November 23, 2016 Page 1 Good Afternoon, The OCA is recommending - - PDF document

Ontario Chiropractic Association Presentation to the Standing Committee of the Legislative Assembly on Bill 41: The Patients First Act, 2016 November 23, 2016

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Good Afternoon, The OCA is recommending two amendments to Bill 41 to remove barriers and enable patient- focused integrated care for low back pain and other musculoskeletal conditions. The amendments will enable LHINs and other agencies to utilize chiropractors. BACKGROUND One in five Canadians suffer from chronic non-cancer pain with back pain as a leading condition.1, 2: Three of the top four causes of disability in North America are musculoskeletal in nature including low back and neck pain.4 Evidence points to back pain as a leading reason for opioid prescriptions. A recent study found that 50% of people prescribed opioids in the United States reported back pain.12 However, according to the new 2016 Centres for Disease Control and Prevention’s Guideline for Prescribing Opioids for Chronic Pain, the use of nonpharmacological therapies is preferred.13 With the opioid situation in Canada described as a crisis, the importance of non- pharmacological therapies is highlighted by the Canadian Chiropractic Association being invited to the National Opioid Summit last weekend and being a signatory to the Joint Statement of Action. Chiropractors are educated, trained, and competent to provide MSK assessment, diagnosis, and treatment. They offer a compelling option for better managing MSK conditions across the healthcare system. The literature supports that spinal manipulation therapy (SMT) or adjustments are effective in relieving pain and improving function.14 SMT is recommended by numerous clinical practice guidelines, including the Bone and Joint Decade Task Force15, and the American College of Physicians.16 ONTARIO'S LOW BACK PAIN PILOTS There are currently two Ministry pilots aimed at improving care of low back pain: the Inter- professional Spine Assessment and Education Clinic (ISAEC) pilot, and the Primary Care Low Back Pain (PCLBP) pilot. Both integrate chiropractors in key clinical roles.

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ISAEC The ISAEC pilots have demonstrated that engaging chiropractors and advanced practice physiotherapists in assessment and education of low back pain patients decreases unnecessary diagnostic imaging, specialist visits, and their associated costs.17 PCLBP The PCLBP pilot integrates chiropractors and other practitioners into inter-disciplinary primary care settings, and provides a comprehensive assessment and treatment model. In addition to back pain, the "typical" PCLBP pilot patient suffers from significant co- morbidities including other MSK conditions, diabetes and other chronic diseases, and mental health and addictions issues. Many have characteristics similar to high cost users of the health care system.18 In addition to decreased specialist referrals, reduced unnecessary diagnostic imaging, the PCLBP pilot is also indicating reduced use of opioids. PROPOSED AMENDMENTS TO BILL 41 Our two minor suggested amendments to Bill 41 and Acts amended by The Bill reflect the key principles of:  Eliminating barriers;  Building evidence informed solutions; and  Developing inter-professional care pathways across the healthcare continuum. Currently, patient access to optimal care is limited by the eligibility requirements for Ministry or LHIN funding. This barrier prevents patients from accessing health professionals who may be the most qualified. This is because eligibility for funding is limited to specific professions, as

• pposed to being determined by patient need, practitioner competence, and best use of health

human resources. Homecare and Community Services Act, 1994 Under the Homecare and Community Services Act, unlike services delivered by physiotherapists, occupational therapists, social workers and nurses, services delivered by chiropractors are not listed as “professional services.” This means that an approved agency, such as a CCAC (or a LHIN following a transfer order under Bill 41) is not authorized to purchase chiropractic professional services and; therefore, patients cannot access them as they can physiotherapy services. It means even though chiropractors are on the list of eligible practitioners to be hired in Family Health Teams, Community Health Centres, Aboriginal Health

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Therefore, we recommend that: Section 1(3) of Bill 41, which amends Paragraph 11 of Subsection 2(2) of the Local Health System Integration Act, 2006, be amended by including “musculoskeletal care” and/or “musculoskeletal services” as follows:

• 16. “A person or entity that provides musculoskeletal services in a clinic setting including

physiotherapy services or chiropractic services” that is not otherwise a health service provider.” Therefore, we recommend that Bill 41 include an amendment to the Home Care and Community Services Act, 1994 to: Include chiropractic services under “professional services” in Section 2 (1) (7). Access Centres, and Nurse Practitioner Led Clinics, they do not qualify for funding under the Home Care and Community Services Act, 1994. We know that technically this can be changed by regulation but we also know that there have been no changes made to the Regulations since 1999. Given the success of the Ministry’s current LBP pilots and the thrust of the provincial low back pain, chronic pain, and opioid strategies, we believe this is a significant gap in the provision of appropriate care for Ontarians. Local Health System Integration Act, 2006 (LHSIA) Historical funding arrangements mean that, chiropractic clinics are not defined as “health service providers” and, this creates barriers and inconsistencies in patients’ access to appropriate care. Section 1 (3) of Bill 41 repeals Paragraph 11 subsection 2 (2) of the definition of “health service provider” under the Local Health System Integration Act, 2006. Bill 41 substitutes Paragraph 11 by adding several new entities to the definition of “health service provider”, including: (16) “A person or entity that provides physiotherapy services in a clinic setting that is not

• therwise a health service provider.”

