Joint
Cover Letter to United Healthcare
October 9, 2007
Mr. Robert J. Sheehy
Chief Executive Officer
UnitedHealthcare
450 Columbus Blvd.
Hartford, CT 06103
Dear Mr. Sheehy:
This letter is a joint
communication from the undersigned chiropractic organizations. Our
organizations represent the mainstream of the chiropractic profession
in the areas of professional practice, research and clinical guidelines.
We write to you today in connection with the recent special bulletin
pertaining to chiropractic services related to children, adolescents
and headaches (United Healthcare Network Bulletin, Volume 21, September
2007). It states: "United Healthcare had previously concluded
that certain services provided as a part of chiropractic care were
unproven. A recent review of the clinical evidence in published peer-reviewed
medical literature leads us to further conclude that chiropractic
services for treatment of children and adolescents is unproven and
services for treatment of headaches is unproven."
Attached is an analysis
which demonstrates that the above policy is not only flawed but more
importantly poses a threat to the health of children, adolescents
and those individuals suffering with headache pain who may be insured
or otherwise covered under United Healthcare programs and policies.
We view your recent policy determination to be a material denial of
essential benefits and coverage paid for by employers and other insureds.
The broad stroke elimination of these important benefits is, in our
view, not only unconscionable but is an abrogation of the promises
made to cover chiropractic services to employees, individuals and
their dependants.
We note that none of our
organizations were contacted or consulted in connection with your
drastic and unprecedented denial of benefits to adolescents, children
and those suffering with headache pain. In our opinion, this raises
serious questions as to your intentions and we question to whether
your motivation for the bottom line outweighs your responsibility
to provide coverage for appropriate and needed healthcare services.
We would therefore request
the immediate rescission of the above-referenced policy. We offer
our assistance to provide whatever input your organization may need
to craft policies that are reflective of health needs of chiropractic
patients under your programs. We intend to inform our patients, state
and federal regulatory authorities, members of the various state legislatures,
members of Congress and the public of what we view as your inappropriate
and reckless action in the denial of needed healthcare benefits to
adolescents, children and those suffering with headache pain under
your program.
We stand ready to engage
in constructive dialog on these matters, but the first step in the
process must be the immediate rescission of the policy contained in
the above-referenced network bulletin.
Sincerely,
Glenn D. Manceaux,
D.C.
President, American Chiropractic Association
Wayne M. Whalen, DC, DACAN
Chair, Council on Chiropractic Guidelines and Practice Parameters
Charles Herring, D.C.
President, Foundation for Chiropractic Research and Education
Carl S. Cleveland III,
D.C.
President, Association of Chiropractic Colleges
R. Jerry DeGrado, D.C., F.I.C.C
President, Congress of Chiropractic State Associations
John Maltby D.C.
President, International Chiropractors Association
CCGPP Analysis/Letter to UHC
October 8, 2007
To: Stephen J. Hemsley
President and Chief Executive Officer UnitedHealth Group
9900 Bren Road East,
Minetonka MN 55343
From: Dr. Wayne Whalen, Chairman, Council on Chiropractic Guidelines
and Practice Parameters (CCGPP)
RE: United HealthCare NetworkBulletin Volume 21 September 2007
Recently UHC released a special bulletin, United HealthCare NetworkBulletin
Volume 21 September 2007, concerning chiropractic services related
to children, adolescents, and headaches. It states,
"United HealthCare had previously concluded that certain services
provided as a part of chiropractic care were unproven. A recent review
of the clinical evidence in published peer-reviewed medical literature
leads us to further conclude that chiropractic services for treatment
of children and adolescents is unproven and services for treatment
of headaches is unproven."
The Council on Chiropractic Guidelines and Practice Parameters, the
principal agency in the United States that evaluates literature of
interest to chiropractic practice, reviewed this bulletin and has
serious concerns, especially over the potential harm to children as
a result of this policy. We are also concerned over the health and
welfare of those patients suffering headaches, who as a result of
this policy will be denied medically necessary and evidence-based
chiropractic care. Given the research available on the topics in question,
in combination with how evidence is translated into clinical practice,
we believe the conclusions and policy limits implied by UHC based
upon the literature was flawed in many respects. We respectfully request
that United Healthcare forward the results of the "recent review of
the clinical evidence" referred to in the UHC information release
for the CCGPP to evaluate. Please consider the issues identified below.
