DCs standard remuneration with a phony “medical necessity” gatekeeper who is paid to keep the gate closed.

They also have other ways to keep their knee on our necks taking the breath out of our practices. The onerous “medical necessity” rule occurs when ASH arbitrarily denies patient costs and subsequently providers are not allowed to bill the patient as we do for all other insurance coverage. For example, presently I have 5 cases where my charges amounting to $1,510.00 were denied that I cannot collect from the patients.

Too often insurance verification is difficult because the ASH clerks are foreign agents who speak improperly and often give incorrect information about coverage. Instead of admitting its mistake, ASH penalizes the practitioner by not paying the bill and then telling the patients it was the practitioner’s office fault, not their fault, thereby turning the patients against their practitioner who becomes the scapegoat.

There have been numerous patient complaints in reviews at the BBB and YELP about these very issues. These patient whistleblowers understand how they have been denied their contracted services with a bait-and-switch scenario where the policy promises a number of office visits that are never allowed by ASH’s phony “medical necessity” gatekeeper. Indeed, the more one investigates the corporate culture at ASH, the worse its Standard of Care appears to short-change patients from their contracted services.

I urge the Consumer Services Division – Managed Care to investigate this apparent insurance fraud conducted by ASH, just as the New Jersey authorities found ASH guilty of many similar offenses.

PRACTICE TYRANNY

As the founder of EBM, David L. Sackett, wrote, “Without clinical expertise, practice risks becoming tyrannized by evidence”, the strategy used by ASH to cut costs:

 “Good doctors use both individual clinical expertise and the best available external evidence, and neither alone is enough. Without clinical expertise, practice risks becoming tyrannized by evidence.” [3]

Dr. Sackett is spot-on with his warning that EBM will be “hijacked by purchaser and managers to cut the costs of health care” as we witnessed with ASH. In this regard chiropractic care continues to be tyrannized by ASH cost-cutters with their cookbook policy. If this is not tyranny of by cookbook practice, what is?

Dr. Rick Cole also warns:

ASHN controls cost by several mechanisms. First, they have a significantly lower fee schedule. Chiropractors are reimbursed on average 30% of what medical doctors are reimbursed for the same services. Secondly, they limit the amount and types of services that can be reimbursed by contract. While the best medical evidence supports simultaneous interventions for the treatment of musculoskeletal conditions, chiropractors can only use one therapeutic intervention per visit. So, the chiropractic physician must choose between therapeutic interventions like electric stimulation, ultrasound, myofascial release, or exercise while a multimodal approach is most effective.

Finally, they require chiropractors and their patients to fill out several pages of paperwork every few visits to allow for authorization of care that ASHN determines is appropriate. This paperwork requirement tends to frustrate the patients and certainly is a hassle for the chiropractic physicians and staff. As the frustration and hassle of seeing a provider goes up, utilization goes down. ASHN makes it clear in provider notifications that chiropractic physicians with more than a 6.5 visit average per year per patient will be required to submit more forms and will be under greater scrutiny.

In light of the expert comments by Drs. Studin, Sackett, and Cole, I request ASH provide any evidence-based guideline (other than its own biased study) that requires pre-authorization of “medical necessity” via the requirement of re-evaluation on the 5th visit, the justification for its average of 6.5 office visits, and the prohibition of spinal x-rays for “nonspecific” back pain (which I will show is a misapplied medical misnomer, not a chiropractic term).

FOLLOW THE MONEY, FOLLOW THE LIES

Despite ASH’s attempt to hide behind the banner of EBM to defend its draconian policy, many experts are now speaking out against EBM itself. Trisha Greenhalgh and colleagues argue EBM has had negative unintended consequences in their paper, Evidence based medicine: a movement in crisis?, (BMJ 2014) revealing problems that have unexpectedly arisen in this movement. ASH could be the standard bearer of these dire consequences.

According to the authors:

“Evidence based medicine has not resolved the problems it set out to address (especially evidence biases and the hidden hand of vested interests), which have become subtler and harder to detect. This is particularly true when ideological biases are at play.”

As Trisha Greenhalgh mentioned, we now see LaBrot’s “hidden hand of vested interests” at play:

 “Political ideology not [reasonable and effective] practice parameters, distort guidelines for ‘best practices.’”

Nowhere has ASH executive Dr. LaBrot mentioned which “evidence-based best-clinical practice guidelines” he uses. However, it appears ASH has it created its own Frankenstein Standard of Care that terrorizes both patients and the chiropractic profession.

The hypocrisy of Dr. LaBrot to portray ASH as an EBM program is evident not only by its biased managed care study to sell its draconian MCO to payors or employers, but by his own double-standard of care that changes with his personal financial motivation e.g., the “hidden hand of vested interests”.

Remarkably, the Arizona Chiropractic Society found Dr. LaBrot can be accused of a double standard in terms of guidelines he chooses to follow now compared to when he was a practitioner and author of his own guideline. For example, in 1995 Dr. LaBrot wrote a book,  A Standard of Care for the Chiropractic Practice, that grossly contradicts the ASH standard of care he now enforces. Indeed, he has flip-flopped on his Standard of Care issue when his own financial interest became involved.

The Arizona Chiropractic Society newsletter updated MARCH 2011, published an article, Practice Guidelines Endorsed by ACS. Here is an excerpt about LaBrot’s duplicity:

“In the mid-1990s, ASH Vice-President for Clinical Affairs, Thomas E. LaBrot, DC. wrote a book entitled A Standard of Care for the Chiropractic Practice. It included specific recommendations for number of treatments for non-traumatic and traumatic conditions whether mild, moderate or severe. ACS also endorses these guidelines which are summarized here. The book is posted here and is out-of-print. The number of treatments allowed are approximately four times more than ASH allows today under the guidance of Dr. LaBrot.

“Included is the page from the book with the following recommendations for number of visits per condition:

  1. Mild traumatic 9-17 visits
  2. Moderate traumatic 19-45 visits
  3. Severe traumatic 39-68 visits
  4. Mild non-traumatic 5-12 visits
  5. Moderate to severe non-traumatic 14-28 visits

According to the Arizona Chiropractic Society:

“ASH is now believed to allow coverage for an average of 6.5 visits per patient episode of care and treatment. These parameters of care are believed to have been developed largely by Dr. LaBrot. There have been no breakthroughs in treatment allowing patients to recover much faster than in the 1990s, and the human body has not improved its ability to heal since that time. The only change since the mid-1990s has been the source of Dr. LaBrot’s income [the hidden hand of vested interest]. In the mid-1990s, Dr. LaBrot was an Arizona treating doctor and his income came from delivering treatment to patients. Now, his income comes from ASH which makes more money when less treatment is rendered. Along with the change in source of income came the dramatic reduction in recommended number of treatments per condition.

“When ACS goes to court, the key issue will be establishing the generally accepted medically necessary dose of chiropractic care. ASH maintains the number of visits should be in the single digits, i.e., 5 or 7 or 10, for example. ACS maintains that the number of visits should be in the double digits in accord with Chapter 8 of the Mercy Guidelines, the ICA Best Practices and Treatment Frequency and Duration Guidelines, and now even the LaBrot book “A Standard of Care for the Chiropractic Profession.” We agree with LaBrot version 1995, not version 2011. It will be extremely difficult for Dr. LaBrot to explain his departure from his own published standards from the 1990s. This document may be the smoking gun in litigation.”

FALLACIES AT ASH

Although the EBM has taken hold in healthcare for better or worse, as in politics there are always two or more sides in every issue. This is most clear in the chiropractic profession with the majority of classic chiropractors striving to offer “best practices” that have evolved in the empirical world of practice, aka, Practice-based Evidence, derived from 120 years of experiential evidence in the field. However, now on the other side we see the emerging world of tainted EBM controlled by MCOs with the “hidden hand of vested interests” clearly not working to the clinical benefit of patients.

FALLACY OF SPINAL X-RAY PROHIBITION

Undoubtedly the most egregious policy impairing scientific chiropractic and placing patients at risk by ASH’s treatment guideline is the bewildering restriction on the standard use of spinal x-rays by DCs to detect vertebral subluxations, the mainstay of classic chiropractic care.

This is a huge issue so let me give it a thorough explanation. Just as it would be laughable to deny dentists the right to dental x-rays or an orthopedist the right to image musculoskeletal injuries, ASH has taken the best scientific tool out of our hands with this prohibition on spinal x-rays and exposed patients to risk and DCs to guesswork and lawsuits.

Well known is the common ploy by ASH to routinely deny the use of spinal x-rays in the analysis/examination of back pain patients. Rather than recognizing the clinical need to detect structural problems in the patients’ spine to detect vertebral subluxations, pathoanatomical problems (disk abnormalities, arthritic spurs, osteoporosis), or overall spinal patterns (scoliosis, kyphotic cervical spine, tilted/rotated pelvis, spondylolisthesis, short leg syndrome), ASH wants DCs to turn a blind eye and guess in the treatment process in order to save itself paying this expense.

Just as its limited treatment plan makes no sense, likewise, Dr. LaBrot gives his foolish reasons to deny spinal x-rays:

“The diagnostic benefits of performing x-rays must be weighed against the risk of ionizing radiation. The need for radiographic examination should be based on evidence supported indications derived from appropriate history and physical examination findings. The majority of patients presenting to ASH Group Contracted Chiropractors do so for uncomplicated spinal pain and, in the absence of clinical indications or “red flags,” do not require an initial x-ray evaluation.”

