Chiropractic Care Again Ignored: This time for money

[Note: this is a revised post of another blog post of mine at]

The news item Sunday 7/10/11 that there is a new ‘medication adherence score’ being launched by FICO, the folks who brought credit scoring to our lives reports, tells us that we will soon be subject to an analysis of our compliance with filling prescriptions that physicians write for us in the course of medical care.

This sounds somewhat benign. Physicians only write prescriptions for what we absolutely need, don’t they? It would be helpful if those in the system had their medical records flagged so that they could receive ‘extra counseling, followup and phonecalls,’ right?

Not so much. Statistics from 2006 indicated that 2.2 million people were hospitalized due to harmful prescriptions. Cited in the report source for those figures were 1992 data from a national pharmacy database that found a total of 429,827 errors from over 1,000 US hospitals. Medication errors were found for one in twenty patients, leading to the mathematical conclusion that more than 90,000 patients annually were harmed by medication errors in the country as a whole. This was one of the more startling revelations in the Institute of Medicine’s 2001 seminal work on health system change agency, Crossing the Quality Chasm.

As chiropractors, we are already painfully aware of this. We probably frequently run the gamut of emotions from numbness to rage over the issue; I know I do. But the more serious issue here, in my view, is that as a profession we don’t really know how many of our patients are in our offices and NOT filling their prescriptions. We are used to the fact that we add value to the system overall by helping people non-medicinally and non-surgically. And we are accustomed to–even though angered by–the fact that our value is not seriously considered by the system as a whole. But FICO’s new approach–which requires data-mining of our medical records–moves this willful ignorance to a whole new level, and in my view adds the the list of serious threats to our profession.

In its report Crossing the Quality Chasm, the Institute of Medicine listed a set of design principles for improving the health care system of the 21st century. Among them are assertions that the system needs to see the patient as the source of control. This is not simply a false level of reverence being applied to individuals who are supposedly at the center of ‘patient centered care.’ This is in fact an acknowledgement that the entire dynamic of control, power, decision-making, permissions, and information flows needs to not simply loop the patient/individual/consumer in when the system is expanded to include them, but to be fundamentally redesigned into a new hub-and-spoke model. Another requisite design element is listed as being shared knowledge and decision-making, while yet another is the need for transparency. How are we doing with all that, by the way?

FICO can certainly claim that they are only following one additional design principle in the IOM report, anticipation of needs. But here’s the problem: medical and pharmacy records do not have any provision for accounting why an individual has not filled a prescription.

Many of the reasons are, in fact, potentially serious and need to be addressed: the elderly in particular are often unable to fulfill prescriptions because of financial barriers, memory issues, and so on. Not obtaining many of those prescriptions can be life-threatening. But that’s not the whole story, and the underlying dynamic is what has me most incensed over this.

The reality is that we (consumers) do not command any of the information regarding our behaviors in the marketplace, nor online. We have no idea how much data is actually being collected about us, and the degree to which we can be individually identified through electronic vectors from our web and purchasing histories should give all of us pause–or heartburn. But medical records are supposedly one area where we supposedly should have some semblance of comfort that our privacy is protected, right? Hope you’re sitting down.

Again, the reality is that our privacy is NOT protected. When we sign in to a doctor’s visit and we periodically sign that little form that has the title ‘HIPAA’ on it, we commonly sign away our ability to restrict access to our medical information. Medical records are commonly ‘mined’ for information on the frequency, outcomes, and application of different kinds of medical treatments, medication usage, and so on. In fact, many doctors’ offices and health systems make a good chunk of change from allowing access to your records and this ‘data mining.’ One thing about this effort, though: it is normally anonymous. So our names and other information that could be used to personally identify us are not included. (I say, ‘normally.’ Data breaches are increasingly common; according to the National Healthcare Anti Fraud Association, 80% of healthcare organizations have reported one or more data breaches that involve the loss of health information.)

From another angle, the information that is not listed in most medical records is extremely relevant here, and through FICO‘s product will be codified as fact with no ability for consumers to rebut its falseness. The reality is that many consumer/patients do not fill prescriptions because they are using other healthcare providers for clinically- and cost-effective care, and the prescriptions are simply unneeded or a secondary priority and choice at the time. And most physicians do not ask whether their patients are using other providers or types of care, especially when they involve complementary and alternative healthcare. So if I have a bad back and I consult with my medical physician and get prescriptions for pain relief and muscle spasms, but end up getting care from a doctor of chiropractic, acupuncturist or massage therapist (or a potential host of other options) that is effective for me, and my medical doctor doesn’t know about it, I will be listed as ‘non compliant’ in my medical record–and accumulate a black mark towards myFICO ‘medical adherence score.’ And anyone who thinks that FICO is not going to find some way to link medical adherence and credit scoring together in their databases is dreaming. Buckle up.

The level of offense in the ability of FICO to mine our medical and pharmacy records as a way of measuring our ‘compliance’ is, in my view, extremely severe. I intend to revise every HIPAA permission slip I’ve signed with my doctors and health systems, and I will explicitly forbid them to grant access to my information to any other entity without my explicit permission.

So what matters here, as chiropractors, and what can we do? One thought is to begin to track, in our offices–and record in their records–how many of our patients are NOT filling prescriptions because they are receiving chiropractic care. Any accumulated information about this would put a real dollar value on how we potentially add value to America’s health care system.

Another thought is to recommend that our patients–and our own families–revise the HIPAA permission slips we have on file in medical doctors’ offices. There is an option (which I have checked as a matter of course, believing it was a kind of ‘good data citizenship’) that gives our doctors’ offices and systems the ability to share our data with others.

No more.

We should also seriously consider the implications of our own use of these HIPAA forms.

Further, I think that we should seriously consider offering our patients form letters of protest about this practice, and suggest that they can individually consider and choose whether to use one of them and take them to their medical doctors’ offices and request that they be incorporated in their medical records.

We have, unfortunately, become accustomed to the fact that our personal privacy is under constant assault, and our protections are being steadily reduced. But this issue is more than simply an additional degree of erosion in personal information rights. It’s an entire section of personal territory sliding off into the sea. As doctors of chiropractic, and as citizens, we should all be very, very aware, concerned, and moved to action.

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