Some 70 years ago, a branch of American government was depicted as dabbling in totalitarianism. In his groundbreaking and provocative book Louisiana Hayride,¹ Harnett Thomas-Kane describes the reign of Huey "Kingfish" Long as Louisiana governor during the 1930s. During that time period, graft went into high gear while personal liberties were suspended; Long and his henchmen reigned supreme, building lavish monuments to themselves at the state capitol in Baton Rouge. During the height of the Depression, this was a heady period in Louisiana state government in which the most outrageous and excessive behavior was tolerated, while those still in charge of law enforcement and equal rights looked the other way. The rallying cry from the Kingfish to keep everyone in line was, "Share the wealth!" - as if he cared.

In many ways, the U.S. health-care system is following suit. With runaway costs (despite managed care) driven primarily by pharmaceuticals,^2,3 chiropractic - a more economical alternative whose effectiveness for a variety of conditions has been amply demonstrated^4-13 - continues to be excluded or downgraded in many instances, ranging from outright exclusion to egregiously inequitable reimbursements for similar or superior services rendered to patients for given conditions. Discrimination in reimbursement practices in the insurance industry, for example, has led to the lawsuits courageously headed by the American Chiropractic Association against Trigon Blue Cross Blue Shield and the Health Care Financing Administration's Medicare Part C regulations.¹⁴

The yardstick for endorsement and accessibility of health-care modalities is presumably evidence. At least one recent study suggests that, in terms of having at least one relevant randomized clinical trial supporting the type of health care delivered, chiropractic stacks up rather well. Using a critical-appraisal method with quality scores modified from a leading methodological researcher,¹⁵ Adrian Wenban assessed the proportion of interventions supported by clinical trials in his suburban chiropractic practice, and compared them with the corresponding values in medical practice obtained from a systematic review of the literature. He found 68% of his chiropractic interventions thus supported, comparing well with the values seen in inpatient general medicine (50-53%); internal medicine (65%); pediatric practice (40%); hematology-oncology (24%); general practice (31-38%); inpatient general surgery (24%); and pediatric general surgery (11%).¹⁶ While the evidence in support of medical procedures may not be as paltry as once suggested,^17,18 there is every reason to expect that the growing body of research in support of chiropractic interventions is entitled to a fair and detailed hearing.

Where are we going with this? In a recent report, the ACA has provided what could go down as the most twisted punchline to this saga that I have ever seen. On the issue of lower pay scales provided for doctors of chiropractic compared to those of medical doctors (for the same services delivered), when the folks at Trigon were confronted with the lead studies suggesting the superiority of chiropractic care in the treatment of neuromusculoskeletal conditions and were asked to provide any contrary study to justify their actions, they showed two cards at the table (Are you ready, kids?):

1. They failed to provide any study to the contrary.
2. They relied on the greater expense for the education of medical doctors compared to chiropractors to justify their discriminatory actions.¹⁹

In this instance, evidence appears not to have amounted to "jack." Let me see if I can extrapolate this correctly. Does this mean that the owner of a Cadillac is entitled to higher social-security benefits because he or she spent more than someone who happens to possess a Toyota? Is there some rebate program for more costly education (which, by the way, we know offers no more hours in the basic sciences²⁰ and decidedly poorer training in musculoskeletal conditions^21-23) that I'm overlooking here?

Finally, it would appear that our brethren at Trigon may have overlooked the fact that much of the DO and MD costs of education are subsidized by public and private entities, unlike those of DCs. Through all the legal proceedings that have hemorrhaged the profession over the years, none strike me as more reminiscent of the arrogance and lawlessness of the Huey Long administration than what Trigon has attempted to argue.

The burning question here, of course, is whether a meaningful response to these major issues will be forthcoming, or whether there will be a reply more in keeping with Rhett Butler's famous reply to Scarlett O'Hara in the movie "Gone With the Wind": "Frankly, my dear - I don't give a damn!" The latter possibility, of course, might conjure up images of a sequel to this film classic, entitled "Trigon With the Wind."

