Hangman's fracture presenting to chiropractic clinic as benign neck pain: a case report.

OBJECTIVE: The purpose of this study is to report a patient who presented to a chiropractic clinic with benign neck and upper back pain; however, the patient also had a recent hangman's fracture due to a drunken fall. CLINICAL FEATURES: A 40-year-old established patient with neck and upper back pain presented to a chiropractic clinic for care. When questioned about the character and etiology of his pain, he reported that it was no different compared to past presentations, saying "it's the same as always." The patient was not questioned about recent trauma and did not report his fall while intoxicated several days prior. After history and examination, the working diagnosis was a low-grade cervical sprain strain with imaging considerations if improvement did not occur quickly as was observed with similar previous presentations. Treatment included chiropractic mobilization of the cervical spine. The following day, the patient reported no improvement. Upon additional questioning, a history of trauma was revealed; and plain radiographic imaging showed a C2 vertebral body fracture. INTERVENTION AND OUTCOME: Immediate referral and evaluation at a local emergency center revealed not only an unstable C2 fracture but a coronal fracture of the left frontal bone extending into the left temporal bone with an associated right subdural hemorrhage along the right hemisphere and tentorium. The patient was placed in a sterno-occipital-mandibular immobilizer brace and discharged 2 days later. CONCLUSION: Historical experience with similar clinical presentations in established patients can influence health care providers to assume a benign causation of symptoms. Conscious effort must be exerted to treat established patients with typical presentations with the same diligence as those of new patients to a chiropractic clinic. This case illustrates that an unstable fracture and hematoma can present to a chiropractic clinic as a seemingly benign problem.

Paying for quality not quantity: a wisconsin health maintenance organization proposes an incentive model for reimbursement of chiropractic services.

OBJECTIVE: The purpose of this study is to describe a reimbursement model that was developed by one Health Maintenance Organization (HMO) to transition from fee-for-service to add a combination of pay for performance and reporting model of reimbursement for chiropractic care. METHODS: The previous incentive program used by the HMO provided best-practice education and additional reimbursement incentives for achieving the National Committee for Quality Assurance Back Pain Recognition Program (NCQA-BPRP) recognition status. However, this model had not leveled costs between doctors of chiropractic (DCs). Therefore, the HMO management aimed to develop a reimbursement model to incentivize providers to embrace existing best-practice models and report existing quality metrics. The development goals included the following: it should (1) be as financially predictable as the previous system, (2) cost no more on a per-member basis, (3) meet the coverage needs of its members, and (4) be able to be operationalized. The model should also reward DCs who embraced best practices with compensation, not simply tied to providing more procedures, the new program needed to (1) cause little or no disruption in current billing, (2) be grounded achievable and defined expectations for improvement in quality, and (3) be voluntary, without being unduly punitive, should the DC choose not to participate in the program. RESULTS: The generated model was named the Comprehensive Chiropractic Quality Reimbursement Methodology (CCQRM; pronounced "Quorum"). In this hybrid model, additional reimbursement, beyond pay-for-procedures will be based on unique payment interpretations reporting selected, existing Physician Quality Reporting System (PQRS) codes, meaningful use of electronic health records, and achieving NCQA-BPRP recognition. This model aims to compensate providers using pay-for-performance, pay-for-quality reporting, pay-for-procedure methods. CONCLUSION: The CCQRM reimbursement model was developed to address the current needs of one HMO that aims to transition from fee-for-service to a pay-for-performance and quality reporting for reimbursement for chiropractic care. This model is theoretically based on the combination of a fee-for-service payment, pay for participation (NCQA Back Pain Recognition Program payment), meaningful use of electronic health record payment, and pay for reporting (PQRS-BPMG payment). Evaluation of this model needs to be implemented to determine if it will achieve its intended goals.

Cost minimization analysis of low back pain claims data for chiropractic vs medicine in a managed care organization.

OBJECTIVE: A managed care organization (MCO) examined differences in allowed cost for managing low back pain by medical providers vs chiropractors in an integrated care environment. The purpose of this study is to provide a retrospective cost analysis of administrative data of chiropractic vs medical management of low back pain in a managed care setting. METHODS: All patients with a low back pain-related diagnosis presenting for health care from January 2004 to June 2004 who were insured by an MCO in northeast Wisconsin were tracked. The cumulative health care costs incurred by this MCO during the 2-year period from January 2004 to December 2005 related to these back pain diagnoses were collected. RESULTS: Allowed costs of chiropractic treatment were 12% greater than medical primary care and 60% less per case than other types of medical care combined, on a per-case basis: median cost of medical primary care was $365.00, chiropractic care was $417.00, and medical nonprimary care was $669.00. CONCLUSION: This study of an MCO's low back pain allowed costs may be better redirected to primary care or chiropractic, given equivalent levels of case complexity. This study suggests chiropractic management as less expensive compared with medical management of back pain when care extends beyond primary care. Primary care management alone is virtually indistinguishable from chiropractic management in terms of costs.

Retropharyngeal abscess presenting as benign neck pain.

OBJECTIVE: To present a case of an uncommon presentation of cellulitis of the neck as benign neck pain. CLINICAL FEATURES: A 44-year-old man had severe neck pain and headaches for 2 weeks with an unknown cause. Minimal response to chiropractic treatment leads to coordination of treatment with the patient's primary care physician. Laboratory assessment and magnetic resonance imaging initially were viewed as insignificant but were repeated and showed a retropharyngeal abscess. INTERVENTION AND OUTCOME: Chiropractic treatment did not reduce the patient's neck pain as expected. Fusion of C1 to C2 was eventually performed. CONCLUSION: Neck pain is a common reason for patients to seek chiropractic care. This case shows an uncommon differential diagnosis for a patient who does not respond quickly to chiropractic treatment for neck pain.