More on Chiros, Back Surgeons and the Murder of the AHCPR - Plus a Parallel Swiss Story
Summary: The 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.
 Neil Kahanovitz, MD, lone gunman aka future NASS president
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."
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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.
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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
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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."
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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.
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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
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