Issue #1: Scope of practice
In this bulletin UHC refers to "chiropractic services" presumably
and mistakenly equating the licensure of the chiropractic profession
with the singular modality/treatment of spinal manipulation. As is
known, chiropractic physicians are primary care/portal of entry physicians
recognized by statute at both federal and state levels, e.g. Medicare,
Medicaid, Department of Defense and Veterans Administration programs,
just to name a few. The treatment of special patient populations,
e.g. children and adolescents, and specific conditions, e.g. headaches
have been established for many years to be well within the scope of
a chiropractic practice. Treatment includes not only spinal manipulation,
but also active and passive therapeutic modalities, evaluation and
management services, instruction on lifestyle modifications, diet
and exercise, posture and nutritional advice and other facets of chiropractic
practice. Chiropractic is not limited to just spinal manipulation
and the UHC bulletin is unclear whether other aspects of a chiropractic
clinical encounter are reimbursable.
Issue #2: Discriminatory policy/standards
In our opinion, it does not appear that UHC’s new standards
concerning research and new announced policy were applied in equal
fashion across the spectrum of healthcare professions. In fact, if
every licensed profession were held to the same unrealistic standard
being imposed on the chiropractic profession, virtually no treatment
or drug would be reimbursable by UHC. As is commonly known, the FDA
did not permit research on children until 2005. In fact most pediatric
dosages were prescribed on a hypothetical by-weight basis because
of this restriction. Therefore, there remains no significant body
of data, beyond case studies, etc. (i.e. no RCTs), supporting the
treatment of children by typical medical intervention. Clearly the
new UHC policy holds chiropractic physicians to a different set of
standards. What medical treatments exist that UHC believes are supported
by significant literature? Is UHC denying payment to medical and osteopathic
physicians and physical therapists for treatment of children and adolescents
and for treatment of headaches? If not, we request that UHC forward
the literature supporting the decisions to continue to reimburse those
interventions for our review.
Issue #3: Research
A brief review of the literature revealed numerous papers related
to spinal manipulative therapy (SMT) and cervical pain, including
headaches. Chronic and cervicogenic headaches remain some of the most
prevalent forms of headaches, and chiropractic physicians are particularly
well-trained to treat these condition. The CCGPP respectfully requests
that UHC produce the review of the literature referenced in the bulletin
for our review so we can crosscheck with other available sources to
examine the accuracy of the interpretation of those studies. We will
further address the issue of headaches under separate cover after
we receive UHC’s literature search on the topic.
Literature related specifically to children is less voluminous; however,
is it truly necessary? What evidence does UHC have in its possession
indicating that the spines of children and adolescents respond any
differently to spinal manipulation and numerous other passive and
active interventions used not only by chiropractic physicians, but
medical and osteopathic physicians and physical therapists? What evidence
exists that would suggest to UHC that children and adolescents are
somehow immune to spine injury/pain? To deny coverage for a special
population of patients based upon the lack of research is analogous
to denying payment for spinal manipulation for patients living in
West Virginia since no randomized trials exist for that population
of patient. In our opinion UHC’s logic is flawed in its application
of research in a clinical setting. Does UHC possess any literature
suggesting that the spines of children and adolescents respond any
differently to passive and active modalities and treatment compared
to adult populations for which spinal manipulation has proven value?
The literature clearly shows that children suffer significant back
pain. In fact, in a study of 1,126 children, the prevalence of nonspecific
back pain increases dramatically during adolescence from less than
10 percent in the pre-teenage years up to 50 percent in 15- to 16-year-olds.
Of 1,122 backpack users, 74.4 percent were classified as having back
pain, validated by significantly poorer general health, more limited
physical functioning, and more bodily pain. There is widespread concern
that heavy backpacks carried by adolescents contribute to the development
of back pain.
Other contributing factors to the near epidemic of back pain in adolescents
are: sedentary lifestyle, obesity, de-conditioning, excessive sitting,
poor diet, etc. These issues not only can all be addressed, but are
being routinely addressed with successful therapeutic outcomes, in
the normal visit to a chiropractic physician.
