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More on Chiros, Back Surgeons and the Murder of the AHCPR, Plus a Parallel Swiss Story PDF Print E-mail
Written by John Weeks   

More on Chiros, Back Surgeons and the Murder of the AHCPR - Plus a Parallel Swiss Story

SummaryThe  IBN&R story on the killing of the Agency for Healthcare Policy and Research (AHCPR) which Business Week referenced and which I reported ("Back Surgeons, Chiropractic and the Murder of a Federal Agency on Evidence-Based Medicine") has stimulated a good deal of interest. The politics of evidence is hugely significant in the CAM-IM integration discussion. More detail is included here ... plus a parallel story from Switzerland, via JACM

1.    The Killing Campaign: From Reed Phillips, PhD, DC

"I enjoyed the (IBN&R) article on the murder of the AHCPR. I was a member of the North American Spine Society (NASS) while all this was going on and was automatically placed on a mailing list requesting funds and letters of support to fight the injustices of the guidelines produced by the AHCPR. What was brought out in your article was certainly evidenced in the materials I received."

(Italics added, to account for Phillips' sarcasm in a personal email.)

Phillips is an educator who has actively promoted chiropractic's research agenda since the mid-1970s. He is president of Southern California University of Health Sciences, chairs the Academic Consortium of Complementary and Alternative Health Care, and served recently as chair for the advisory board to the federal initiative to offer chiropractic inside the Veteran's Administration.

Image
Neil Kahanovitz, MD, lone gunman aka future NASS president
2.   The Agency for Health Care Policy and Research: 1989-1995

The AHCPR was established by Congress with bipartisan support in 1989. The agency was charged with measuring health care outcomes and formulating clinical practice guidelines. A major driver was the high cost of healthcare expenditures. The public health goal was to provide a basis for consistent quality and cost-effective care, particularly in the more common and costly areas of medicine. A late 1994 AHCPR guideline effectively endorsed chiropractic above conventional treatment for acute low back pain. Following an effort to squelch publication of the guideline, then an intense lobbying campaign, AHCPR funding was gutted and its guidelines initiative killed, in 1995.


3.   Not a Single Assassin: Neil Kahanovitz, MD, and the North American Spine Society


The writer of the Business Week article chose to demonize a single back surgeon in attributing cause for the killing:
"In 1993, the federal government's Agency for Health Care Policy and Research convened a panel to develop guidelines for back surgery. Fearing that the recommendations would cast doubt on what doctors were doing, a prominent back surgeon protested to Congress and lawmakers slashed funding to the agency."

Kahanovitz became
NASS's president,
  honored for his "insight 
into national and
political efforts."
 
This is false history. In fact, while an individual surgeon, Neil Kahanovitz, MD, drove the effort, the killing of the AHCPR followed a fierce lobbying effort involving a significant organization of deeply interested practitioners, organized as the North American Spine Society. This "Society" now has the addition of an affiliated trade association/guild, the National Association of Spine Specialists with a legislative action center, and a political action fund. In 2000, Kahanovitz became NASS's president. In a statement available on the web, his predecessor honors Kahanovitz for his "insight into national and political efforts."

Business Week does no one a service in obscuring the culpability of organized medicine behind the face of a single physician. As an interesting irony, Kahanovitz takes office in 2000 and engages an initiative to explore the role of chiropractic in back care.

3.   NASS' Battle Framing: Stop Redundancy, Save Money, Reduce the Deficit

The NASS argued that AHCPR is redundant, inefficient, and wasteful. NASS noted that medical societies and HMOs had already
turned out 1500 guidelines. NASS told the Republican Congress that came into great power in 1995, following Newt Gingrich's revolution, that this federal government agency was inappropriately meddling in what doctors should do. Besides, the AHCPR was inefficiently turning out guidelines, only 15 in 5 years. What value then, the AHCPR's $150-million annual budget? Gutting the AHCPR could both get the feds out of the telling doctors what to do and help with the federal deficit, according to this self-less logic.

The American Chiropractic Association (ACA) lobbied against the dismantling and to retain the AHCPR and its guidelines process. Their case was framed around the critical role of the AHCPR in creating cost savings. They spoke of the AHCPR's good work in technology assessment, and with prostate disease, cardiac disease, otitis media, pneumonia and ... low back pain. The ACA, with the newfound potential for presence of chiropractic in US medicine, granted by the opening door oif AHCPR's acute low-back guideline, had a profound self-interest in maintaining the AHCPR's authority. The guideline appeared to create a niche in US medicine for chiropractic, which had been the AMA's favorite whipping boy for decades.

 
The report estimated
a 35% savings over the
cost of standard treatment,
if the low back guideline
was
implemented.

And this
didn't include
indirect cost benefits.

Just as the potential loss of authority and income moved NASS, the depth of economic opportunity for chiropractic was not lost on the chiropractors.  As Louis Sportelli, DC, noted in a column in Dynamic Chiropractic (January 16,1995): "If the doctors of chiropractic only cornered the market on one condition, i.e., back pain, there would not be enough DCs to handle the volume."


4.   Estimated Cost Savings, and Challenge to the Low Back Guideline's Release

A study on the economic impact of the AHCPR guideline for acute low back pain, was engaged by Douglas Conrad, PhD, the panel chair for the guideline. The study was carried out by Daniel Cherkin, PhD, and others.  Among the findings:

  • The "social costs" - treatment, morbidity, mortality - were estimated at $12-billion.
  • Low back pain was the second leading reason for ambulatory care visits.
  • The report estimated a 35% savings on the cost of standard treatment, if the guideline was implemented.
  • Indirect cost-savings, not included in the study, were believed to be much higher.