I wrote to Dr. Tom LaBrot to ask if he could show me one study where one patient was hurt by “the risk of ionizing radiation” by spinal x-rays, and he could not prove his point because it is just not true.

Many experts disagree with Dr. LaBrot/ASH’s position on spinal x-rays. Dr. Jerry Cuttler, PhD, Nuclear Sciences and Engineering, past president of Canadian Nuclear Society, refuted Dr. LaBrot’s claim of the “risk of ionizing radiation”:

“Is it safe to be exposed to low-level radiation? You can go to two different places for answers:

1) If you go to the radiation protection people, whose job it is to protect everyone from any exposure to radiation (human-made), you'll find there’s a higher risk of cancer.

2) But, if you go out into the real world, who do you know that’s ever been harmed by low-level radiation? There’s just no evidence of that.”

Considering there is no proof whatsoever spinal x-rays performed by DCs have caused any radiation poisoning to anyone, LaBrot’s warning is a moot point especially in light of the value of a visual analysis of patients’ many spinal issues. Indeed, he is simply gaslighting the profession built on a false premise.

Even Harvard Health disagrees with ASH’s policy in its article, Radiation Risk From Medical Imaging:

“Most of the increased exposure in the United States is due to CT scanning and nuclear imaging, which require larger radiation doses than traditional x-rays. A chest x-ray, for example, delivers 0.1 mSv, while a chest CT delivers 7 mSv — 70 times as much... The benefits of these tests, when they're appropriate, far outweigh any radiation-associated cancer risks...”

You can see that Harvard admits the real problem with radiation stems from CT scans and nuclear imaging, not from spinal x-rays taken by DCs.

Dr. Mark Studin spoke of “treating blindly” in his paper, Should Chiropractic Follow the American Board of Internal Medicine’s Recommendations on X-Ray?:

“Based upon the literature, radiation is not cumulative and has rendered no evidence of long-term effects. Therefore, the Doctor of Chiropractic must weigh the risk of treating blindly in the presence of clear biomechanical markers. Treating blindly is often done at the expense of our patients and the malpractice carriers, especially in a scenario where little risk exists.”

In my 40-year practice, the reason I believe most patients need a set of spinal x-rays is due to an accumulation of lifetime of spinal injuries beginning with youthful sports injuries, work-related injuries, auto accidents, to repetitive stress from prolonged sitting/standing as adults. A lifetime of spinal injuries and bio-mechanical stress cannot be detected without the use of spinal x-rays; not even a CT or MRI will show as much as a simple spinal x-ray.

Just as its minimalist sub-optimal treatment plan makes no sense in regard to evidence-based clinical guidelines, so does the ASHN explanation for refusing x-rays:

“The diagnostic benefits of performing x-rays must be weighed against the risk of ionizing radiation.”

As the Harvard study suggests, “The benefits of these tests, when they're appropriate, far outweigh any radiation-associated cancer risks...”

Indeed, a picture is worth a thousand words and there is no better picture than spinal x-rays, and for ASH to deny this tool is putting patients at risk and forcing chiropractors to guess.

ASH has purposely misapplied medical-oriented research (principally its own) to stop care or limit imaging while ignoring EB research that supports more office visits like CCPGG or active rehab (UK BEAM[4]) or numerous chiropractic techniques (CBP, Pettibone, Gonstead, Grostic) using spinal x-rays as part of best practices for LBP.

This is an issue initially debated within chiropractic but now dismissed as nonsense by experts. I will later cite more experts who totally disagree with ASH’s exclusion of spinal x-rays as a diagnostic tool by suggesting there is a radiation threat to patients. In fact, no study has ever proven that position, but ASH’s in-house staff pushes its policy as profession-wide prohibition  as a sales pitch to insurance companies in order to lower costs by denying proper care.

CHOOSING WISELY OR BLINDLY GUESSING

The ASH x-ray prohibition policy is a good example of research bias and cherry-picking of the literature to push its “hidden hand of vested interests” agenda rather than best care procedures.

This skewed policy is based on a hotly contested paper known as Choosing Wisely led by the ABIM Foundation (American Board of Internal Medicine,) about unnecessary medical care services. It should be noted this program was primarily aimed at MDs, not DCs, for their wasteful practices. Many experts now agree most MDs are inept in spinal diagnosis and treatment, so x-rays are meaningless. Indeed, medical x-rays of the spine only detect “incidentalomas” used to railroad gullible patients into medical spine care such as spinal injections and disk surgeries.

Another unmentioned danger is far greater harm than radiation from spinal x-rays — the harm of medical spine care itself. When chiropractic patients are denied adequate care by ASH, many are driven to medical spine care that is renowned for its contribution to opioid abuse and failed back surgery.

 As we have seen with the recent opioid crisis, thousands of people then become addicted and die annually from “outdated medical care” such as opioids. The same can be said of failed back surgery victims considering 50-90% fail leaving a wake of disability and despair that has reached into the millions of people since these profiteering surgeries began.

The chart below shows 2,500 per one million victims of medical spine care are seriously injured or die annually, but little is said in the media or by government officials. As well, the iatrogenic rate for chiropractors is a mere 1 in 5.85 million. Indeed, who’s hurting whom?

The medical scam behind these shocking medical rates is the “bad disk” diagnosis that has been debunked by science but goes unmentioned by MDs to patients and has led to the pandemic of failed back surgeries.

Indeed, most medical LBP diagnosis based on pathoanatomical issues are misleading as stated by the Mayo Clinic, Systematic Literature Review of Imaging Features of Spinal Degeneration in Asymptomatic Populations,” that found ‘bad disks’ are apparent in asymptomatic patients e.g., by age 50, 80% of asymptomatic pain will show disk abnormalities, but have no pain.

Richard Deyo, MD, PhD, and Donald Patrick, PhD, MPH, in their book, Hope or Hype, The obsession with medical advances and the high costs of false promises, also spoke of this misleading disk diagnosis that they dubbed “incidentalomas” because they are incidental to the patients’ pain and now considered part of the normal aging process like grey hair:

“But finding things makes doctors and patients more enthusiastic about doing the tests and seems to justify them many of these abnormalities are trivial, harmless, and irrelevant, so they’ve been dubbed ‘incidentalomas.’”

“Nonetheless, these incidentalomas get treated. It’s easy to be fooled into thinking that if the patient does fine, it’s because we found an abnormality and treated it. But with an incidentalomas, the patient was destined to get better anyway because the condition was a non-disease to begin with.”

Yet patients are unaware of such research studies or the EB guidelines, so they are railroaded by ASH and inept MDs onto the medical railroad, thanks in part to ASH limiting chiropractic care for these serious cases.

Here is a short list of studies showing the poor outcomes and high risk of spine surgery resulting in Failed Back Surgery Syndrome (FBSS):

Estimates from randomized controlled trials indicate that up to 50% of patients may have an unsuccessful outcome following lumbar spinal surgery.

Reduced odds of surgery were observed for those under age 35, women, Hispanics, and those whose first provider was a chiropractor. 42.7% of workers who first saw a surgeon had surgery, in contrast to only 1.5% of those who saw a chiropractor.

  • 2018: Failed Back Surgery Syndrome: A Review Article, by James Daniell and Orso Osti found fusion surgery has a substantial failure rate, which they estimated as high as 46%. Moreover, many patients opt for repeat surgery, but that often leads to “diminishing returns.”

“Although slightly more than 50% of primary spinal surgeries are successful, no more than 30%, 15%, and 5% of the patients experience a successful outcome after the second, third, and fourth surgeries, respectively.”[5]

On the other hand, DCs use imaging seek to detect the bio-mechanical basis of back pain in the altered vertebral motor unit, not merely ‘bad disks,’ so the reasons for spinal imaging are much different for MDs looking solely for pathoanatomical problems (Red Flags, bad disks) vs. DCs looking for functional and bio-mechanical structural issues (vertebral subluxations / spinal lesions / spinal dysfunction).

Recently posted online at the BMJ Open website yet another paper pointed out how medical radiographs often lead to misdiagnosis and unnecessary interventions. Clinician, Patient and General Public Beliefs about Diagnostic Imaging for Low Back Pain: Protocol for a Qualitative Evidence Synthesis explained:

 “Unnecessary diagnostic imaging for low back pain drives flow-on effects such as overuse of advanced imaging, opioid prescriptions, spinal injections and surgery.”

You should note the unnecessary diagnostics leads to the “overuse” of medical procedures, not chiropractic care. Also note there is no mention of excessive radiation to the patients in this BMJ article, the biggest risks are outdated model of medical spine treatments as The Lancet refer to “usual spine care”:

Unnecessary diagnostic imaging is associated with substantial harm including the risk of overdiagnosis.13  Overdiagnosis occurs when diagnostic imaging detects incidental findings that are common in the asymptomatic population (eg, intervertebral disc degeneration14) and provides the patient with a diagnostic label that brings them no benefit or causes harm. Diagnostic labeling leads to medical overuse, a problem which is growing internationally.15 Unnecessary diagnostic imaging for low back pain drives flow-on effects such as overuse of advanced imaging, opioid prescriptions, spinal injections and surgery.16 17 Evidence from clinical guidelines suggests that most of these interventions have little to no benefit, and substantial risk for harms, in patients with non-specific low back pain.18-20

As The Lancet review noted “substantial harm came from overdiagnosis”, not radiation, leading to unnecessary “outdated model of medical spine care” – opioids, spinal injections, and disk surgery — is a substantial risk to patients in many ways from misdiagnosis, mistreatment, medical iatrogenic injury such as opioid abuse and failed surgical treatments leading to a lifetime of disability.

