Dr. Ronald J. Farabaugh, past chairman of The Clinical Compass (formerly CCGPP), became the National Physical Medicine Director for Advanced Medical Integration Group, LP in 2015, sits on the Board of Advisors for the Official Disability Guidelines, and is the founder/owner of Chiro Systems, an evidence-based, patient-centered, practice-management company dedicated to assisting DCs establish a more evidence-based office and referral mindset. For 33 years, Dr. Farabaugh owned the Farabaugh Chiropractic Office and served as the clinic director of the integrated center.
In this episode of TechTalk Podcast, Brad Cost, Dr. Jay Greenstein, and Dr. Ronald Farabaugh sit down to discuss:
Anecdotal stories that launched Ron into chiropractic and keep his passion alive.
Making clinical-decisions based on evidence for the safety of patients.
Dr. Farabaugh's paper on the cost effectiveness of chiropractic vs medical care.
SHOW NOTES:
4:15 – Dr. Farabaugh’s journey to chiropractic. “I was pre-med at the University of Pittsburgh because my life's dream was to become a surgeon. In my second year at Pitt, my father, who had been on high blood pressure medication for 15 years, had a stroke. It was a mild one he recovered from, but I went home to visit him in the hospital and found out they took him off all the medication he was on. I kept asking why they took him off that medication that's supposedly been keeping him alive for 15 years and they avoided that topic like the plague. I kept pressing and they finally said they thought it was the medication that caused his stroke because it took his blood pressure down too far. I was mystified. I went back to Pitt’s pharmacy library to surround myself with books when these two pharmacy students sat down. Two more guys sat down, who turned out to be a pharmacy professor and the Dean of Pharmacy, and we started discussing drugs for two hours. Runs out one drug relieved his brain. One relieved his heart. One relieved his kidneys. Every drug just relieved a different symptom of his blood pressure, but none of it got to the cause. Back then, lifestyle, diet, nutrition, all that stuff wasn't even discussed. They couldn't answer my question and medicine just made no sense to me at that point. I knew I wanted to stay in the health field, so I went home, and visited a dentist, an osteopath, a chiropractor. I saw this chiropractor in my small hometown in Pennsylvania, taking down people's blood pressure with an adjustment as they sat there in the office. I wondered how it worked, and he explained theory of the homeostasis, the nervous system, the spine, and how it all works. It just made perfect sense to me, so I went home to announce I was going to go to chiropractic school. I've never regretted it for one second. I loved my career. I've had nothing but fun. I feel like I haven't even worked. I feel like I've been semi-retired for 40 years because I went to work every day, having a blast.”
8:30 – Anecdotal evidence. “I saw anecdotal evidence that an adjustment can help blood pressure, so I got all excited about that. I went to chiropractic school and the whole art, philosophy, and science of chiropractic just intrigued me, but especially the science part. It didn't take me a whole long time in practice to realize if you're going to do what we do, you better have lots of tools in your tool belt because what works for one person is not going to work for another. We do these adjustments, even if you're musculoskeletal like I now am, you see things that happen. I had a 74-year-old woman come into me, deaf. I hollered at her the whole way through the consultation. The day after one neck adjustment, she comes in holding both her hearing aids in her hand, tears down her face, saying it was the first morning in 25 years she could hear the paper rustle as her husband read it in the morning. I didn't go out and advertise chiropractic for deafness. That was one anecdotal story. Here's the way I reconcile it. We have tons of research, so I can safely say with lower back pain, neck pain, and headaches, you have like a 95% chance of me helping you with my adjustment. The flu is like 50-50. We need more research on special conditions and a case study doesn't cut it in the scientific world. Thank God it happened because that's how I got into chiropractic, but the reality of it is I can't say that my adjustments are replacement for blood pressure medication for those who need it. I've come to accept. God put us all down here for a reason. I know what I'm good at and what I get my best results in. If I start to drift outside that, I have a whole host of docs and other providers I can refer to.”
