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Kaiser no longer paying for neck manipulation

 
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Kaiser no longer paying for neck manipulation - August 31, 2010 6:56:06 AM   
JSPT

 

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http://www.sciencebasedmedicine.org/?p=6681

Thoughts on the impact to our profession?  Is this a good or bad sign?
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RE: Kaiser no longer paying for neck manipulation - August 31, 2010 9:10:37 AM   
bonez

 

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Well I would suggest it is bad for all. If you take out the chiro reference and look at the process you will see that an insurer is choosing to follow the evidence it picks to base it's coverage on. A side form the safety issue that some have posted here maybe over blown, there is little to suggest that mobilization is any better.
Now mobilizing P.T.'s need to be concerned that the next pen stroke will be that they won't cover any manual treatment for the C spine. If you accept the logic of not enough preceived benefit then mobilization better be next.
I would say that overall it is bad for all manual therapists in all professions.

(in reply to JSPT)
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RE: Kaiser no longer paying for neck manipulation - August 31, 2010 11:33:06 AM   
SJBird55

 

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Chiropractic care and chiropractic philosophy of care is different than physical therapy care and philosophy.  If I have read various aspects of chiropractic care correctly, manipulation is provided to reduce subluxations... subluxations which have never been seen or proven.  So... could be a good thing.  I am going to assume, certain procedural codes will not be reimbursed.

Physical therapists DO have outcome studies proving the effectiveness of manual therapy combined with therapeutic exercise.  Physical therapists do not code their interventions as "manipulation."  Physical therapists use 97140 which is a procedural code for manual therapy.  Manual therapy is a general procedural code and not a specific code like the manipulation codes chiropractors use.

(in reply to bonez)
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RE: Kaiser no longer paying for neck manipulation - August 31, 2010 12:03:17 PM   
proud

 

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quote:

ORIGINAL: bonez

Well I would suggest it is bad for all. If you take out the chiro reference and look at the process you will see that an insurer is choosing to follow the evidence it picks to base it's coverage on. A side form the safety issue that some have posted here maybe over blown, there is little to suggest that mobilization is any better.
Now mobilizing P.T.'s need to be concerned that the next pen stroke will be that they won't cover any manual treatment for the C spine. If you accept the logic of not enough preceived benefit then mobilization better be next.
I would say that overall it is bad for all manual therapists in all professions.


You may be right Bonez. But most likley wrong.

As SJ said, PT is a different animal than chiropractic. I'm afraid chiropractic has shot themselves in the foot on so many repeated occasions that digging themselves out of that hole may be impossible. Outrageous claims and a poor adherence to scientific inquiry has landed Chiropractic where it is.

Having stated that....I see the PT community appears set to be filling this absurd void. Too many PT's fail to acknowledge the failure of the biomechanical model and replace it with more scientifically accurate modes of application. Too many PT's performing CST, Myofascial release among others.

Unless we get it in gear...we may land ourselves in the sphere of the wacky as well...

< Message edited by proud -- August 31, 2010 2:30:16 PM >

(in reply to bonez)
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RE: Kaiser no longer paying for neck manipulation - August 31, 2010 1:03:54 PM   
TexasOrtho


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+1 to SJ and proud.  Kudos to Kaiser on this one. 

I'm always suprised how manipulation can be perceived as a homogenous event.  The contextual differences between PT and traditional chiropractic manipulation are huge.  One lends itself to enablement and relatively low utilization.  The other...well we are all familiar with that story.  This is just another paragraph in that epilogue.

_____________________________

Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
Movement Science Podcast and Blog

(in reply to proud)
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RE: Kaiser no longer paying for neck manipulation - August 31, 2010 2:05:54 PM   
bonez

 

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If you actually read the post they base their decision on the limited evidence regarding usefulness in c spine conditions. Much of Andrew Ball's recent posts review the present state of the evidence regarding procedures for the c spine.
In that material manipulation was as good or slightly better than mobilization in their reviews. There seems as always a rush to say Chiro is neg this and that. The next step as they follow the evidence is to now question the validity of mobilization for the same conditions.
PT as the mobilizing profession, needs to be worried as the next step takes a shot at them. What is missed is that the conclusions were drawn on not the most current evidence reviews available. The bone and joint task force speaks to the need for further study as the evidence base is still so limited. 