I wholeheartedly agree with this position as I have written extensively on my blog, Chiropractors for Fair Journalism. A few years ago I wrote about this medical back scam in a series of articles in Dynamic Chiropractic showing how “incidentalomas” found by inept MDs on imaging lead to unnecessary interventions and surgery.

Perhaps ASH’s time would be better spent warning spine patients to seek a competent classic DC first before seeking medical spine care considering every evidence-based spine guideline now recommends chiropractic care as a front-line treatment rather than railroading them to medical spine care by denying an adequate chiropractic treatment program.

In light of the evidence-based guidelines, obviously ASH’s “perverse motivation” to drive complicated cases to MDs that ASH does not cover is dangerous to patients as well as denying classic chiropractors the best diagnostic tool.

Many chiropractic techniques utilize spinal radiology to detect and measure spinal subluxations. Here are examples include: BJ Palmer’s HIO, Wernsing’s Atlas Specific, Grostic, NUCCA, Pettibon, Sweat’s Atlas Orthogonality, Harrison’s CBP, Gonstead, Pierce-Stillwagon, Toftness, Diversified, Zimmerman’s Specific Adjusting, Logan Basic, Mears, Jones’ Life Cervical, Blair, Orthospinology, Barge’s Tortipelvis and Torticollis, Aragona’s ASBE, Stucky Integrated Methods, and NUCCA.[6]

The largest chiropractic colleges have also objected to the prohibition of spinal imaging:

Palmer College sent a letter to its alumni rejecting the recommendations of the ACA and Choosing Wisely. In this letter, Chancellor David Marchiori, DC, DACBR, PhD, stated: “The American Chiropractic Association (ACA) recently released recommendations to reduce “unneeded or overused (chiropractic) services” in support of its “Choosing Wisely®” campaign to improve doctor-patient communication and patient care. While the ACA should be lauded for its efforts to improve communication and care, I am compelled to respond to its recommendations regarding the use of plain film radiography. “Specifically, Palmer College does not support the narrow scope of plain-film use endorsed by the ACA, “In the absence of red flags, do not obtain spinal imaging (X-rays) for patients with acute low-back pain during the six weeks after the onset of pain” and “Do not perform repeat spinal imaging to monitor patients’ progress.” Neither would Palmer College support statements that convey the opposite extreme of clinical decision making. These decisions are not typically black and white, but contextual to clinical circumstances. Palmer College acknowledges and supports the latitude needed by clinicians to navigate the “shades of gray” encountered in clinical practice related to the use of diagnostic imaging.

“The ACA’s criteria overly simplify what are complex clinical decisions based on the patient’s history, clinical presentation, physical examination, and therapeutic intent. Their criteria fail to consider fully the value of imaging studies to assess patient biomechanics, structure, and contra-indications related to chiropractic care. “Complex clinical decisions are best left to clinicians and their patients, guided by current best evidence, clinical experience, and patient values.”

Here is another response from a leading chiropractic college on this issue:

Life University (LIFE) is proud to have been one of the first chiropractic colleges to publicly denounce the ACA Choosing Wisely campaign. On September 19, 2017, LIFE’s President Dr. Rob Scott discussed the University’s opposition to the campaign in a publication of Today’s Chiropractic Leadership (TCL). LIFE’s Doctor of Chiropractic program has long advocated for the continued necessity for radiographs for the purpose of identifying and correcting vertebral subluxation and for the efficacy and safety of delivering a chiropractic adjustment. From 2008-2010, LIFE contested a concern for over-utilization of x-rays by the CCE. In successfully advocating for the use of plain film radiographs, LIFE argued that in addition to the triggers for medical necessity, the presence of appropriate indicators for specific chiropractic techniques that rely on x-rays are applicable criteria for “chiropractic necessity” of radiographs if appropriately documented in a patient’s record. As the ACA Choosing Wisely radiographic recommendations are only inclusive of triggers for medical necessity, LIFE strongly rejects these recommendations and any guideline, standard or criteria that limits the necessary and appropriate tools for a Doctor of Chiropractic to safely and efficaciously identify and correct vertebral subluxation.

For those DCs who use spinal imaging to analyze the spine for bio-mechanical / structural / vertebral subluxation problems, obviously x-rays fulfill three criteria to warrant the use of chiropractic x-rays:

a)     X-rays are “clinically important” as the most accurate test to determine the level and nature of subluxations,

b)     Knowing these levels of VSC will “alter patient management” to make treatment safer and more specific,

c)      Obviously, a specific imaging analysis about the spinal health, structure, and alignment will “improve patient outcomes”.

Obviously, the academic right-wing partisans and non-practitioners who oppose spinal x-rays are advocates of “guessing blindly” to manage patients by putting patients at risk to indiscriminate manipulation rather than a scientific imaging analysis to specify the probable spinal problems. This is putting patients at risk and should be investigated by the CONSUMER SERVICES DIVISION – MANAGED CARE to protect patients from sub-optimal care.

THE KING OF IMAGING HAS SPOKEN!

This undocumented x-ray prohibition by ASH and Choosing Wisely has gotten push-back from the leading expert on radiology and literally the man who wrote the book, Dr. Terry Yochum, DC, DACBR, Fellow, ACCR, who is a diplomate of the American Chiropractic Board of Radiology and served as its vice president and president for seven years (1983-1990).

An adjunct Professor of Radiology at the Southern California University of Health Sciences and member of the Department of Radiology at the University of Colorado School of Medicine, Dr. Yochum is the co-author of Essentials of Skeletal Radiology – the required textbook in radiology at all 50 chiropractic colleges and used in more than 100 medical schools around the world.

He states his objections to the ASH and Choosing Wisely stance taken by the ACA in this article published in Dynamic Chiropractic, “X-Ray: To Be or Not to Be - That Is the Question”:

For the past year, I have been asked by many practicing chiropractors, college presidents, faculty and others what my opinion is on the "Choosing Wisely" guidelines the American Chiropractic Association (ACA) recently adopted for its members. The specific guideline I am referring to reads, "In the absence of red flags, do not obtain spinal imaging (x-rays) for patients with acute low-back pain during the six weeks after the onset of pain."

Many doctors have related the negative impact these guidelines have had on their ability to provide appropriate care to their patients. In fact, I so commonly field questions from attendees at seminars, conferences and other professional events I attend, that I feel compelled to share a few thoughts on the topic with a broader audience within the profession through this publication.

A Flawed Process

My first concern with this guideline is in regard to the process followed by the ACA to produce its "Choosing Wisely" criteria. For years, the ACA Council on Diagnostic Imaging and the American Chiropractic College of Radiology have been recognized by the ACA as the de facto authorities for the chiropractic profession on issues related to diagnostic imaging.

As an active member of the ACA's own Council on Diagnostic Imaging (CDI) and the CDI's subordinate organization of the American Chiropractic College of Radiology (ACCR), I am perplexed that the ACA didn't engage our group of content experts on the "Choosing Wisely" project. In my opinion, this is a significant oversight by the ACA.

Excluding Clinical Judgment

The ACA's "Choosing Wisely" statements on radiology also exclude practitioner clinical judgment. As written, the first statement disallows the competent and well-trained practicing chiropractor from using his or her clinical acumen and experience to determine when an X-ray will be necessary to give the patient the appropriate diagnosis and/or treatment needed.

To deny practicing chiropractors their rights and responsibilities to exercise clinical judgment based on rational clinical practice creates a public health hazard and a potential medical liability. The guidelines poorly adapt to the needs of a profession that relies heavily on both the biomechanical analysis of the spine for treatment planning and the application of physical forces in treatment delivery.

I believe these key factors have been neglected in developing the guidelines and are, in large part, why they are not being widely embraced by the profession.

Ignoring the Importance of Biomechanical Considerations

The guidelines have not given appropriate attention to the importance of the biomechanical information that can be gleaned from weight-bearing spinal radiographs. Biomechanical information impacts how practitioners specifically treat their patients.

A short-leg syndrome or increased lumbar lordosis with an increase in the Ferguson's sacral base angle, which may translate into a lumbar facet syndrome, may be important to the clinical context of care. The presence of clinically silent congenital anomalies and structural changes such as scoliosis, spondylolisthesis, os odontoideum, blocked vertebra or transitional segments at the lumbosacral junction, with or without an accessory joint articulation, certainly impact which form of treatment would be appropriate or not appropriate for the patient.

The ACA's first "Choosing Wisely" statement does not allow for biomechanical considerations.

Ironically, the importance of structural defects seems to be recognized in related content on the ACA's website, at the same time it is categorically dismissed by the ACA's "Choosing Wisely" document.

For example, in an article titled "'Choosing Wisely'" X-Ray Recommendations Reflect Evolving Evidence, and Accepted Standards," under the subheading, "always weighing benefits versus risks," the author states: "One really wants to avoid putting a dynamic thrust into a transitional segment with an accessory joint." I agree with the author acknowledging that the presence of a transitional segment with accessory joints is important, yet it does not meet the "red flags" threshold adopted within the "Choosing Wisely" statements. Without appropriate radiographic images, this variant would go undetected.

