News & Views

Medicare’s shift from passive payer to active purchaser of health care

I submitted the following letter to the editors of local newspapers on September 1, 2009.  Events over the past fours years have done nothing to convince me that the government has changed their approach to health care.

While the debate on health care reform rages in Washington, D.C. and around the country, an important change is already underway in government-funded health care, specifically Medicare.  In the Fall 2008 edition of “The Pulse of CMS” published by the Philadelphia Regional Office of the Centers for Medicare and Medicaid Services (CMS), “…CMS reiterates its commitment to implementing Value Based Purchasing and transforming Medicare from a passive payer to a prudent purchaser of health care.”  An August 20, 2009 e-mail entitled “Medicare Demonstrations Show Paying for Quality Health Care Pays Off” states that “[t]he CMS value-based purchasing (VBP) initiative is designed to tie Medicare payments to performance on quality and efficiency and is part of CMS’ effort to transform Medicare from a passive payer to an active purchaser of higher quality, more efficient health care.”

Improving the quality of health care is a noble goal, but what are the implications of Medicare’s shift from “passive payer” to “active purchaser?”  What is the role of the individual patient when the government assumes the role of purchaser of health care?  I submit that the government is assuming the parental role in making health care decisions, relegating the patient to the status of dependent child.

I have been a doctor for 30 years.  I have seen the government and insurance companies assume a larger and larger role in health care decisions.  While they certainly have the right to decide what services they will cover, I believe that the patient should have the final decision in matters of health care.  Patient choice and the patient-doctor relationship are vital for good health care; they will be diminished when Medicare becomes the active purchaser of health care.

Limitations of MRIs

Magnetic resonance imaging (MRI) is helpful because it allows us to see nerves, discs, and other soft tissues that are hard to visualize with plain X-rays.  However, it has its limitations:  It often shows “problems” where there are no “problems.”  Research has shown that 20-76% of people without symptoms show disc herniation on an MRI.  A study published in the March 14, 2013 issue of the New England Journal of Medicine describes the dilemma faced by doctors.

Writing in HealthDay, Serena Gordon describes the results of the study:

“The current study included nearly 300 people randomly assigned to receive either surgery or conservative care for their sciatic pain, all of whom had signs of disc herniation on their initial MRI.  A follow-up MRI was done one year later, and the two MRIs were compared with patient results.”

“After a year, 84 percent of those in the study reported successful treatment.  Follow-up MRIs showed that 35 percent of those with a favorable result still had disc herniation compared to 33 percent of those with an unfavorable result.”

“Favorable outcomes were reported in 85 percent of those with disc herniation on their follow-up MRI and in 83 percent of those without disc herniation, according to the study.”

In addition to disc herniation, Nancy Walsh, a staff writer for MedPage Today, reports that “nerve-root compression was present on MRI in 24% and 26% of patients reporting favorable and unfavorable outcomes, respectively.”  “Visible scar tissue was present among 88% of patients who had undergone surgery, in most cases surrounding the nerve root.  Among patients with scar tissue, 86% reported a successful outcome, as did 75% of those without scarring.”

Dr. Devon Klein, chief of musculoskeletal radiology at Lenox Hill Hospital in New York City, said it well:  “You can’t treat the MRI.  You have to treat the patient.”

How Effective Are Flu Shots?

Recently I wrote about the benefits of spinal manipulation in improving the body’s immune function.  What about the influenza vaccine?  The goal of vaccination is to stimulate the body’s immune system so that it is can resist a virus when exposed to it.  How well does the influenza vaccine work?  Writing in the New York Times on November 5, 2012, Roni Caryn Rabin describes the results of research on the effectiveness of influenza vaccines:  “Last month, in a step tantamount to heresy in the public health world, scientists at the Center for Infectious Disease Research and Policy at the University of Minnesota released a report saying that influenza vaccinations provide only modest protection for healthy young and middle-age adults, and little if any protection for those 65 and older, who are most likely to succumb to the illness or its complications.”  The scientists’ solution is to develop a better vaccine, but that will take years.  Ms. Rabin suggests “another option for those who want to reduce their risk of influenza and flu-like infection:  Wash your hands more often.  There is good evidence this works.”

Update:  The CDC estimates that this year’s flu vaccine was 56% effective overall but only 9% effective against Influenza A (H3N2) for those who are 65 years old and older.

Spinal Manipulation for the Flu

The worst Influenza pandemic in the last 100 years occurred in 1918; an estimated 50-100 million people died worldwide.  However, reports from both chiropractic and osteopathic doctors indicate a much lower death rate for those patients who received spinal manipulation.  Charles Masarsky, D.C. states that the death rate for standard medical care was 5-6 percent, whereas the death rate for osteopathic care was 0.25 percent.  Chiropractic historian Walter R Rhodes, D.C. reports that “[n]ational figures show that 1,142 chiropractors treated 46,394 patients for influenza during 1918, with a loss of 54 patients—one out of every 886.”  The implication is that spinal subluxations depress the immune system, whereas correcting subluxations assists immune function.  This conclusion has been strengthened by recent research that shows a link between chiropractic adjustments and improved immune response.  Both history and research show that regular spinal adjustments are an important part of maintaining optimal health.

Foot orthoses improve balance

Several of my older patients have expressed concerns about falling.  A recent study in the journal Rheumatology examining the use of foot orthoses in elderly women reached the following conclusion:  “Foot orthoses were effective for improving balance and for reducing pain and disability in elderly women. Orthoses can be used as an adjuvant strategy to improve balance and to prevent falls in the elderly.”

An Important Anniversary

December 3rd is an important day for me because I opened my first office in Mount Jewett on this date in 1979.  Much has changed in the 33 years since that first day in practice.  Then I was a single man, fresh out of college and unaware of how much I still had to learn. Now I am a husband, father, and grandfather and aware that I still have much to learn.  But my goal remains the same–to provide chiropractic health care for people who live in rural Western Pennsylvania.

Welcome to my blog

I asked my web page designer to give me the option to share news and links with you.  He says that makes me a blogger–so welcome to my blog.  In the weeks and months ahead I hope to share helpful information with you.