(in reply to TexasOrtho)
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RE: Kaiser no longer paying for neck manipulation - September 1, 2010 10:04:39 AM   
jesspt

 

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Don't DC's bill a cervical manipulation the same way physical therapists do: 97140?

If so, are they using the providers license number nad the patients' ICD-9 code to trigger a denial?

As a PT who occasionally uses thrust in the cervical spine, I'm a bit concerned here, for the very reasons Bones stated above. Insurers in general use the evidence in a way that benefits them and their bottom line, not in a way that benefits those they insure, although the two may not be mutually exclusive. Is this the harbinger of things to come? Are we only one poorly designed study away from getting the same treatmetn the chiropractors have gotten here?

_____________________________

Jess Brown, PT
Board Certified in Orthopaedic Physical Therapy

(in reply to bonez)
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RE: Kaiser no longer paying for neck manipulation - September 1, 2010 1:40:36 PM   
TexasOrtho


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I actually read the post.  I also actually read this randomized clinical trial in the Archives of Physical Medicine published about 10 minutes ago.  Kaiser is not acting irrationaly here.  I wonder when we are going to loosen up and be willing to acknowledge only the treatment paradigm needs a major adjustment.


A Randomized Controlled Trial Comparing Manipulation With Mobilization for Recent Onset Neck Pain



from Archives of Physical Medicine and Rehabilitation by Andrew M. Leaver, Christopher G. Maher, Robert D. Herbert, Jane Latimer, James H. McAuley, Gwendolen Jull, Kathryn M. Refshauge

Abstract: Leaver AM, Maher CG, Herbert RD, Latimer J, McAuley JH, Jull G, Refshauge KM. A randomized controlled trial comparing manipulation with mobilization for recent onset neck pain.Objective: To determine whether neck manipulation is more effective for neck pain than mobilization.Design: Randomized controlled trial with blind assessment of outcome.Setting: Primary care physiotherapy, chiropractic, and osteopathy clinics in Sydney, Australia.Participants: Patients (N=182) with nonspecific neck pain less than 3 months in duration and deemed suitable for treatment with manipulation by the treating practitioner.Interventions: Participants were randomly assigned to receive treatment with neck manipulation (n=91) or mobilization (n=91). Patients in both groups received 4 treatments over 2 weeks.Main Outcome Measure: The number of days taken to recover from the episode of neck pain.Results: The median number of days to recovery of pain was 47 in the manipulation group and 43 in the mobilization group. Participants treated with neck manipulation did not experience more rapid recovery than those treated with neck mobilization (hazard ratio=.98; 95% confidence interval, .66��"1.46).Conclusions: Neck manipulation is not appreciably more effective than mobilization. The use of neck manipulation therefore cannot be justified on the basis of superior effectiveness.

 
----
My bolds. 


< Message edited by TexasOrtho -- September 1, 2010 1:44:17 PM >


_____________________________

Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
Movement Science Podcast and Blog

(in reply to jesspt)
Post #: 8
RE: Kaiser no longer paying for neck manipulation - September 1, 2010 2:32:58 PM   
JSPT

 

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Talk about timing.  Way to be Roddy-on-the-spot!

I couldn't agree more with the findings.  My thoughts that mobilization is just as effective and safer than manips, period(.) 

To repeatedly manip the c-spine is reckless in my opinion, and only has plausible benefits for mechanical, acute neck pain.  Any manips for chronic pain or to treat allergies, TMJ, or any other subluxation-based sequelae is not a valid approach.

(in reply to TexasOrtho)
Post #: 9
RE: Kaiser no longer paying for neck manipulation - September 1, 2010 2:44:31 PM   
bonez

 

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Guys you both miss the point. For me for the moment forget the chiro/physio thing. The fear is that the next step will be that manual treatment of the c spine is on the chopping block.