Moving Forward: Two Suggestions

I encourage the ACA to create a task force to revisit this guideline with these two suggestions in mind:

First, make every effort to ensure that the insights of those within our profession with expertise in diagnostic imaging are taken into consideration. To this end, I would respectfully request the ACA involve the profession's content experts, such as inviting one or more diplomates of the American Chiropractic Board of Radiology to serve on a task force.

Second, I suggest the guideline take into consideration the particular needs of the chiropractor as a spinal manipulator, who may need more information than his or her allopathic counterparts, to determine the safety and potential efficacy of applying mechanical force to the musculoskeletal system as part of his or her treatment regime. I believe a revision would be in the overall best interests of practicing doctors of chiropractic, the patients they serve, and the ACA.

I hope my opinion is received in the same constructive spirit in which it is rendered. I am a longtime member and supporter of the ACA.

Another renowned expert on spinal radiology is Dr. Phil Arnone, Past President ACA Council on Diagnosis and Internal Disorders. He was the head of the ACA Task Force on Imaging who spoke on the importance of x-ray in chiropractic and the irony he sees now with the prohibition of spinal x-rays mindset:

I am so saddened by the current direction and commentary.

However, the ability to measure the biomechanics of the spine has a drastic effect on outcome which applies to all techniques. 

Since Atlas Orthogonal, Orthospinology and NUCCA use similar standards, and CBP and Pettibone also use similar standards of measurement, it is my goal with my ACA committee to research and combine these standards. Once these are in place we can reach out to other non-orthogonal approaches and invite them to compare their process and further standardize the profession’s use and interpretation of x-rays.

In a recent conversation with Mark Studin, DC, he explained how the Orthopedic and Neurosurgery groups are now interested in spinal digitization as they are recognizing that surgical outcome can be either adversely or positively affected based on the juxta-alignment of the upper Lumbar and Thoracic region.

As a result, they are looking for ways to better understand and measure spinal misalignment patterns through radiographic procedure and utilize those measurements to aid in their success. They recognize that they cannot see those patterns by visual observation.

Interesting they see the value but not our trade organization.

Other chiropractic experts have debunked the notion that spinal x-rays should be limited to only “red flag” situations is unproven, such as the Official X-ray Guideline of the International Chiropractors Association (ICA):

III) Spinal Radiography Background, Utilization, and Costs

RECOMMENDATION

Spinal radiography is an important legal privilege of practicing chiropractors in North America, is an important component of chiropractors’ analysis and management of presenting patients, and should not be limited to the ‘red flag’ x-ray only model…

Recently, this same subgroup of DACBRs and academics have been suggesting that Chiropractic x-ray privileges be confined to “Red Flag” cases only.1-5,8,9,21,26 Problematically, managed care organizations (MCO’s) use these “Red Flag” documents to enforce their mandatory reduction in radiographic utilization rates of practicing chiropractic clinicians.34,35 In fact, there is no evidence that these policies actually benefit the patient; but there is evidence that this increases the profits of MCO’s and insurance providers.36,37 Thus, it becomes clear that current attempts to limit radiography utilization rates of chiropractic clinicians is motivated more by profits and less by what is best for the patient.[7]

 

"The ICA believes that these recommendations are out of line with the established standards of chiropractic practice, ignore the large body of clinical and outcomes data that demonstrates the utility, indeed clinical wisdom of such procedures, and clearly can and will, if followed unquestioningly, place patients at risk by delaying or denying diagnostic procedures that have been proven to best serve patients' needs."

"Radiography is a scientifically proven, clinically valid and appropriate method to evaluate multiple aspects of human spinal anatomy, identify vertebral subluxations, altered spinal biomechanics, postural misalignments, pathology and in providing information and safeguards in rendering chiropractic care in clinical practice."

Fortunately, there are more scientific chiropractors who recognize the value of a scientific imaging analysis to guide their treatment plan.

X-Ray Imaging Is Essential for Contemporary Chiropractic and Manual Therapy Spinal Rehabilitation: Radiography Increases Benefits and Reduces Risks by Paul A Oakley 1Jerry M Cuttler 2Deed E Harrison 3

Abstract

To remedy spine-related problems, assessments of X-ray images are essential to determine the spine and postural parameters. Chiropractic/manual therapy realignment of the structure of the spine can address a wide range of pain, muscle weakness, and functional impairments. Alternate methods to assess such spine problems are often indirect and do not reveal the root cause and could result in a significant misdiagnosis, leading to inappropriate treatment and harmful consequences for the patient. Radiography reveals the true condition and alignment of the spine; it eliminates guesswork. Contemporary approaches to spinal rehabilitation, guided by accurate imaging, have demonstrated superiority over primitive treatments. Unfortunately, there are well-meaning but misguided activists who advocate elimination or minimization of exposures in spine radiography. The radiation dose employed for a plain radiograph is very low, about 100 times below the threshold dose for harmful effects. Rather than increasing risk, such exposures would likely stimulate the patient's own protection systems and result in beneficial health effects. Spine care guidelines need to be revised to reflect the potential benefits of modern treatments and the lack of health risks from low X-ray doses. This would encourage routine use of radiography in manual spine therapy, which differs from common pharmacologic pain relief practice.

If evidence is the key to better health care, please show where ASH is following evidence-based spine care guidelines to improve outcomes without shortchanging patients or providers. ASH cannot because they do not follow reputable evidence-based guidelines for chiropractic care by Dr. Terry Yochum, field practitioners, chiropractic universities, or technique developers. Instead, ASH has cherry-picked the opinion of a minority group of naysayers in order to “squeeze care to increase profits” or, as the ICA report mentioned, ASH is “motivated more by profits and less by what is best for the patient.”[8]

Today there are many experts who disagree with ASH’s claim to exclude x-rays is based on the premise as harmful to patients. As I mentioned, Dr. Tom LaBrot, an ASH executive, could not give me one study proving his point. I seriously doubt his mistaken opinion will stand up in a courtroom when compared to the following expert opinions from the website, RADEVIDENCE.ORG. Here is an excerpt:

Risks & Benefits

In recent years, there has been widespread media coverage of studies purporting to show that radiation from X-rays, CT scans and other medical imaging causes cancer. But such studies have serious flaws, including their reliance on an unproven statistical model, according to a recent article in the journal Technology in Cancer Research & Treatment. Corresponding author is Loyola University Medical Center radiation oncologist James Welsh, MS, MD.

"Although radiation is known to cause cancer at high doses and high-dose rates, no data have ever unequivocally demonstrated the induction of cancer following exposure to low doses and dose rates," Dr. Welsh and co-author Jeffry Siegel, PhD, write.

The widespread belief that radiation from X rays, CT scans and other medical imaging can cause cancer is based on an unproven, decades-old theoretical model, according to a study published in the American Journal of Clinical Oncology.

The model, known as linear no-threshold (LNT), is used to estimate cancer risks from low-dose radiation such as medical imaging. But risk estimates based on this model "are only theoretical and, as yet, have never been conclusively demonstrated by empirical evidence," corresponding author James Welsh, MD and colleagues write. Use of the LNT model drives unfounded fears and "excessive expenditures on putative but unneeded and wasteful safety measures."

THE FALLACY OF NONSPECIFIC / UNCOMPLICATED LBP

Let me respond to yet another mistaken belief by ASH:

“The need for radiographic examination should be based on evidence supported indications derived from appropriate history and physical examination findings. The majority of patients presenting to ASH Group Contracted Chiropractors do so for uncomplicated spinal pain and, in the absence of clinical indications or “red flags,” do not require an initial x-ray evaluation.”

ASH disavows the need for spinal x-ray imaging based on two points: 1) x-rays are harmful due to radiation poisoning and 2) not needed for “uncomplicated” back pain. Let me address these fallacies.

To ASH, every case is considered “uncomplicated” and “nonspecific” since it does not allow differential diagnosis and x-ray imaging in spinal analysis to detect subluxations or to detect spinal pathoanatomic problems. These generic terms are used only by researchers or medical spine practitioners who cannot identify biomechanical issues such as vertebral subluxations or joint dysfunction.

Indeed, the use of the terms nonspecific or uncomplicated is an admission to their ignorance. If they cannot see a “bad disk” or other pathoanatomical problem, then they are clueless. They could not detect a vertebral subluxation if shown by Terry Yochum himself.

John “Jay” Triano, DC, PhD, explained in his paper, “Biomechanics of Subluxation: Modern Evidence of Buckling Mechanism. [9] The so-called “uncomplicated” or “nonspecific” spine problems stem mainly from bio-mechanical “buckling”  problems due to axial overloading upon the vertebral motor unit consisting of synovial facet joints and lumbar disks, which in turn leads to nerve problems:

“Several characteristics of buckling behavior are known (Tables 3 & 4). Table 3 lists the factors that potentiate spinal buckling. An obvious causative factor is a single overload event that exceeds critical load for the conditions. For less severe tasks, the process is more complex. Normal creep deformity occurs with prolonged static posture. Creep alters the constitutive properties of the tissue and the relative critical load. Under the right conditions, even a small additional load will cause the joint to buckle. Rapidly applied loads also are associated with buckling and vibration reduces the threshold necessary to achieve it. Finally, tissues that are damaged, as in discopathy, may buckle sooner and reach maximum displacement (deformation) under lower peak loads than do healthy tissues. 