16:28 - Marrying evidence-based with clinical decision-making, patient values, and patient response to care. “Let's talk about what evidence-based means first off. Evidence-based simply means you're using research knowledge to inform your clinical decision-making. Evidence-based doesn't put you in any kind of tight box - it just helps you inform. If you had evidence that one exercise was better than another type of exercise, why wouldn't you want to know that? If one therapy was better than another therapy and helped advance your patient quicker, why wouldn't you want to know that? In our profession, we have this divide between philosophical people and evidence-based people. We need to stop dividing each other. If you want to limit yourself to subluxation correction, to sports chiropractic, to disc, to headaches, to pregnancy, to elderly, to infants, no problem. Who would be against that? But what does evidence mean? Evidence means you're using research to inform your decision and clinical decision-making, but it also means you're considering established clinical guidelines. You treat for two to six visits, and measure pain and functions. Treat, measure, treat, measure, treat, measure. Sooner or later, you're going to get a plateau - at that point, discharge. If that discharge is 100% better, great. You don't have to refer them anywhere. But if after you treat, measure and treat, and there's absolutely no better, you better be thinking about a referral, right? It could be to one of your colleagues, could be an orthopedic surgeon, could be for diagnostic tests, but that's just it. You're simply marrying evidence-based with clinical decision-making, patient values, and patient response to care.”
18:59 – Stay current, but not over-reliant. “Everybody’s aware of some of the papers that have just been published, but if you don't read past the title or abstract, you don't really have a grasp on what the paper is actually telling you. We need more people to read guidelines. Jay, you’re one of the best evidence-based guys I know. Why do I say that? Jay and I used to have a disagreement over x-rays, but Jay actually considered the research, read the guidelines and he modified his argument, not that I'm the end-all-be-all of accurate information. Because we read, we have an advantage over those chiropractors that don't read. The godfather of evidence-based medicine said, if you don't stay current with evidence, you quickly become outdated. If you become over-reliant on evidence, you become tyrannized by the evidence. That's why you need a balance of evidence, clinical decision-making, and patient values. Sad to say, not everybody wants to have an adjustment. Some people actually want opioids.”
22:11 – Understanding insurance. “Think of insurance this way. I'm going to make insurance super easy for everybody, and I think we can agree on this. I just put my hands three feet apart. Here's what you need for chiropractic in your lifetime, birth to death. At what point do you need and can benefit from chiropractic birth to death? However, insurance only pays for this much of it. Don't think of insurance necessarily as dictating care or driving your clinical decisions. They're not in that business. They're in the business of here's the policy and here's the things that are pre-programmed into our billing system that we're going to pay for. If you go outside that, they're not going to pay for it. They're not dictating policy. Chiropractors don't read our own policies. That's the problem. We don't know what's covered and what's not covered half of the time. If you just accept insurance, money pays for this much of it, get them out of acute pain, and then they’re transitioned to self-pay. I think that's why I didn't have much trouble with insurance for 38 years. I just looked at insurance as marketing. Because I'm on the list, patients come into my office, I get them out of pain, and then we get down to the serious business of changing their lifestyle. That is not insurance.”
37:39 - The Cost Effectiveness of Chiropractic versus Medical Care for Adults with Musculoskeletal Spine Pain. “On March 6th, after almost a two-year work effort by an incredible team, we finally published the paper - The Cost Effectiveness of Chiropractic versus Medical Care for Adults with Musculoskeletal Spine Pain. It's a systematic review. It's been an incredible journey since that paper was published because that paper basically validates what we chiropractors inherently already knew. We know we're saving money, but now we have one of the most extensive ones that's ever been done. We started with 2,200 papers dating back to 1991 and we got that down to 44 of the most impactful, high-quality papers that exists and looks at costs. We let the data tell the story, by the way. We didn't go in with a preconceived notion. We all had an idea where this might go, but we're going to let the data tell the story. When you implement a conservative option in chiropractic, it offsets the high-tech, high-cost services associated with medical care. What are those costs? Advanced diagnostic and imaging, injections, surgery, hospitalizations, ER visits, referrals to specialists, and the list goes on. Drugs, opioids, and total costs go down. The number one takeaway from the paper was, if you want a lower cost, send patients to a chiropractor. The second thing that we found was the earlier you go to a chiropractor, the more significant the savings. It's just kind of common sense, right? The recommendation we put in the paper was payers need to reduce the barriers to access lower co-pays, lower deductibles, no pre-authorization, no medical gatekeepers, no three tier authorization to get something approved. If you get rid of all that, the payers are going to save a lot of money. There's one major issue that people don't consider - static analysis and dynamic analysis. When you look at a budget, the mistake a lot of legislators make is they look at one line item on the budget and see that for chiropractic, they’re spending $30 million. We want to save $5 million, so let's lower it to $25 million, right? Well, that doesn't work because you have to consider the dynamic modeling, which is you affect this line item, you're affecting 10-line items below that. You don't want to lower chiropractic line item. You want to actually increase it and get rid of the access issues so more people go to a chiropractor because if more people are going up here, you have less people accessing those 16 other line items below that are costing the system billions of dollars. We chiropractors are really in a good position. I mean, do you ever feel like you're in the right place at the right time? I mean, I'm not talking to me personally, I'm talking to the profession. We have an opportunity, and we need to get out and educate just like Dr. Rose did with that really good story she did about the VA. We need to get this paper in front of the powers that be at the VA. I guarantee there's somebody there that either doesn't like chiropractic or doesn't quite understand the research or doesn't understand static versus dynamic modeling. We need to explain the mistake that they're making.”
