August 7, 2006

CCGPP Responds to Attacks by Mr. Russell Leonard

Some may have noticed that the Council on Chiropractic Guidelines and Practice Parameters (CCGPP), the authors of the new best practices document, has been a focus of attacks by one particular state association executive director. Mr. Russell Leonard, the executive director of the Wisconsin Chiropractic Association (WCA), is this individual who is offering his advice and directing the profession to reject the years of work by CCGPP, which was formed through the wisdom of nearly every national association.

CCGPP has normally observed a policy of not singling out anyone for criticism. However, Mr. Leonard has aggressively and repeatedly distributed so much misinformation that we are responding to add context to this attack by him, especially since he has implied that he is an authority in these matters.

Mr. Leonard

Mr. Leonard is not a chiropractor, yet he speaks loudly about what he feels that chiropractic practice should be. Without training or experience, he also boldly explains his version of the technicalities of gathering and rating evidence and about standards of research, demonstrating his lack of knowledge about the process. He has vigorously injected himself into this discussion and we feel that answers about Mr. Leonard's underlying true motivation must be provided by him to chiropractic doctors. Chiropractors are primary stakeholders in this critical process for the future of the profession, where research that affects chiropractic must be evaluated, commented on by trained individuals in the profession and then made public to all who interact with us.

To better ask questions of Mr. Leonard, CCGPP feels that chiropractic doctors need to investigate Mr. Leonard's journey to this point.

Is Mr. Leonard historically a part of our leadership that has traditionally worked together for the chiropractic profession? It would appear not, as it is reported to us that Mr. Leonard has had very little to do with other associations and national efforts in the past, increasingly isolating himself and his state. We have frequently been informed that he is known for publicly making disparaging remarks about other associations.

A few years ago, in this already divided profession, Mr. Leonard was preoccupied with a letter and email writing campaign similar to his current attack on CCGPP in an effort to create his own national association. Yet another national association would seem to only cause more division and add chaos, further diluting our professional strength, yet this was strongly advocated as a good idea by Mr. Leonard at the time. The rest of the profession observed that Mr. Leonard was the one behind this cause and his proposal collapsed in short order.

Should chiropractors be adopting Mr. Leonard's advice, based on his success with past efforts to advise chiropractors? We suggest that readers Google both the terms "Russell Leonard" and "Wisconsin Chiropractic Association" to read about court decisions against him and accompanying monetary penalties over the last several years as a consequence of positions that he has advocated.

In 2000, Mr. Leonard was forced to resolve a complaint by the Federal Trade Commission (FTC) that he advised and conspired with his members to price-fix services, a violation of federal law, and he agreed to an FTC-ordered prohibition of such advice to his members (United States of America Federal Trade Commission in the Matter of the Wisconsin Chiropractic Association, a corporation, and Russell A. Leonard, Docket No. C-3943, May 18, 2000).

In 2001, the Madison, Wisconsin newspaper Capital Times reported that another suit by the Wisconsin State Attorney General's office alleged that "the WCA and its director, Russell Leonard, conspired to increase prices paid for chiropractic manipulations and boycotted insurers to receive higher reimbursements."

In another matter, the same newspaper also reported that the state attorney general's office sued and " alleged that in 1996, Leonard and the WCA engaged in anticompetitive practices to keep board members of the WCA's southeast district from sponsoring seminars."

The Wisconsin Chiropractic Association, on behalf of Mr. Leonard's actions, settled these two charges by paying $62,500 to the state of Wisconsin.

In yet another case reported widely in newspapers and in Dynamic Chiropractic on July 2, 2005, a Wisconsin circuit court judge ruled that "the Wisconsin Chiropractic Association and its executive director, Russell Leonard, filed a frivolous lawsuit in 2002 against the [then] chair of the Wisconsin Chiropractic Examining Board, [Dr. Dale Strama], for the sole purpose of maliciously injuring Dr. Strama" by influencing Wisconsin chiropractors to not attend seminars sponsored by a private organization with which Dr. Strama was associated. A 17-page ruling in this case stated in part that "Russell Leonard knew that if he conducted a reasonable inquiry, there would be no facts to support naming Dr. Strama in the suit. He knew how the continuing education applications were handled [by the board of examiners] and deliberately mislead WCA counsel on that critical issue. Dr. Strama.....and several other defense witnesses were all considered more credible witnesses than Mr. Leonard on the issues where their testimony was in conflict. Mr. Leonard does bear ill will toward Dr. Dale Strama and sees [Dr. Strama's organization] as a threat to his own financial gain from commissions he receives from WCA sponsored seminars," with the WCA seminars reported in news coverage to have netted Leonard in excess of $100,000 per year. The judge ordered payment by the Wisconsin Chiropractic Association to Dr. Strama, reported in a number of newspapers to have been approximately $100,000 in 2005.

CCGPP believes that, based on Mr. Leonard's past behavior, his advice to reject the CCGPP best practices document is questionable at best.