As you can see, these are not “uncomplicated” problems, but serious multifaceted bio-mechanical problems that required sophisticated imaging and spinal diagnosis.

Dr. Triano in another paper, Biomechanics Of Spinal Manipulative Therapy, refutes the fallacy of “nonspecific” or “uncomplicated” spinal pain that ASH touts:  

“The field of spinal manipulation has often been treated by the literature, incorrectly, as being homogeneous. Much of the confusion regarding this form of treatment can be traced to the ambiguity surrounding the procedures themselves. This report summarizes the clinical biomechanics of SMT and evidence for its associated manipulable lesion is reviewed.”

ASH’s diagnostic guesswork and consequent sub-optimal program is similar to “The Joint” franchise style of chiropractic care. They give “nonspecific” manipulations at a very cheap price to treat “uncomplicated” problems with “nonspecific” outcomes. In other words, this meager clinical scenario is the ideal ASH model because it “squeezes care to expand profits.”

In fact, the issue of “uncomplicated” or “nonspecific” LBP is mainly a medical term, not a classic chiropractic term. Let me give you the background on this point: medical diagnosis looks only for pathoanatomical problems such as degenerative/herniated disks, degenerative joint disorder, stenosis, fractures, arthritis, cancers, spondylolisthesis, etc., which are the cause of pain in only 10-15% of cases according to Dr. Rick Deyo.

Dr. Richard Deyo acknowledged in his article, “Low Back Pain” that abnormal anatomy was not the cause of most back pain when he admitted, “Perhaps 85 percent of patients with isolated low back pain cannot be given a precise pathoanatomical diagnosis.”[10] This does not mean they cannot be given a precise pathophysiologic diagnosis via VSC.

I understand the need to discourage spinal imaging taken by inept MDs since they are clueless looking only for” incidentalomas”. Undeniably, “bad disks’ seen on x-rays and MRI scans have been used as effective selling points and have greatly increased the number of unnecessary surgeries at an enormous cost and waste.

“In fact,” Dr. Deyo admits, “back surgery rates are highest where MRIs are the highest. In a randomized trial, we found that doing an MRI instead of a plain x-ray led to more back surgery but didn’t improve the overall results of treatment.”[11]  

This difference is the gist in this issue. When patients have LBP and without evidence of pathoanatomical problems, these inept MDs call these cases “nonspecific LBP” since they are not trained to look for “bio-mechanical” or “pathophysiologic” problems of the spine as described in the paper, “Biomechanics of Back Pain,” by Michael Adams, Department of Anatomy, University of Bristol, UK:

“Age-related biochemical changes and loading history can also affect tissue vulnerability. Finally, the concept of 'functional pathology' is introduced, according to which, back pain can arise because postural habits generate painful stress concentrations within innervated tissues, even though the stresses are not high enough to cause physical disruption.”

Researchers such as Deyo now show most LBP is due to pathophysiological problems of the spine, in other words, how the spine functions. Namely, the medical terms of “functional pathology” as Adams suggests or “joint dysfunction” as John McMillan Mennell speaks are the same entity classic chiropractors refer to as the “vertebral subluxation,” referring to the functioning of the spinal motor unity, not only the health or degeneration of the spine.

Studies by chiropractic researchers Drs. Donald Murphy and Eric Hurwitz found joint dysfunction was the cause of neck pain in 69 percent of cases and the cause of low back pain (lumbar and sacroiliac) in 50 percent of patients.[12],[13]

These are bio-mechanical structural problems involving vertebral subluxations that classic DCs use x-rays to detect the location and nature of these bio-mechanical subluxations to know where and how to adjust the spine. Without this tool, we would be “blindly guessing” and putting patients at risk. Imagine if a dentist did not take x-rays and just started drilling!

In effect, ASH is applying a medical standard looking solely for pathoanatomical problems as opposed to a chiropractic problem detecting pathophysiological / bio-mechanical spinal problems. This conflict explains why ASH thinks x-rays are unnecessary considering the ASH guideline is not searching for excellence in clinical care — its goal is to minimize the diagnostic exams to minimize care and reduce cost.

The ICA best practices GUIDELINES also noted the fallacy of ASH’s stringent policy to limit spinal x-rays has a ploy to “increase profits of insurance companies and MCOs, which do not want to pay for chiropractic radiology claims.” [14]

In other words, ASH’s real goal is to “squeeze care to expand profits” using whatever far-fetched statements by non-practicing academic pinheads or misapplied medical guidelines it can find. No other insurance program uses such draconian restrictions on chiropractic analysis of the spine. In fact, if x-rays were not taken and a problem arose, the first thing the plaintiff’s attorney would seek were the diagnostic x-rays and without them the chiropractor would legally be liable for malpractice, and rightfully so. Blindly guessing is not prudent.

Dr. Lou Sportelli, former president of NCMIC, ACA, and the WFC, explained how the ASH problem developed:

“ASH and other similar managed care organizations (MCOs) were a hybrid entity. Initially devised and designed to be the interim between the commercial insurance companies who paid the premium and the employer (or whomever paid the bill) and the patient sold as a method  to provide the convenience for a host of services which were difficult to understand or control.  Chiropractic was the perfect group since insurance companies did not want to or know how to control the disparate lack of uniformity within the chiropractic billing world, and so ACN or ASH and others seized an opportunity to provide that review service for a “piece of the action”.  These groups organized chiropractors who were not included in a plan, got them to sign contracts which often permitted the doctors to be automatically enrolled in silent networks often without their knowledge or actual permission.  These phantom networks then used the billing and pricing services of the entity they enrolled with to limit the #of DCs in the network, # of visits per DC,# and onerous reporting mechanisms to discourage the DC's to bill for more than the minimum # of visits.  This then enabled ASH and others to report to new employers or insurance companies that their network only utilized X # of visits and could save money by their monitoring the system. It was a circular cluster and entities like ASH and others won without the DC's knowing what was happening for many years. To top it all off, the DC's were prevented from communicating with each other or through their associations on fees or be charged with price-fixing (Connecticut for example and others).  So, the individual DC was out there by himself or herself.”[15]

FALLACY OF EVIDENCE-BASED CHIRO TECHNIQUES

If ASH adheres to evidence-based methods as it suggests by denying routine spinal x-rays, why doesn’t ASH police chiropractic clinical techniques since not all adjusting methods are equally supported by clinical evidence?

Once again, ASH “cherry picks” techniques rather than following the “best practices” that would add costs to clinical care if it were to include numerous holistic techniques and new technology.

Undoubtedly this is a hot topic that would interest a huge percentage of DCs who use experimental or unconventional methods including those few who do not use spinal x-rays. It would also upset those who use ineffective techniques.

A comparison of techniques was published in  JMPT“Rating specific chiropractic technique procedures for common low back conditions, by Meridel I. Gatterman, DC, Robert Cooperstein, Charles Lantz, DC, Stephen M. Perle, DC and Michael J. Schneider, DC, PhD. [16]

In the rating scale of 1-10, the effectiveness of procedure ratings for acute low back pain for 10 procedures were quite revealing. Ranking them in descending order for low back pain found the following:

1. HVLA, no drop table (side posture)                                 = 9.5
2. HVLA, prone, with drop table assist                                = 8.7
3. Distraction technique                                                     = 8.7
4. Mobilization                                                                  = 8.0
5. HVLA, prone, without drop table assist                            = 6.4
6. Pelvic blocking procedures                                             = 6.3
7. Lower extremity adjusting                                              = 3.7
8. Instrument adjusting                                                     = 3.7
9. Non-thrust/reflex/low force                                            = 3.5
10. Upper cervical                                                             = 3.3

Conclusion:
The ratings for the effectiveness of chiropractic technique procedures for the treatment of common low back conditions are not equal. Those procedures rated highest are supported by the highest quality of literature. Much more evidence is necessary for chiropractors to understand which procedures maximally benefit patients for which conditions.

Another comparative study was revealed at the 2014 ACC-RAC conference in Orlando by Mike Schneider, DC, PhD, when he presented a new paper, “A Comparison of Spinal Manipulation Methods and Usual Medical Care for Acute Low Back Pain. Dr. Schneider concluded that “manual manipulation provides significantly more reduction in disability and pain at 4 weeks as compared to mechanical manipulation (Activator) or medical care.”

According to the Schneider study, at best Activator is slightly better than NSAIDs / placebo and it was rated extremely low (8th) by the Gatterman study on the scale of effective chiropractic treatments for LBP.  At the worst, it is a deception to promote Activator to the unsuspecting public as modern, gentle and superior to standard classic chiropractic care when it is clearly not.

If ASH is keen on the evidence-based best practices, how does it justify paying for non-traditional methods that are graded so low? Indeed, follow the evidence!

Massage therapy is another sticking point with ASH guidelines that only pay for 15-minute sessions when the standard session is 60 minutes. Can ASH provide justification for its draconian limit when the VA allows 8 weekly one-hour sessions?

Swedish massage an acceptable treatment—In 2015, researchers at the Durham (North Carolina) VA Medical Center and Duke University found, in a pilot study, that Swedish massage is an acceptable and feasible treatment for Veterans with osteoarthritis of the knee. The team looked at 25 Veterans, mostly men, with an average age of 57. The men also had an average body mass index of around 32, above the obesity threshold.

