From: Sigmund Miller, DC (webinfo@ChiroViewPresents.com) The article entitled „Effect of eliminating compensation for pain and suffering on the outcome of insurance claims for whiplash injury", was authored by Cassidy, et al. (NEJM Vol 342, No 16). If you didn¼t read it, the article appears at the end of this broadcast. Following the broadcast, I received a „post¾ from Dr. Michael Freeman. In addition to having the opportunity to communicate on several occasions with Michael, I also had the distinct pleasure of meeting him for the first time since we both presented at a recent state convention sponsored by the Chiropractic Association of Oregon. Michael sent me a copy of his response to this article with permission to pass his comments along to you. . . so enjoy! Here¼s what Michael had to say. . . April 24, 2000 Re: Effect of eliminating compensation for pain and suffering on the outcome of insurance claims for whiplash injury, Cassidy, et al. (NEJM Vol 342, No 16) Dear Colleagues, One of the most misleading pieces of medical literature that I have had the misfortune to come across has been published recently in the New England Journal of Medicine. The study is called the "Effect of eliminating compensation for pain and suffering on the outcome of insurance claims for whiplash injury." In it, the authors describe the results in Saskatchewan of switching from a tort-based system of compensation in which an injured claimant could sue for injuries caused by the negligence of another, to No-fault insurance in which the claimant cannot recover any damages for pain and suffering. The study followed time to claim closure for individuals under the pre- 1995 No-fault system (the Tort system) and did the same for individuals who were injured under the No-fault system. The authors reported that time to claim closure, and thus recovery, was reduced by 54% under no-fault, and attributed the shortened time of recovery to the elimination of compensation for pain and suf! fering. One of the most serious problems with this study is that the authors did not discuss all of the changes that attended the implementation of No-fault, such as mandated rehabilitation and work hardening regimes at six weeks post-crash, and psychological evaluation at insurer-run centers after 12 weeks. The Accident Insurance Act gave the right to the insurer to close the patient¼s claim or withhold benefits if they did not "follow or participate in a rehabilitation program made available by the insurer" (Section 185 [g]). For this reason alone, the authors are incorrect to attribute the duration of recovery to the cessation of compensation for pain and suffering. Another serious problem is the use of time to claim closure as a proxy for recovery. The term "recovery" implies a restoration of normal function, as well as cessation of pain. The problem is that the authors of the Saskatchewan study did not report on the level of pain or function of the people in their study at the time of claim closure. There is no indication in the study that people did any better, or for that matter did not do worse under No-fault insurance. The fact that claims were closed sooner may have been nothing more than an artifact of changing to a system in which injured people cannot negotiate or litigate an injury settlement, and thus there are less administrative reasons to keep the claim open. Additionally, a system that can mandate treatment at centers with practitioners who are employed by the insurer (so-called Tertiary Centers) is also a system in which claim closure could reasonably be expected to be expedited. It is also important to recognize the fact that under the Tort system, the insurer benefited financially by delaying claim closure when a settlement was to be paid. While the authors of this study purported to study the effect of removing the financial motive for continued pain complaints on the duration of recovery from whiplash injuries, all they really did was demonstrate that, in a totalitarian system of health care in which the insurer is given complete control over the lives of its premium payers, it is easier to get a claim closed more quickly. This doesn¼t come as a great surprise to many. Michael D Freeman, PhD DC MPH Forensic Trauma Epidemiologist Department of Public Health and Preventive Medicine Oregon Health Sciences University School of Medicine 2480 Liberty Street NE Suite 180 Salem, Oregon 97303 drmfreeman@earthlink.net 503.763.3528 For those who missed it, here is a copy of the article Michael was commenting on. . . Effect of eliminating compensation for pain and suffering on the outcome of insurance claims for whiplash injury - Cassidy, et al. (NEJM Vol 342, No 16) Westport ‚ Reuters Health April 20,, 2000 Eliminating compensation for pain and suffering, as part of a no- fault compensation system for traffic injuries, results in a lower incidence and improved prognosis of whiplash injury, according to a report in the April 20th issue of the New England Journal of Medicine. Dr. J. David Cassidy, of the University of Alberta, Edmonton, Canada, and colleagues examined the number and duration of claims for whiplash injury in Saskatchewan, Canada, before and after the province switched to a no-fault system that did not allow payment for pain and suffering. The incidence of whiplash claims fell by 28% after the change, the authors report, with a greater decrease among men (43%) than among women (15%). These decreases occurred in the setting of rising vehicle-damage claims and increasing distances driven. Time to closure of a claim decreased 54%. Resolution under both systems was much more likely to be delayed if the claimant had a lawyer, the researchers observe. "The intensity of neck pain [and] the level of physical functioning...were strongly associated with the time to claim closure in both systems," they note. "The type of insurance system has a profound effect on the frequency and duration of whiplash claims and...claimants recover faster if compensation for pain and suffering is not available," the authors conclude. "Legislators may wish to consider the advantages of removing payments for pain and suffering from compensation systems." "The vast majority of claimants undoubtedly have real symptoms, but how these symptoms are labeled, evaluated and treated may have important effects on their perceived severity and duration," writes Dr. Richard A. Deyo, of the University of Washington, in Seattle, in a related editorial. The April issue of Archives of Neurology also features the controversy surrounding whiplash injury. Citing international medical literature describing whiplash injury, Dr. Robert Teasell, of the University of Western Ontario, London Health Sciences Center, London, Ontario, Canada, and associates write, "It is hard to accept that the symptoms of whiplash are the result of an international, translingual conspiracy among malingerers." Instead, these authors assert, "those who experience chronic symptoms...are likely to have a substantive injury." They urge thorough assessment and treatment with such proven interventions as radiofrequency neurotomy. In a response, Dr. Henry Berry, of St. Michael's Hospital, in Toronto, Ontario, Canada, argues that "an adequate physical explanation for the multiplicity of symptoms and disability of chronic whiplash syndrome has not been established." Citing his own study of Demolition Derby drivers, which identified no chronic whiplash syndrome among drivers who averaged some 1,900 collisions in their careers, Dr. Berry concludes that "the context of the injury will be the chief determinant of whether the symptom is brought to medical and legal attention." N Engl J Med 2000;342:1179-1186,1211-1213. Arch Neurol 2000;57:590-593. For those wishing to become "member subscribers" just click http://www.ChiroViewPresents.com. Thanks, Sig Sigmund Miller, DC Dean of Academic Affairs Texas Chiropractic College 281.998.6058