Rods study states that manipulation is no more effective than mobilization. If we don't need to pay for manipulation we wont need to pay for mobilization either. All that is needed is the next study to say that mobs results do not beat otc med blah blah blah and mob will be out too!

(in reply to JSPT)
Post #: 10
RE: Kaiser no longer paying for neck manipulation - September 1, 2010 2:52:58 PM   
bonez

 

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Rod was there any more info available about the study design? VAS for pain scale, other treatment exercise etc.

The difference in this case 4 days longer recovery (47 vs 43) is a small deference suggesting that neither is very good. Finally how was 4 sessions over 2 weeks determined to be the best application? Was there a pattern to how these interventions applied 3 in one week one in a week or random.

The quality of the work also needs to factor into the weight we throw at the conclusions don't you think?

(in reply to TexasOrtho)
Post #: 11
RE: Kaiser no longer paying for neck manipulation - September 1, 2010 3:28:14 PM   
Jon Newman

 

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quote:

ORIGINAL: jesspt

Don't DC's bill a cervical manipulation the same way physical therapists do: 97140?


Apparently not. They use the following

98940 Chiropractic manipulative treatment (CMT); spinal, 1-2 regions
98941 Chiropractic manipulative treatment (CMT); spinal, 3-4 regions
98942 Chiropractic manipulative treatment (CMT); spinal, 5 regions
98943 Chiropractic manipulative treatment (CMT); extraspinal, 1 or more regions

See here for more about the policy.

(in reply to jesspt)
Post #: 12
RE: Kaiser no longer paying for neck manipulation - September 1, 2010 4:03:06 PM   
JWarePT

 

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quote:

ORIGINAL: bonez
The bone and joint task force speaks to the need for further study as the evidence base is still so limited. 


If the evidence for efficacy is so limited, isn't it better to err on the side of caution given the documented cases of severe injury and death from cervical manipulation?

If future research shows that certain types of cervical manipulation turn out to be not only safe, but effective, and PTs want to avoid losing the privilege of performing this intervention (based on a rational mechanism, rather than the dopey subluxation nonsense), then we need to get our butts in gear and prove it.

You do have a point though, bonez.  I doubt Kaiser is considering a new exclusion of lumbar fusion for patients with chronic LBP, despite the growing body of research showing poor outcomes from that procedure.  If it ever came down to an "equal protection" argument, Kaiser would lose hands down.  They only use "protecting the health of their subscribers" when it suits them, it seems.

Why that equal protection principle doesn't apply in health care has always bugged me.

(in reply to bonez)
Post #: 13
RE: Kaiser no longer paying for neck manipulation - September 1, 2010 7:23:36 PM   
proud

 

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quote:

You do have a point though, bonez. I doubt Kaiser is considering a new exclusion of lumbar fusion for patients with chronic LBP, despite the growing body of research showing poor outcomes from that procedure. If it ever came down to an "equal protection" argument, Kaiser would lose hands down.


Absolutely. Set aside the chiro/Physio thing and think about this comment from JwarePT.

If given a choice between a chiropractic neck manipulation for pain and a lumbar fusion...I'd choose the manipulation hands down.

Where is the rigor by Kaiser when looking at all the uneccesary spinal fusions for back pain? Without a doubt a terrible track record for that procedure.... along with astronomically more cost than chiropractic manipulation.

Ya...although I applaud the appropriate scrutiny of the actual benefit of cervical manipulation over run of the mill mobilization....I question the real end game of Kaiser.

So I agree with you Bonez....

(in reply to JWarePT)
Post #: 14
RE: Kaiser no longer paying for neck manipulation - September 1, 2010 8:02:33 PM   
TexasOrtho


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quote:

ORIGINAL: bonez

The quality of the work also needs to factor into the weight we throw at the conclusions don't you think?


Absolutely agree. I'm not wild about the study design and would quibble with some of their end points. Using pain as an isolated end-point itself is troublesome because (as most of us know) it can vary quite a bit given the right context.

"Quality" research is definitely difficult to come by these days so I share your trepidation in taking too much from this particular study - eventhough it is an RCT. Hell an RCT was just published showing craniosacral therapy was beneficial. It's been discussed quite a bit on SS, but your point remains valid.