References

1. Thomas-Kane H. Louisiana Hayride, Gretna, LA: Pelican Press, 1988.
2. Burt CW. National trends in use of medications in office-based practice, 1985-1999. Health Trends 2002; 21(4): 206-214.
3. Report from Department of Health and Human Services, reported in the New York Times, Jan. 8, 2002.
4. Bigos S, Bowyer O, Braen G, et al. Acute Low Back Pain in Adults: Clinical Practice Guideline No. 14. AHCPR Publication No. 95-0642. Rockville, 1994, Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services.
5. Manga P, Angus D, Papadopoulos C, Swan W. The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low Back Pain. Richmond Hill, 1993, Kenilworth.
6. Rosen M. Back Pain: Report of a Clinical Standards Advisory Group Committee on Back Pain. London, 1994, HMSO.
7. Danish Institute for Health Technology Assessment. Low-Back Pain, Frequency, Management, and Prevention From an HTA Perspective. Danish Health Technology Assessment 1(1), 1999.
8. Meeker WC, Mootz RD, Haldeman S. Back to basics...The state of chiropractic research. Topics in Clinical Chiropractic 2002;9(1):1-13.
9. Meeker WC, Haldeman S. Chiropractic: A profession at the crossroads of mainstream and alternative medicine. Annual Review of Internal Medicine 2002;136:216-227.
10. Hurwitz EL, Aker PD, Adams AH, Meeker WC, Shekelle PG. Manipulation and mobilization of the cervical spine: A systematic review of the literature. Spine 21(15):1746-1760.
11. Kjellman GV, Skagren EI, Oberg BE. A critical analysis of randomised clinical trials on neck pain and treatment efficacy: A review of the literature. Scandinavian Journal of Rehabilitative Medicine 1999;31:139-152.
12. Bronfort G, Assendelft WJJ, Evans R, Haas M, Bouter L. Efficacy of spinal manipulation for chronic headache: A systematic review. Journal of Manipulative and Physiological Therapeutics 2001;24(7):457-466.
13. McCrory DC, Penzien DB, Hasselblad V, Gray RN. Evidence Report: Behavioral and Physical Treatments for Tension-Type and Cervicogenic Headache. Des Moines, IA: Foundation for Chiropractic Education and Research, 2001.
14. Cuneo GV. ACA's 2002 annual report. Journal of the American Chiropractic Association 2002;39(11):20-32.
15. Koes BM, Bouter LM, van Mameren H, Essers AHM, Verstegen GMJR, Hofhuizen DM, Houben JP, Knipschild P. Randomized clinical trial of manual therapy and physiotherapy for persistent back and neck complaints: Results of one year follow up. British Medical Journal 1992;304:601-605.
16. Wenban AB. Is chiropractic evidence based? A pilot study. Journal of Manipulative and Physiological Therapeutics 2003;26(1):47. (Full text is online at www.mosby.com/jmpt.)
17. Cuneo G. ACA EVP weekly report. March 26, 2003.
18. Smith R. Where is the wisdom. The poverty of medical evidence. British Medical Journal 1991;303:798-799.
19. Rachlis N, Kuschner C. Second Opinion: What's Wrong With Canada's Health Care System and how to fix it. Toronto: Collins, 1989.
20. Coulter I, Adams A, Coggan P, Wilkes M, Gonyea M. A comparative study of chiropractic and medical education. Alternative Therapies in Health and Medicine 1998; 4(5):64-75.
21. Freedman KB, Bernstein J. Educational deficiencies in musculoskeletal medicine. Journal of Bone and Joint Surgery 2002;84-A(4): 604-608.
22. Freedman KB, Bernstein J. The adequacy of medical school education in musculoskeletal medicine. Journal of Bone and Joint Surgery 1998;80-A(10):1421-1427.
23. Vlahos K, Broadhurst NA, Bond MJ. Knowledge of musculoskeletal medicine at undergraduate and post graduate levels. Australasian Musculoskeletal Medicine May 2002;28-32.

Anthony Rosner, PhD
Brookline, Massachusetts

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