Even though most chiropractors have never heard of him before now, Mr. Leonard is familiar to many leaders in the profession. Perhaps those individuals might also be able to shed more light on this situation. For what might be an illuminating conversation, CCGPP suggests calling any state association executive director or any of the chiropractic college presidents and inquiring of him or her how helpful that Mr. Leonard has been in their past experience and how much they respect him and have enjoyed working with him.

Mr. Leonard's proclamations

He indicates that the profession should wait until there is more evidence. However, we feel that this is an excuse for not doing anything at all and has been heard for the past 20 years. While the profession waits, others outside chiropractic have constructed and are continuing to construct their own documents, often to our detriment. CCGPP has chosen to begin with existing evidence, evaluate and comment on it and identify gaps where the profession needs to do future research.

Mr. Leonard uses the term "best practices guidelines" repeatedly and indicates that they will be employed against the chiropractic profession by insurance companies. First of all, Mr. Leonard has coined the term "best practices guidelines" himself and no such term exists. CCGPP is writing about best practices and not guidelines, the latter being narrowly focused, often to the detriment of the profession. CCGPP has stated repeatedly that guidelines are not being written and this was pointed out directly to Mr. Leonard on many occasions by CCGPP personnel. Best practices, like any document, certainly can be used against the profession. We are realistic and assume they will be misused at times, but CCGPP stands ready to address misapplication when it occurs. We are a permanent organization and will use every means to see that they are employed in the manner intended. The alternative is to have no impact in a document that is used by a carrier or other body, with no recourse as to ownership and usage.

Mr. Leonard projects financial losses of 30-45% of income if this document is promulgated. He does not, however, present any evidence for such a claim.

There is also an attack on the grading scale of evidence, yet carriers and all others have the same information already. Not only that, carriers and others have no process for stratifying that evidence as to its meaning or power, something that CCGPP is determined to provide. Similar scales have been applied to various treatments for decades and have thus far not led to widespread rejection of modalities. The scales merely reflect the evidence: there is less good research for passive modalities like electrical stimulation (and epidural steroids, some drugs, lumbar corsets etc) than for manipulation and active care, but no evidence of looming denials because of it.

The participation of others outside of the profession in the development process is condemned in other attacks, yet this only further points out Mr. Leonard's lack of familiarity concerning how such documents are constructed. Internationally accepted evaluation tools, such as AGREE, mandate the participation of all stakeholders in order to be judged valid. If the analyses of documents which have been determined to be flawed in the past are reviewed, readers will discover that this lack of stakeholder participation was one of the major omissions.

Mr. Leonard intimates that CCGPP created the best practices document as a response to the requests of state workers compensation boards such as Texas and California, with the consequent implication that CCGPP is a tool of the insurance companies and state agencies. The reality is far different. Chiropractic associations in California and Texas were among those who discussed with CCGPP the problems they were having with workers compensation and expressed their interest in assistance by CCGPP. The Congress of Chiropractic State Associations and most other national associations charged CCGPP with this task in 1995. The process of the research began long before these state problems and was in response to the foresight that these types of problems would increasingly arise. Mr. Leonard was informed of this genesis and timeline in 2004, but has instead repeated his own version of the events.

Necessity of CCGPP best practices

As there is an increasing reliance on evidence to inform, justify, and refine decisions, payment to providers is aimed increasingly at achieving outcome priorities, with these issues a salient focus of CCGPP.

The daily need for valid information about diagnosis, prognosis, therapy and prevention is overwhelming and continues to increase. The inadequacy of traditional sources for this information because they are out-of-date, inaccurate, too voluminous or too variable in their validity for practical clinical use is increasing and CCGPP's document is to address these issues also.

As chiropractic has become increasingly immersed in the social system in America, the challenge to demonstrate its effectiveness has also grown. CCGPP has been charged with identifying indicators of effectiveness via reviews of literature.

CCGPP was also created as a response to persistent problems with third-party payors as well as with the interpretation of evidence by those outside the profession. The CCGPP mission is to provide consistent and widely adopted chiropractic practice information, so that consumers and others have reliable information on which to base informed health care decisions.

What if nothing is done? Chiropractors will be increasingly subject to documents developed by others; information overload will continue; loss of market share to more effective services (or the perception of more effective services) may be on the horizon and lack of input about published research biases are also increasingly likely.

The trend is not diminishing. The profession has to manage our portion of the onslaught of the evidence-based practice process and all of the other associated issues or someone else will manage it for us.

Asking questions

CCGPP anticipates that one may wish to call or write Mr. Leonard (608-256-7023; fax 608-256-7123; 521 East Washington Avenue, Madison WI 53703; email RLeonard@aol.com) and inquire about his curious campaign of misinformation and ask what his true motivation is in attacking a project that the profession has called for and critically needs.

CCGPP has no problem answering hard questions about the best practices document and we actively solicit all stakeholder comments (CCGPP, PO Box 2542 Lexington, SC 29071 - 803.808.0640 - Fax 803.356.6826 - ccgpp@sc.rr.com).