Of the original 25 Veterans in the study, 23 completed a regimen of eight weekly one-hour massage sessions. More than 90 percent of them said they wanted to continue to receive massage as part of their arthritis treatment plan, and nearly 90 percent thought other Veterans would try it if it were offered in VA.

They also reported, on average, about a 30 percent improvement in pain, stiffness, and function.

The VA also conducted another study in 2016: Massage for Pain: An Evidence Map where it states:

“Many Veterans desire complementary and integrative health or alternative medicine modalities, both for treatment and for the promotion of wellness.”

The promotion of wellness care or maintenance care as many DCs suggest is another valuable evidence-based treatment that ASH refuses to allow despite research showing the benefits:

Chiropractic Maintenance Care

Two recent studies have examined chiropractic maintenance care.

  1. Efficacy of preventative spinal manipulation for chronic low back pain and related disabilities: a preliminary study.

Descarreax et al. Studied 30 patients with chronic nonspecific low back pain (chronic defined as >6 months duration) (Descareaux et al., 2004). Half were given 12 SM treatments in an intensive 1 month period and no treatment for a 9 month follow up period. The other half were given the same intensive 1 month treatment of SM but, in the subsequent 9 months they received a maintenance SM every 3 weeks. Pain and disability were monitored via a visual analog pain score and a modified Oswestry questionnaire, respectively. Both groups reported improved pain scores at the end of the intensive SM period and maintained those scores over the subsequent 9 months. While both groups also reported improved Oswestry disability scores at the end of the intensive treatment period, only the group receiving the maintenance care during the 9 months follow-up period maintained that improvement. Patients not receiving SM maintenance care reverted to pre-treatment disability levels over the follow-up period.’

References.

Descarreaux M, Blouin JS, Drolet M, Papadimitriou S, Teasdale N. Efficacy of preventative spinal manipulation for chronic low back pain and related disabilities: a preliminary study. J Manipulative Physiol Ther 2004;27(8):509-14.

  1. Does maintained spinal manipulation therapy for chronic nonspecific low back pain result in better long-term outcome?

The treatment of chronic, non-specific low back pain (Senna and Machaly, 2011). These researchers randomly assigned 60 study participants with chronic nonspecific low back pain (>6 months duration), into 3 study groups of equal size; (1) Lumbar SM without maintenance care received 12 SM treatments over a 1 month period followed by no treatment for the succeeding 9 months, (2) Lumbar SM with SM maintenance care also received 12 SM treatments over a 1 month period followed by “maintenance SM” every 2 weeks for the succeeding 9 months, and (3) Placebo Lumbar SM in which 12 sham SM treatments were administered over a 1 month period followed by no treatment for a 9 month follow up period. Pain and disability scores, generic health status, and back-specific patient satisfaction were measured at baseline and at 1, 4, 7, and 10 month intervals. Study participants reported significantly reduced pain and disability scores in both of the SM study groups compared to the sham SM group at 1 month. However, only study participants receiving SM followed by SM maintenance care showed improvement in pain and disability scores at the 10 month evaluation. By contrast, pain and disability scores were at pre-treatment levels for study participants in the SM without maintenance care and sham SM groups at 10 months.’

References.

Senna MK, Machaly SA. Does maintained spinal manipulation therapy for chronic nonspecific low back pain result in better long-term outcome? Spine (Phila Pa 1976) 2011;36(10);1427-37.

The British Medical Journal also published an article by Jaime Guzman about the value of intensive rehab that ASH refuses to allow: 

“Conclusions: The reviewed trials provide evidence that intensive multidisciplinary biopsychosocial rehabilitation with functional restoration reduces pain and improves function in patients with chronic low back pain.”[17]

We DCs are forced by ASH only to temporarily treat patients with minor chronic problems on the average for 6.5 treatments only and are not able to help patient via “rehabilitation with functional restoration [that] reduces pain and improves function in patients with chronic low back pain.”

Another effective treatment for LBP and disk problems is non-surgical spinal decompression. If ASH supports evidence-based “best practices,” why does it not pay for this unique high-tech method for patients with severe LBP, sciatica, and/or disk abnormalities that have not responded the classic chiropractic care or usual medical spine care? The evidence is clear spinal decompression restores disk height and decreases discogenic LBP.

Instead of paying for this high-tech effective advancement in spinal care, ASH prefers to pay for the minimalist “The Joint” model of care that has reduce our clinical skills to blindly adjusting indiscriminately for nonspecific back pain. This is a regression in our profession that puts patients at risk and flies in the face of 120 years of research into the art of chiropractic care.

SUMMARY

I have proven the ASH modus operandi is baseless regarding:

  • Purporting to follow EBM guidelines,
  • Unwarranted in terms of ASH’s limited patient care, and
  • Misguided with its prohibition on spinal imaging.

With this plethora of evidence against the entire ASH program, a case has been made the main goal of ASH is the perverse motivation to
“squeeze care to expand profits” at the patients’ and providers’ expense. Other expert opinions have made the same claim, such as:

  • As the New Jersey lawsuit stated, “cutting benefits appears to be the business model of American Specialty Health.”  
  • Dr. Louis Sportelli said: “ASH and other MCOs seized an opportunity to provide a review service for a “piece of the action”. 
  • Dr. Rick Cole surmised: “Injection into the doctor-patient relationship by the carrier in this manner is a violation that cannot be tolerated. They call it "oversight" for improved care, but it really is just cutting the bill… MCOs are not attempting to improve patient care. They are only concerned with lowering the cost of the care and attacking the expense by lowering the fees, lowering the access, and limiting the number of approved procedures. Plus, we need to remember that the managed care companies earn a financial bonus for not paying claims.”
  • Dr. David Sackett predicted, “Some fear that evidence-based medicine will be hijacked by purchasers and managers to cut the costs of health care.” This is exactly the goal of ASH—to cut the cost of health care at the expense of patient care and provider remuneration.
  • Mark Studin, DC, FASBE(C), DAAPM, DAAMLP, Adjunct Associate Professor of Chiropractic, University of Bridgeport, reported in his paper, Evidence-Based Practice vs. Best Practice, that this brand of “evidence-based” medicine is actually “…a dangerous innovation, perpetrated by the arrogant to serve cost cutters and suppress clinical freedom."
  • Regarding the policy at ASH, Dr. Trisha Greenhalgh hit the nail on the head: “Political ideology [and the “hidden hand of vested interests”] not [reasonable and effective] practice parameters, distort guidelines for ‘best practices.’”
  • The ICA best practices GUIDELINES noted ASH’s stringent policy to limit spinal x-rays as a ploy to “increase profits of insurance companies and MCOs, which do not want to pay for chiropractic radiology claims.” [18]
  • Richard Cole, DC, suggests ASH’s sole motivation is to make profits by cutting claims. “In attempting to work with these managed care organizations in the past, I have never received a call recommending that I take more X-rays, provide more care or add rehab (evidence informed care) to a patient's regimen.”

As you can read the testimonies of the BBB and YELP patients, numerous experts and groups concur that ASH is a danger to the welfare of patients who are denied their contracted services and quality care. I have shown its major justification to limit spinal imaging and length of care are baseless attempts to cut costs that defraud patients of their contracted services and denies chiropractor fair access to the marketplace compared to inept MDs.

It’s past time for the Market Oversight Division to police this malicious group of unethical and greedy ASH employees just as New Jersey did recently. If not, ASH will continue to “contain and eliminate” more patients and DCs from its program. It is past time to remove ASH’s boot from the neck of the chiropractic profession and every downtrodden enrollee in the ASH program.

 

 

APPENDIX

ASH LAWSUITS

  1. ACA files class action lawsuit challenging ASHN's, CIGNA's improper practices

Chiropractic Economics January 7, 2013
January 7, 2012 — The American Chiropractic Association (ACA) has filed a class action lawsuit against American Specialty Health Inc. and American Specialty Health Networks Inc. (collectively, “ASHN”), and Corporation and Connecticut General Life Insurance Company (collectively, “CIGNA”).

The litigation alleges a litany of problems with the defendants, including arbitrary reductions of care, lack of communication to providers and patients resulting in coverage and payment errors, and interference with doctors’ duty to exercise professional clinical judgment in managing patients’ treatment plans.

Chiropractors network under fire for plan management

By Angela Gonzales  – 

Sep 9, 2001,

Upset over dismal payments and arduous paperwork from one of the nation's largest chiropractic networks, Arizona chiropractors allege that American Specialty Health Networks is breaking one of the state's newest laws.

At issue is House Bill 2600, a law that went into effect in January and requires managed care companies to pay for a minimum of 12 chiropractic visits for its members. To comply with the law, managed care companies such as Cigna HealthCare of Arizona and Blue Cross Blue Shield of Arizona contracted with ASHN to handle their chiropractic business.

Alan Immerman, president of Independent Chiropractic Physicians, said he believes ASHN is breaking the law.

"The law says they have to approve a minimum of 12 medically necessary visits per year," Immerman said. "They're allowing four or five. Then you have to send in documents asking for more. They commonly don't let you even get to 12."