We understand the rationale for this to be housekeeping in that it will allow current funding arrangements to be continued, but it limits the ability to implement new and innovative models.

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This would provide for both the continuation of existing programs, and also provide for the implementation of future innovative and collaborative interprofessional models. CLOSING REMARKS The early successes of both ISAEC and the PCLBP pilots are demonstrating that new models of care, which integrate clinicians based on professional competencies and expertise, provide significant benefits. In these models, chiropractors have a leading role. While the Ontario Chiropractic Association supports the Patients First Action Plan, we believe the current wording of Bill 41 creates a barrier and inequity because patients cannot access chiropractic services directly funded by LHINs and other agencies. By addressing these two concerns, the province can strengthen consistency and standardization of services while being responsive to local differences. We appreciate the opportunity to comment on this important piece of legislation and policy reform. ENDNOTES

1Schopflocher, D., Taenzer, P., & Jovey, R. (2011). The prevalence of chronic pain in Canada. Pain Research & Management. The

Journal of the Canadian Pain Society, 16(6), 445-450.

2Moulin, D. E., Clark, A. J., Speechley, M., & Morley-Forster, P. K. (2002). Chronic pain in Canada: Prevalence, treatment and the

role of opioid analgesia. Pain Research and Management, 7(4), 179–184.

3Andersson, G. (1997). The epidemiology of spinal disorders. In J.W. Frymoyer (2nd ed.), The adult spine: principles and practice

(93-141). Philadelphia: Lippincott-Raven.

4Vos, T., Flaxman, A., Naghavi, M., Lozano, R., Michaud, C., Ezzati, M.… Murray, C. (2012). Years lived with disability (ylds) for

1160 sequelae of 289 diseases and injuries 1990—2010: A systematic analysis for the global burden of disease study 2010. The Lancet, 380(9859), 2163 – 2196.

5Bombardier, C., Hawker, G., & Mosher, D. (2011). The impact of arthritis in Canada: Today and over the next 30 years. Arthritis

Alliance of Canada.

6Leveille, S., Jones, R., Kiely, D., Hausdorff, J., Shmerling, R., Guralnik, J. ... Bean, J. (2009) Chronic musculoskeletal pain and the

• ccurrence of falls in an older population. JAMA, 302(20), 2214-2221.

7Sinclair, A., Conroy, S., & Bayer, A. (2008). Impact of diabetes on physical function in older people. Diabetes Care, 31(2), 233-235. 8Molsted, S., Tribler, J., & Snorgaard, O. (2012). Musculoskeletal pain in patients with type 2 diabetes. Diabetes Research and

Clinical Practice, 96, 135-140.

9Roberts, M., Mapel, D., Hartry, A., Worley, A., & Thomson, H. (2013). Chronic pain and pain medication use in chronic obstructive

pulmonary disease. Annals of the American Thoracic Society, 10(4), 290-298.

10HajGhanbari, B., Holsti, L., Road, J., & Reid, D. (2012) Pain in people with chronic obstructive pulmonary disease (COPD).

Respiratory Medicine, 106(7), 998-1005.

11Slater, M., Perruccio, A., & Badley, E. (2011). Musculoskeletal comorbidities in cardiovascular disease, diabetes and respiratory

disease: the impact on activity limitations; a representative population-based study. Biomedical Central Public Health, 11, 77.

12Deyo, R., Von Korff, M., & Duhrkoop, D. (2015). Opioids for low back pain. British Medicine Journal, 350, g6380. 13Dowell, D., Haegerich, T.M., & Chou, R. (2016). CDC guideline for prescribing opioids for chronic pain — United States. Morbidity

and Mortality Weekly Report (MMWR) Series, 65(RR-1), 1–49. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1

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14van Tulder, M., Koes, B., & Malmivaara, A. (2006). Outcome of non-invasive treatment modalities on back pain: An evidence-

based review. European Spine Journal, 15(1), S64-S81.

15Guzman, J., Haldeman, S., Carroll, L.J., Carragee, E.J., Hurwitz, E.L., Peloso, P., … Hogg-Johnson, S. (2008). Bone and joint

decade 2000–2010 task force on neck pain and its associated disorders: Clinical practice implications of the bone and joint decade 2000–2010 task force on neck pain and its associated disorders: from concepts and findings to recommendations. Spine, 33, S199–

• S213. doi: 10.1097/BRS.0b013e3181644641.

16American College of Physicians. (2016). Guidelines. Retrieved from https://www.acponline.org/clinical-information/guidelines. 17 University Health Network. (2015). Inter-professional spine assessment and education clinics. Retrieved from:

http://www.isaec.org/

18Centre for Effective Practice. (2016). PCLBP pilot qualitative evaluation phase 1 – report of findings. Toronto, Ontario: Author.