43:29 – Consequences when removing the conservative option. “If I could throw one anecdotal story in, this is a real live patient of mine, 22 years ago. He was training to be a Columbus policeman, and, on his last day of training, his instructor picks him up, pile drives him into the mat headfirst, knocks him out cold. They rushed him to the hospital, and he had surgeons arguing over whether his neck was fractured or not. He wound up with sympathetic reflect dystrophy, now called chronic regional pain syndrome, where his had numbness and pain in his right arm. That that was a shooting hand, so it disabled him from ever being a policeman. He suffered severe, severe chronic pain ever since then. The only thing that kept him functional was chiropractic adjustment. We did a true biopsychosocial model. I was coordinating with the pain management guys at Ohio State University - a psychologist, massage therapist, acupuncturist, and myself. With a chiropractic adjustment, he could do things. I only had two patients in 38 years that I saw every single week and he was one of those, just to put it in perspective. The consultants in work comp, our own brethren, kept denying it, saying the current pain is not related to the original injury. He had a permanent partial impairment. He has had nothing but pain since his injury. They kept denying it and denying it and denying it, so he finally gave up. He couldn’t do it anymore and he gave up his work comp. Work comp denied the conservative option for him. As a result of that, he was only taking opioids and was addicted to so many drugs. It was unbelievable. His marriage started falling apart and I've got permission from his wife to tell this story, by the way. A couple of weeks ago, he sits down, has a typical argument about marriage stuff that happens so often, and he was at his end. He was mentally, physically completely worn down thanks to these consultants who kept denying the conservative option. He reached into a cabinet beside him, pulled out a gun and ended his own life. As far as I'm concerned, that is an absolutely wrongful death that should have never occurred. When you remove the conservative option and the only thing people then have is access to opioids, what the heck do you think is going to happen? It's the stupidest thing. For somebody to say, we don't want people relying on chiropractic, you don't want them relying on chiropractic at a whopping $50 a visit, but you're willing to spend $3,000 to $5,000 a month in the medical side to help control these people's chronic pain. As you can tell, it stirs me up a little bit, this story, because it just drives my passion now to get out and tell this story everywhere. I want to be in front of every legislator to tell this story. Because when you remove the conservative option, you are harming the public and you're costing yourself massive amount of money.”
46:52 – Going to war with evidence as the weapon of choice. “It takes an army. We're in a war and evidence is our best weapon, but evidence in the hands of one soldier is going to win one battle. We need an army. At the Clinical Compass, we're developing tools, PowerPoints, handouts. We're basically creating a ready-made manual. If you want to go out and do presentations to an employer group, we'll give you the tools and even meet with you if you want to explain how to explain the PowerPoint. We're happy to do that, but we absolutely need an army. Who you take this information to is important, right? Our knee-jerk reaction is sending it to the medical director of the insurance company. Well, they don't make policy. It's okay to educate them, but they're not going to make the decisions on changing policy, right? We got to get higher up than that, to get the legislators, to the people who take financial risk, to employers unions, TPAs, actuarial firms who are educating these employers. You want to save on chiropractic, make it a $75 co-pay. No, you dummy. You're going to cost this company a lot of money.”
RESOURCES
CONTACT RON
Call at 847-579-2721
Comments