Kaiser most certainly isn't making this decision based on beneficence. They've undoubtedly observed that chiropractors historicaly rack up the most charges for manipulation and are attempting to titrate this to what they consider to be an acceptible level. Based on this alone, we should all be concerned. I also agree that Kaiser would have made a MUCH more cost effective solution by more closely scrutinizing high dollar procedures such as fusion or even cardiac catheterization. Seems a bit penny wise.

I think this issue probably is at best tangential to the core problem of having our practice patterns dictated to us. The problem within the problem is we (I mean all health care professions) have done a piss-poor job of demanding the highest standards of clinical and ethical practice amongst ourselves. The result is a heavy handed approach from private and federal payors.

We all share the blame in these kinds of issues. But yet again, I believe this makes an even STRONGER case for scrutinizing what we do more closely within the context of science and evidence. Failure to do so leaves us more susceptible to the whims of others to control our future - often to the detriment of the patient.

< Message edited by TexasOrtho -- September 1, 2010 8:26:08 PM >


_____________________________

Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
Movement Science Podcast and Blog

(in reply to bonez)
Post #: 15
RE: Kaiser no longer paying for neck manipulation - September 1, 2010 8:25:21 PM   
SJBird55

 

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Without seeing the actual full text... knowing the history of Christopher Maher's definition of "manipulation," I'd question if thrust manipulation occurred.  Maher was one of the investigators "testing" the clinical prediction rule for manipulation for the lumbar spine and the research was horrible.  Thrust manipulation didn't even occur with the majority of the patients!  So... Maher does seem like a nice guy... and Maher has published quite a bit, but due to that particular study with the CPR and the results/discussion, I have a little bit of distrust with his work and would be more likely to read the whole thing myself before believing an abstract.  Just sayin'

(in reply to TexasOrtho)
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RE: Kaiser no longer paying for neck manipulation - September 1, 2010 9:56:32 PM   
bonez

 

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quote:

ORIGINAL: JWarePT

quote:

ORIGINAL: bonez
The bone and joint task force speaks to the need for further study as the evidence base is still so limited. 


If the evidence for efficacy is so limited, isn't it better to err on the side of caution given the documented cases of severe injury and death from cervical manipulation?

If future research shows that certain types of cervical manipulation turn out to be not only safe, but effective, and PTs want to avoid losing the privilege of performing this intervention (based on a rational mechanism, rather than the dopey subluxation nonsense), then we need to get our butts in gear and prove it.

You do have a point though, bonez.  I doubt Kaiser is considering a new exclusion of lumbar fusion for patients with chronic LBP, despite the growing body of research showing poor outcomes from that procedure.  If it ever came down to an "equal protection" argument, Kaiser would lose hands down.  They only use "protecting the health of their subscribers" when it suits them, it seems.

Why that equal protection principle doesn't apply in health care has always bugged me.


I am newer to the board but I do refer you to several of the points made By Andrew Ball in the last two weeks regarding safety with HVLA and mobs. I truly get the grief between the LOUD and PROUD sublx chiros and traditional PT, I share some of the many concerns myself.

All that said there is certainly a strong anti manip bias here on this board. I believe that the stronger anti chiro bias clouds some peoples ability to assess the current research and it's conclusions. There is not great data either way if you actually critically review the research methodology. There appears to be a slight lean to suggest that manip is nosed into the lead when applied to the proper conditions.

The IMPORTANT issue here is that uncontested, this represents a further step into we will control your profession by choosing our favourable data for ALL manual professions.

I think that it is foolish to assume that this will stop chiro from billing Kaiser as they could just as easily code their treatment as mobilization and just debate the grade of force. This would effectively thwart this effort and they are still in business.

(in reply to JWarePT)
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RE: Kaiser no longer paying for neck manipulation - September 1, 2010 10:35:27 PM   
TexasOrtho


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Bonez. I agree with the likely chiropractic response btw. Any self-serving group of providers would do the same thing. We'd expect the same thing from PT or orthopedic surgeons.