  1. Horizon’s new cost-cutting plan raises fear that trips to chiropractor may be limited

Posted Aug 12, 2019

by Susan K. Livio | NJ Advance Media for NJ.com

Armed with data that says New Jerseyans are among the most frequent users of chiropractic care and physical therapy in the nation, the state’s largest health insurance company says it intends to team up with a national claims reviewer to scrutinize patient bills in the coming year.

Horizon Blue Cross Blue Shield of New Jersey sent out letters in the past week to the thousands of licensed acupuncturists, chiropractors and occupational, physical and speech therapists to alert them to the company’s proposed partnership with American Specialty Health Network, a national utilization review company.

The move immediately raised fear from therapists and chiropractors that the insurer intends to limit how many times patients can see them.

They wasted no time firing off letters to the state Department of Banking and Insurance to ask regulators to block the arrangement. And they started alerting their patients and state lawmakers about how the company’s partnership with an insurance carrier serving 3.7 million people in the state will discourage treatment and undermine their livelihoods.

“This is going to add a tremendous amount of administrative work to get people’s care approved. What is going to happen is patients are going to be frustrated with the delays and not seek the care they need," said Michael Goione, a chiropractor with a 30-year practice in Red Bank.

  1. DELAWARE DEPARTMENT OF INSURANCE MARKET CONDUCT EXAMINATION REPORT
  2. TENNESSEE

UNITED STATES DISTRICT COURT MIDDLE DISTRICT OF TENNESSEE NASHVILLE DIVISION RICHARD COLE, BRADFORD COLE, CARY JUSTICE, MICHAEL MASSEY, and DON WEGENER:

  1. ARIZONA CHIRO SOCIETY: LAWSUITS TO PROVIDE NEEDED RELIEF FOR ARIZONA CHIROPRACTORS
  2. NEW JERSEY: ASHN settled and fined $11.75 million.
  3. CONNECTICUT
  4. MARYLAND

 

INEPT MDS

Unquestionably a leading “widespread misconception” in spine care is the notion MDs are qualified to diagnosis and treat musculoskeletal disorders such as LBP.

Researcher Richard Deyo, MD, MPH, author of “Watch Your Back!”, also mentioned physician incompetence in diagnosis and treatment of low back pain:

“Calling a [medical] physician a back pain expert, therefore, is perhaps faint praise — medicine has at best a limited understanding of the condition. In fact, medicine's reliance on outdated ideas may have actually contributed to the problem.”[19]

Dr. Deyo recognized in 1998 what The Lancet review acknowledged twenty years later in 2018—the outdated medical models of care used by incompetent MDs. Nothing has changed except the wake of disability and addictions have increased.                        

Dr. Scott Boden, director of the Emory Orthopedics & Spine Center, agreed with Dr. Deyo: “Many, if not most, primary medical care providers have little training in how to manage musculoskeletal disorders.”[20]

A study showed 70% of osteopathic graduates failed to attain a passing score on the MSD competency examination.[21] For a profession whose roots began in manipulative therapy, osteopaths today have adopted the current failed medical model.

Another startling testimony about medical incompetence due to “prejudices and controversy” in spine care was given at the Wilk v. AMA trial by John C. Wilson, Jr., MD, former chairman of the American Medical Association’s Section on Orthopedic Surgery:

“The teaching in our medical schools of the etiology, natural history, and treatment of low back pain is inconsistent and less than minimal… At the postgraduate level, symposia and courses concerning the cause and treatment of low back and sciatic pain are often ineffective because of prejudices and controversy… MDs often displayed a disturbing ignorance of the cause and treatment of low back and sciatic pain, one of mankind’s most common afflictions.”[22]

More studies confirm the inadequate education in medical schools:

In the United States, musculoskeletal disorders represent the most common health complaints, accounting for more than 130 million physician visits and 10% to 28% of all primary care visits each year and costing approximately $850 billion a year. These costs account for a substantial portion of the country’s health-care expenditures.

Despite these facts, our own institution has had no required medical student musculoskeletal clerkship rotation or elective for several decades, and a landmark study in 2003 by DiCaprio et al. found that only 20% of allopathic medical schools in the United States had a dedicated musculoskeletal clerkship, making the quality of musculoskeletal training for medical school graduates inadequate.

This discrepancy appears to persist beyond the training years and into the realm of clinical practice. In a survey of family care physicians, 51% said that they had insufficient training to address musculoskeletal issues, which may be related to the fact that 56% of the respondents stated that medical school was their only source for formal musculoskeletal instruction.

  • 1998: Freedman and Bernstein published a landmark study in the Journal of Bone and Joint Surgery, wherein they administered a validated musculoskeletal competency examination to 85 recent medical graduates who had begun their hospital residency. Of these medical doctors, 82 percent failed to demonstrate basic competency on the examination, leading the authors to conclude, “We therefore believe that medical school preparation in musculoskeletal medicine is inadequate.”
  • 2004 study, Musculoskeletal Curricula in Medical Education: Filling In the Missing Pieces, by Elizabeth A. Joy, MD, and Sonja Van Hala, MD, MPH, described the formal training of medical graduates:

“The average time spent in rotations for courses devoted to orthopedics during medical school was only 2.1 weeks. One third of these examinees graduated without any formal training in orthopedics. As would be expected, these data suggest that limited educational experience contributes to poor performance.”

“Surveys show that undergraduate medical students spend very few hours on the musculoskeletal system, both in basic science and in clinical training. It would be considered negligent for a medical graduate to be incompetent at adequately assessing the heart or lungs, yet it is quite common for students to leave medical school without being able to make a general assessment of the musculoskeletal system.”

“The average time spent in rotations for courses devoted to orthopedics during medical school was only 2.1 weeks. One third of these examinees graduated without any formal training in orthopedics. As would be expected, these data suggest that limited educational experience contributes to poor performance.”

“Surveys show that undergraduate medical students spend very few hours on the musculoskeletal system, both in basic science and in clinical training. It would be considered negligent for a medical graduate to be incompetent at adequately assessing the heart or lungs, yet it is quite common for students to leave medical school without being able to make a general assessment of the musculoskeletal system.”

Undoubtedly, the notion of medical expertise in spine care remains a “widespread misconception” that has led to the opioid crisis and poor clinical outcomes.

Today researchers show medical primary care physicians lack training in musculoskeletal disorders (MSDs),[23] are more prone to ignore recent guidelines,[24] more likely to suggest spine surgery than surgeons themselves,[25] and only 2% of primary care physicians (PCPs) refer to DCs as a nondrug treatment despite our superior training and results.[26]

Of course, medical primary care providers (PCP) have been the promiscuous providers who created the present opioid crisis. Mr. Mark Schoene makes the case primary care medical practitioners are, in fact, very dangerous to patients:

“One can make the argument that the most perilous setting for the treatment of low back pain in the United States is currently the offices of primary care medical practitioners—primary care MDs. This is simply because of the high rates of opioid prescription in these settings. [27]

Not only are “pill mills” involved in this scam, but internal medicine, primary care, and family practice were also among high prescribers, followed closely orthopedic surgeons.  Of the more than half million prescribers analyzed for this study, only 385 were identified as pain specialists.[28] Apparently all types of MDs are jumping on this drug bandwagon.

According to Jonathan Chen, MD, PhD and instructor of medicine and Stanford Health Policy VA Medical Informatics Fellow:

“Opioid prescriptions are dominated by general practitioners — the family doctors, internists, nurse practitioners and physician assistants that most patients see for common problems —and not by a small cadre of high volume ‘pill mill’ prescribers once thought to be fueling this epidemic.” [29]

This criticism of MDs came to light due to the opioid epidemic when numerous governmental agencies investigated the cause of this crisis, such as the National Pain Strategy that recommended the need for a cultural transformation in how to manage chronic pain cases admitting MDs were a poor choice:

“Physicians are not adequately prepared and require greater knowledge and skills to contribute to the cultural transformation in the perception and treatment of people with pain.”[30]

 

JCS CURRICULUM VITAE

 

JAMES C. SMITH, MA, DC

1103 RUSSELL PARKWAY

WARNER ROBINS, GA 31088

478-922-4091

jcsmith@smithspinalcare.com

www.smithspinalcare.com

www.chiropractorsforfairjournalism.com

 

Present Positions:  

      Smith Spinal Care Center, Owner

      Chiropractors for Fair Journalism, Director

Educational Background:  

      B.S. Conservation of Natural Resources, 1970

                University of California, Berkeley

      M.A. Sociology of Sport, 1972

                Goddard College, Cambridge, Mass.

      Doctor of Chiropractic, 1978

Life Chiropractic College, Marietta, Ga.

 

Teaching Experience: 

Livingston College, Rutgers University, New Brunswick, N.J., 1972-75,

Sociology of Sport & Intercollegiate Sports Coach

Adjunct Professor: National University of Health Sciences, 2001

Research Assistant: Dr. Rob Scott, Life University, 2019 to present

 

Athletic Achievements:

1968 All-American Track; Varsity Football, University of California, Berkeley

1966 CIF SS Sprint Champion; All-County Football, Upland High School, Upland, Calif.

 

Professional Achievements:

2002 ACA Chairman’s Award for Outstanding Service to the Chiropractic Community

 

Author

Publications  & Presentations

      Books:                               

      A Chiropractic Paradigm

      The Path to Mastery in Chiropractic

How to Avoid Back Surgery: Chiropractic—the Proven Method for Back Pain

Poisoned Love: When a Chiropractor and an Orthopedist Fall in Love…

The Medical War Against Chiropractic: the untold story from persecution to vindication

To Kill a Chiropractor: the media war against chiropractors

 

 

 

Magazines & Journals       

Dynamic Chiropractic

      Staff Management - Hiring New Staff Members

      Management & Transformational Leadership

      Can You Imagine?