Another study of 54 pediatric patients concluded that patients responded
favorably to chiropractic management, and there were no reported complications.
Numerous recognized and respected guidelines support the use of spinal
manipulation, along with other therapies, in the treatment of back
pain. Just this month, the widely-respected journal, Annals of Internal
Medicine stated: *Recommendation 7: *For patients who do not improve
with self-care options, clinicians should consider the addition of
nonpharmacologic therapy with proven benefits—for acute low back pain,
spinal manipulation [emphasis added]; for
chronic or subacute low back pain, intensive interdisciplinary rehabilitation,
exercise therapy, acupuncture, massage therapy, spinal
manipulation [emphasis added], yoga, cognitive-behavioral
therapy, or progressive relaxation.
Issue # 4: Clinical skills, financial impact, and patient
safety
Given the reality of back pain in children and adolescents, why would
UHC restrict access and benefits to the profession best suited to
evaluate and treat these conditions? Chiropractic physicians clearly
possess more education and clinical skills in the area of musculoskeletal
diagnosis and treatment compared to general allopaths and physical
therapists. If this policy is permitted, young patients and those
suffering headaches will have nowhere to turn except to general medicine.
Will that shift result in dollars saved? The answer is no. A limited
or complete loss of chiropractic benefits will result in a shift and
increased payment for traditional care with its inherent higher costs
for treatment, diagnostics and risks associated with prescriptions
and invasive procedures. Given the fact that our society, especially
the young, is already overmedicated, does that policy make good fiscal
or epidemiological sense? In CCGPP’s opinion, it does not. We are
justifiably concerned that UHC’s policy will force unnecessary drugs
on headaches sufferers and on children who suffer back pain and other
conditions commonly treated by chiropractic physicians. The side effects
of those drugs can easily be avoided by the use of more conservative
chiropractic care.
Issue #5: Proper
use of guidelines
In CCGPP’s opinion,
UHC failed to consider that evidence/research is only one facet of a
best practice strategy in clinical practice. Other equally important
elements include clinical decision-making/experience, patient values,
documentation, process of care, response to care, and risk stratification.
Over reliance on literature is impractical in a clinical setting where
unique patient attributes often exceed the strict controls found in
most randomized controlled trials. The CCGPP wishes to remind UHC of
the following concerning guidelines:
All guidelines serve merely as background information to assist doctors
in the clinical decision-making process.
A guideline serves as a "compass" for care, not a cookbook for care.
Guidelines should never be used punitively or as prescriptions for care.
Each patient is unique and treatment recommendations must be based on
the specific factors pertaining to the individual case.
Guidelines are only one piece of evidence to consider when considering
the medical necessity of care. Other pieces of evidence include: research,
clinical experience/decision-making, patient values, risk stratification,
process of care, response to care, documentation, etc. Again, guidelines
are not cookbooks with rigid dosages for treatment.
Nearly all guidelines are based upon the acute, non-complicated patient.
These are not the typical patients found in clinical practice.
Issue #6: Civil Rights of children
A major concern of CCGPP is the possible violation of civil rights against
this special population, children. Discrimination based upon age is
not acceptable in any venue. Given the lack of reason, science, logic,
clinical applicability, and the apparent double standards imposed on
chiropractic versus medical licensees, this policy should be immediately
withdrawn by UHC. Forcing children into more invasive medical procedures,
including medications, by denying coverage for more conservative treatment
should not be acceptable to anyone.
We sincerely hope the observations of CCGPP and recommendations contained
in this letter are seriously considered by UHC Please provide us with
either confirmation that this egregious policy has been rescinded, or
the specific literature synthesis upon which you relied as the basis
for the policy. We would also like to note that CCGPP, with its extensive
literature searching and review abilities, is available to provide both
peer-reviewed and consensus information about chiropractic practice
that can be useful to all parties, and we do consider United HealthCare
as a stakeholder. If there are additional questions, please do not hesitate
to contact my office. I can be reached at (619) 258-1144 or by electronic
mail atDrWWhalen@aol.com.
Sincerely,
Wayne Whalen, DC, DACAN Chair Council on Chiropractic Guidelines and
Practice Parameters (References can be found in PDF copy of letter by
clicking
here.)
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