On another topic. I'm assuming by the "anti manipulation bias" you are referring to people like Proud and myself? I perform thrust manipulation to the thoracic spine for cervical and cervicogenic headaches, and still on occaision to the lumbar spine. Assuming you are talking about folks like us who use it more sparingly than others, how can you be sure the bias is with us?

Of course that's a bit tongue-in-cheek. We all have bias. But I am not "anti" manipulation. I am in favor of a realistic understanding of the evidence incorporated within the context of a patient's episode of care. Many models of care incorporating manipulation (subluxation, move it and move on, I feel like it, I want to be a hero, etc...) are not only out of phase with evidence, they are out of phase with our ethical mandate to expect the best from ourselves and our profession.

Manipulation, IMO, is a fascinating study in what we don't really know about manual care. It is overutilized, underutilized, overstated, underappreciated...a complete textbook of uncertainty from a scientific standpoint. YES...of course there are individual studies that...but of course any one of us could find research saying the other...the circle of uncertainty goes on. Our practice patterns should transparently reflect this uncertainty. Pretending otherwise is at best disingenuous and at worst an egregious ethical breach to our patients.

So just to clear up...again. I'm not ANTI anything other than an incomplete or incorrect model of care.

_____________________________

Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
Movement Science Podcast and Blog

(in reply to bonez)
Post #: 18
RE: Kaiser no longer paying for neck manipulation - September 2, 2010 1:01:16 AM   
bonez

 

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Rod good response. I have followed Andrews posts with interest. I would be lying if I said that I  don't have a bit more pro manip bias however I have dabbled for years in a Gineresque style of mobilization thinking I was out on an island. It may surprize you to know that I cross read a bit more than most of the regular Chiro posters.

It is striking that there maybe more risk associated with mobilization (insert Andrew's info) than we all thought. Since I have chose it in cases where I may have concerns about a potential risk and thought it would be safer.

The anti manip bias idea for me stems from the fact that as this thread started with Jesse's post, most seemed to cheer, the "anti chiro boy we know manip is bad" mantra. It just strikes me as odd that those same individuals totally miss how this stands to affect their turf.

I don't know, I started here too late, the run ins that involved Dr Ball. I do agree that maybe many PT manipulators don't see always the same results as say myself since it is my belief that it takes a lot of work to be good at this stuff. The simple idea that some cavitation equals good HVLA is really not true. I understand that we really can't say we affect a certain area but within my profession patients will tell you that you all do the same thing but it works better when .... does the manipulation. This leads me to believe that my control of force localization of contact direction of thrust cause a preceived effect different than a quick thrust here or there.

It is really unfortunate that those PT's that wish to use HVLA could not get and benefit from instruction of good Chiro manipulators in the same way as many of my profession could use a tuning in on the whole construct of rehab exercise from you who clearly master it better than many of us.

(in reply to TexasOrtho)
Post #: 19
RE: Kaiser no longer paying for neck manipulation - September 2, 2010 9:24:12 AM   
proud

 

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Well I'm not exactly anti-manip...cripes I travelled over 2000 miles to go to a course called "manipalooza".

I do however disagree entirely with this stance:

quote:

I do agree that maybe many PT manipulators don't see always the same results as say myself since it is my belief that it takes a lot of work to be good at this stuff.


I'd take out the term "alot" or at least qualify it. I certainly would say I am a better manipulator today than I was say one year ago....and as with anything, practice does improve the ease with which one can apply something.

But "alot" to me anyway implies a level of difficulty that does not exist here. There are probably 10-20 techniques overall...the rest is just variations and attempts to claim higher specificity.

Manipulation to me is an interesting "phenomenon" more than anything else. Certainly there has been supporting literature of it's effects within the DRG as well as some central effects. So it certainly does something to down-regulate. Thus I use it...

Although I'm becoming less and less convinced the more I read that manipulation is actually..required. It may even be detrimental long term because of the constructs it re-enforces.

Patient do love it..and if you cannot provide it.....you run the risk( mistakenly) of being percieved as "less skilled". The way I see it, manipulation exists because of some culturally generated percieved need for this treatment.

One day...I hope to never use it....

(in reply to bonez)
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