      Unity or Anarchy? (3 part series)

      Mystery Science Profession

      Too Many Notes, Mozart

      The Chiropractor Is Naked!

      The Chiropractor As Hero

      Voodoo Diagnosis

      Humpty Dumpty & Workers’ Comp.

      Affirmation Action in Chiropractic

      Bad for Business--But Good for People

      Stormin’ the Capitol: NCLC 2001

      American Healthcare: Truth or Dare?

      Celebrate Our Victories!

      Believe or Understand?

Back Surgery: Too Often, Too Ineffective, Too Costly (4-part series)

The American Chiropractor 

      In Search of Excellence or Excess?

      Cooks & Chiropractors

      Sour Grapes, AMA!

      Killer Subluxation

      Between a Rock & a Hard Place

      Smart Marketing: Top of Mind Awareness

      Smart Internal Marketing

The Journal of the ACA

      Time to Crow

      Dr. Smith Goes to Washington

      We Are Family

      Strangling the Golden Goose

      Managing the Patient from Hell

      ACA Today Newsletter of the American Chiropractic Association

NCLC in First Person: “You Toucha My Fender, I Smasha Your Face”

The American Journal of Clinical Chiropractic

      Ethics in Chiropractic—Pursuit of Image or Ignominy?

      CAM Scam

      Stormin’ the Capitol

The Journal of Chiropractic Humanities

      Chiropractic Ethics: An Oxymoron?

      Microsoft & Medicine

Florida Chiropractic Association Journal

      Chiropractic “PC” Style

      Blueprint for Success

The Journal of Chiropractic Medicine

      Back Surgery: Modern Medical Pitfall

Fighting to Help Lower Costs: Making a Financial Case for Chiropractic

The Georgia Chiropractic Journal

      The Bane of Chiropractic, November 1996

Discounted Chiropractic Care, January 1999

Bad For Business, But Good For People, February 1999

Jump on the Bandwagon to Better Health, Naturally, June 1999

Pleading Chiropractic's Care to Workers' Comp, December 2000

 

 

Seminar Presentations

British Chiropractic Association—Fall Convention, 2007       

Georgia Chiropractic Association - Practice Boosters Seminars

      Practice Consultants - Advanced Client Program Instructor

      N. W. Florida Chiropractic Society - Smart Marketing Seminar

      Chiropractic Paradigm - Practice Management & Marketing Seminars

      Palmer Chiropractic College (West) - Symposium to Preceptor Class

      ACA Sports Injuries & Physical Fitness - Keynote Speaker at their annual                         convention before the Olympic Games in Atlanta, Georgia

      NYCC Career Development Program

      Life University Fall Conference

Florida Chiropractic Association Conventions at Tampa, Del Ray Beach, Panama City, Jacksonville, and Orlando

National College of Chiropractic Homecoming and Ethical Practice Mgt. Class in 2000

CBP 2000 Semi-Annual Reno Seminar

Rhode Island Chiropractic Society convention

Governor’s Commission on Workers’ Compensation, Jekyll Island, Georgia

Los Angeles Chiropractic College lecture on ethical practice management

Chiropractic Poli-Sci seminar sponsored by NUHS

Oklahoma Association for Chiropractic Education

ACC-RAC 2012 Talk to Academic Officers

 

Political Involvement:

GCA’s Delegate to the Congress of Chiropractic State Associations: 1999, 2000

ACA member to the National Chiropractic Legislative Convention

GCA representative to the Governor’s Advisory Commission on Workers’ Compensation

ACA PR Ad Hoc Committee

NCLC attendee, 1999, 2001, 2002

ACC-RAC attendee many times

World Federation of Chiropractic member

 

Online Website:

I have maintained a website Chiropractors for Fair Journalism  dedicated to encourage journalism in our profession directed at the media and public.

 



[1] I sponsored the Dawg Jawg for 20 years to raise money for a new animal shelter in Warner Robins

[2] Sackett, D. L., Rosenberg, W. M., Gray, J. A., Haynes, R. B., & Richardson, W. S. (1996) Evidence based medicine: What it is and what it isn't. British Medical Journal, 312(7023), 71-72

[3] Sackett, D. L., Rosenberg, W. M., Gray, J. A., Haynes, R. B., & Richardson, W. S. (1996) Evidence based medicine: What it is and what it isn't. British Medical Journal, 312(7023), 71-72

[4] Underwood M et al. United Kingdom Back Pain Exercise and Manipulation (UK BEAM) Randomized Trial: “Cost Effectiveness of Physical Treatments for Back Pain in Primary Care,” British Medical Journal, 2004;329:1381-1385. 42517(7/2005)

[5] Failed Back Surgery, The BACKLetter, Vol. 33, No. 7, July 2018

[7] Practicing Chiropractors’ Committee on Radiology Protocols (PCCRP) For Biomechanical Assessment

Of Spinal Subluxation in Chiropractic Clinical Practice Accepted for Inclusion in the National Guideline Clearinghouse July 2009. (pages 45-46)

 

[8] Practicing Chiropractors’ Committee on Radiology Protocols (PCCRP) For Biomechanical Assessment

Of Spinal Subluxation In Chiropractic Clinical Practice Accepted for Inclusion in the National Guideline Clearinghouse July 2009. (pages 45-46)

 

[9] John “Jay” Triano, DC, PhD, gave a precise explanation in his paper, “Biomechanics of Subluxation: Modern Evidence of Buckling Mechanism.”278 He explained there are a set of joints between two adjacent vertebrae comprising the “motor unit” where motion and weight-bearing occur. These gliding zygapophyseal joints,

[10] Deyo RA, Weinstein JN. Low back pain. N Engl J Med 2001 Feb 1;344(5):363-70.

[11] Richard A. Deyo, MD, MPH and Donald L. Patrick, PhD, MSPH, Hope or Hype: The Obsession with Medical Advances and the High Cost of False Promises, AMACOM books, (2005): 36-37

[12] Donald R Murphy and Eric L Hurwitz, Application of a diagnosis-based clinical decision guide in patients with neck pain, Chiropractic & Manual Therapies 2011, 19:19

[13] Donald R Murphy and Eric L Hurwitz, “Application of a diagnosis-based clinical decision guide in patients with low back pain,” Chiropractic & Manual Therapies 2011, 19:26

[15] Private communication with JC Smith, May 27, 2020.

[16] JMPT, 2001 Sep; 24(7):449-56.

 

[17] BMJ 2001;322:1511-1516 ( 23 June )Multidisciplinary rehabilitation for chronic low back pain: systematic review, Jaime Guzmán, research fellow, a Rosmin Esmail, Cochrane Collaboration coordinator, a Kaija Karjalainen, research fellow, b Antti Malmivaara, assistant chief physician, b Emma Irvin, manager, information systems, a Claire Bombardier, senior scientist. a

 

[19] Deyo, RA. Low -back pain, Scientific American, pp. 49-53, August 1998.

[20] S Boden, et al. “Emerging Techniques For Treatment Of Degenerative Lumbar Disk Disease,” Spine 28(2003):524-525.

[21] Stockard AR, Allen TW. Competence levels in musculoskeletal medicine: comparison of osteopathic and allopathic medical graduates. J Am Osteopath Assoc. 2006 Jun;106(6):350-5

[22] JC Wilson,  “Low Back Pain and Sciatica: A Plea for Better Care of the Patient, Chairman's Address,” JAMA, 200/8, (May 22, 1967):705-712.

[23] Elizabeth A. Joy, MD; Sonja Van Hala, MD, MPH, “Musculoskeletal Curricula in Medical Education-- Filling In the Missing Pieces, The Physician And Sports Medicine,” 32/ 11 (November 2004).

[24] PB Bishop et al., “The C.H.I.R.O. (Chiropractic Hospital-Based Interventions Research Outcomes) part I: A Randomized Controlled Trial On The Effectiveness Of Clinical Practice Guidelines In The Medical And Chiropractic Management Of Patients With Acute Mechanical Low Back Pain,” presented at the annual meeting of the International Society for the Study of the Lumbar Spine Hong Kong, 2007; presented at the annual meeting of the North American Spine Society, Austin, Texas, 2007; Spine, in press.

[25] SS Bederman, NN Mahomed, HJ Kreder, et al. In the Eye of the Beholder: Preferences Of Patients, Family Physicians, and Surgeons for Lumbar Spinal Surgery,” Spine 135/1 (2010):108-115.

[26] Matzkin E, Smith MD, Freccero DC, Richardson AB, Adequacy of education in musculoskeletal medicine. J Bone Joint Surg Am 2005, 87-A:310-314

[27] The BackLetter, volume 30, number 10, 2015

[28] “Top 5 Percent of Opioid Prescribers Write 40 Percent of US Narcotic Prescriptions.” Express Scripts, June 9, 2014, PRNewswire

[29] Jonathan Chen, Overprescribing of opioids is not limited to a few bad apples, Stanford Medicine News Center, Dec 14 2015

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