In a November 18, 1994 memo, David Lanier, MD, the AHCPR's Project Officer on the low back pain guideline, sent the cost report out, with a cover note which underscored the intense politically environment of the guideline's release:
"(Panel chair) Doug Conrad asked me several months ago to distribute copies of the paper reporting on the economic analysis of the low back pain guidelines. The report, however, has had to take a back seat over the past months to the task of dealing with legal challenges to the release of the guideline." (bold italic added)
It appears from the comments that the staffer, due to political pressure, was not even releasing, to the advisory panel, a document requested by the chair. Let freedom ring.


5.   From Chiropractor Avery Jenkins, DC, and from ex-WSCA Exec David Matteson

Dr. Jenkins sent this note: "Very interesting (IBN&R) story. Having been a chiropractic physicianb for over a decade, I hve seen most of the day-to-day bigotry that continues to exist against us, but I admit to soem surprise at just how nasty the MDs continue to be. Ah, well, so long as I and my colleagues keep taking the candy out of the baby's mouth, we can continue to expect the temper tantrums."

The polarization is ugly, though understandable, unfortunately, given the context. Long-time CAM-IM policy leader, David Matteson, executive director of the Washington State Chiropractic Association, at the time of the AHCPR battle over evidence in medicine, sent a more reasoned comment to IBN&R which underscored what a challenge the guideline and then the gutting of the AHCPR created for the chiropractic profession. What relationship with mainstream medicine was chiropractic to take? What relationship to the idea of good will? To integration? To the meaning of evidence, except as a political tool?

6.  A Parallel Suppression of CAM-IM Evidence from Switzerland: 1998-2005



"All CAM researchers
should at least take
some notice of this
process in order to
understand the
compexities of the
issues at stake and
of the power plays
  of different stakeholders 
in the game."


Harald Walach, PhD 
Fast-forward to the present. Harald Walach, PhD, an international advisor to a seven year, $5.5 million exploration of CAM-IM by the Swiss government, begun in 1998, concluded a recent report on the work with the following:
"Public authorities, health systems researchers, and, in fact, all CAM researchers should at least take some notice of this process in order to understand the compexities of the issues at stake and of the power plays of different stakeholders in the game.
-- Harald Walach, PhD, The Swiss Program for the Evaluation of Complementary Medicine, Journal of Alternative and Complementary Medicine, Vol 4, Number 3, 2006, April 2006, pp. 231-232.
Caught up in the first wave of intrigue over the potential value of CAM-IM for health care, the Swiss goverment funded a multi-year process to evaluate the usefulness, economic viability and effectiveness of five interventions: homeopathy, phytotherapy, anthroposophic medicine, neural therapy and Traditional Chinese Medicine. Walach states that, despite obstacles, including early ignorance of many participants and decision makers, "a reasonable body of data was amassed that would have allowed a clear political decision."

However, a change in Swiss administration found a new health department leader, one Pascal Couchepin, in charge of the process. Walach states that Couchepin "confessed publicly, before even looking at the data, that he did not have much favor for complementary medicine, and that saving costs would probably demand a cut in public epxenditures at the cost of complementary medicine." All 5 of the approaches were removed "from the public reimbursement scheme even before the data were fully analyzed and known, let alone publicly discussed."

 

The Swiss official
called the CAM data
"waste products
which
do not bear
  any relevance
to the 
political decisions."


Why the sudden lack of interest in data? Walach writes that the reason was leakage of information from the study that some complementary therapies were "cheaper than expected and, in fact, probably even cheaper than conventional care." In fact, according to Walach, the entire process was shut down, "authorities demanded a full blockage of all public communications about this topic, prohibited the researchers to make any statements, and closed up all data, files and reports connected to the research."

When Walach protested, he received an email response from the vice president of the Swiss federal agency involved with the process who, according to Walach, "literally called the data 'waste products which do not bear any relevant to the political decisions.'" Walach particularly bemoans that the cost-effectiveness process "was prematurely stopped and, to my knowledge, did not reach a final conclusion."

 
These stories teach us that
the process of integration

is a political-economic
endeavor, in which research
is a move of the Bishop
on the chess board.

And anyone following
the news lately will have
learned that even the
Bishops can be more than
a little reprehensible.

Comment: Following these two, apparently parallel stories, I feel like an owner of a new puppy, putting his nose in his waste products before chucking him outside. I don't think this is necessarily a personal pathology, though I will leave it to others to rule that out. There is a kind of oppressor-oppressed psychology that kicks in here. Because the idea of evidence is sometimes used as a sadistic, boarding house switch in the integration debate, I do confess to a kind of pleasure in seeing these other, powerful, shadow "truths" outed.

When the dominant "side" of this oppressor-oppressed situation - to use a polarized construct - has evidence supporting only 20%-25% of what it does (see the Business Week article), there is clearly no evidence-based "side" in this discussion. This process of integration is essentially a political-economic endeavor, in which research is employed as a move of the Bishop on the chess board. And anyone following the news the last few years will have learned that even the behavior of the Bishops can be a more than a little reprehensible.

Resource: For access to the Walach article, contact Mary Ann Liebert, Inc., publishers, 140 Huguenot Street, New Rochelle, NY 10801-5215; (914) 740-2100 or (800) M-LIEBERT

Your Comments (this link to the IBN&R forum on this topic)



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