Category: Perspective

:dropcap_open:C:dropcap_close:hiropractors are often considered to be true entrepreneurs. This is because they often graduate from their educational program and immediately open and build their own businesses from the ground up, without a formalized support system. Furthermore, they do not have a business model that provides them immediate patient flow and income, unlike other healthcare professionals. More than ever, chiropractors need to spend time and money continuing their entrepreneurial education because they are working as entrepreneurs.

Continuing one’s education offers many great benefits. The benefits of self-development include:

• Better care for patients. For chiropractors, patient care is the top priority. By continuing your learning through professional development opportunities, you are able to offer better care to your patients. Continuing education ensures that you are knowledgeable about the most recent research and techniques, which can be helpful to your patients and ensure they are receiving the best care available.

• Opportunity to promote your business. By obtaining a certification in a new technique or even having knowledge in a new procedure, you are able to promote your business and yourself as an expert in this area. This will help you attract new customers and expand your business.

• Growth as a professional. As a professional, continuous learning is important to ensure that you are constantly growing. This is what keeps you challenged and interested in the profession. For chiropractors, pursuing self-development opportunities is important to make sure you are learning new things and challenging yourself professionally.

While many chiropractors are turned away from professional development opportunities because of the cost, it is a cost that is well worth the price. It is important that continuing education opportunities are considered an investment, rather than an expense. This is because it is an investment in the chiropractor’s future, in helping them develop the skills to further their ability as a professional. Furthermore, the IRS allows professionals to deduct learning opportunities on their taxes each year, which also includes professional development. Because of this, it’s important that a chiropractor keeps a running tally of the courses that they take and the associated expenses to ensure they are reimbursed the proper amount from the IRS. This makes it even more affordable and appealing to chiropractors, especially those who practice on their own.

In addition, engaging in professional development opportunities helps chiropractors build reputation within the field. This is important for several reasons. For one, it gives chiropractors an opportunity to build a network, which will in turn help build their client base and provide support if he or she chooses to move to a different practice in the future. Engaging in conversations with other chiropractors is a good way to help develop as a professional, as it’s easy to share best practices and other information casually. Furthermore, it opens doors to present at national conferences, which raises a chiropractor’s profile among key vendors and companies that provide services. This is helpful because it allows them to build relationships with these vendors for product discounts. It may even provide an opportunity to chiropractors to try out new equipment or services because of their clout within the industry.

Overall, engaging in self-development opportunities as a chiropractor provides many personal and external benefits. It can help improve the chiropractor’s overall ability to serve his or her patients, while building the business through networking and a higher profile within the industry. From the patient’s point of view, engaging in continuing education is important because it will augment the services that can be provided and will ensure the chiropractor is focused on the newest techniques and understands the latest research that has been released.

:dropcap_open:W:dropcap_close:hen I was first asked to write an article about the words adjustment and manipulation, a flurry of thoughts and emotions hit me…not the least of which was the question, “Aren’t we over this yet?”  But after thinking about it for a few weeks I’ve come to the realization that we will never really get beyond this quagmire any time soon.  Essentially this is because these words define us in a way that helps create our professional identity and distinguishes us (for better or worse) from the rest of the manipulative professions.  So, relative to the future of our profession, there is no question that language matters because in order to communicate with our patients, amongst ourselves, with other professions and the public at large, words are the basis for all understanding.  Personally I am convinced that given who we are as a profession, the words unique to our profession like adjustment and subluxation will not go away within the foreseeable future.  Given that, I think the more important questions are, “What do these words mean?” and “How can we use them to advance the profession?”

The Clarity of Definitions

As a teacher to new members to our profession, I firmly believe it’s necessary to learn our lexicon.  This is important not only for historical reasons, but also to understand the present and future debates regarding chiropractic and, more importantly, to add to and access the scientific literature and improve patient care. But in order to debate or utilize published evidence, we must be clear and consistent with the words we use. To my knowledge the most comprehensive work to date on establishing consensus in our profession regarding our terminology was done by Gatterman and Hansen in 1994 (1).  In the heroic attempt to bring some order to the chaos, they organized and reported on the work of an international Delphi panel, whereby these leaders offered their conclusions about the various words and definitions we commonly use.  I would suggest that as a profession we continue to use the definitions that were crafted at that time until a similar process is undertaken to update them.  As such, an adjustment is defined as “ANY (emphasis added) chiropractic therapeutic procedure that utilizes controlled force, leverage, direction, amplitude, and velocity which is directed at specific joints or anatomical regions.  Chiropractors commonly use such procedures to influence joint and neurophysiological function.”

As I see it, there are both strengths and weaknesses in this definition.  The strengths include the fact there was 87% agreement by the panel members to adopt this definition and that it is inclusive of the myriad of the subluxation/joint dysfunction interventions that we use, including high velocity, low amplitude (HVLA) manual thrust procedures, instrument-assisted thrust procedures, pelvic blocking, and even flexion-distraction procedures.  I personally like it because when someone tells me she had an adjustment, I immediately know she knows something about what we do and has probably visited a chiropractor.  I also like it because it implies that there is a high level of precision involved when giving an adjustment.  I believe this is an important distinction relative to other manipulative professions which can be used to our advantage when we explain our different types of adjustments.   Of course the major weakness is that it is so broad and vague that it is useless as a word when performing research investigations, having meaningful intraprofessional or interprofessional dialogue, or crafting legislative or public policies or practice guidelines. 

As for manipulation, the Gatterman and Hansen definition is “a manual procedure that involves a directed contact to move a joint past the physiological range of motion, without exceeding the anatomical limit.” The strength in this definition is that it had 91% agreement among panel members and is relatively specific.  For example, manipulation is distinguished from mobilization and other manual therapy procedures.  It is highly useful as the basis for a research investigation even though often there must be further refinement of the term; as a literature search term it is far more useful than the word adjustment.  Certainly as we integrate ourselves further into mainstream health care systems, it is the word that is best understood.  It is the word typically used to describe the commonly used hands-on HVLA thrust procedure and there is no particular benefit to not using it.  Indeed, we have used it to our great advantage when other professions have published favorable trials on neck pain, back pain or headaches (among other things) and used manipulation as one of the interventions.  As an example, the recently published UK Evidence Report was a review on randomized controlled trials on conditions which were treated by manipulation (not adjustment), many of which were performed by non-DCs (2).   This document is extremely useful in evidencing at least some of what we do to those outside of the profession and clearly advances our cause to support and increase the utilization of our services.

In conclusion, I will close with this thought regarding what words we use: follow the money.  As we better define ourselves and our procedures and truly determine which of those are most safe and effective, I am convinced we will separate ourselves from the pack and this will help us flourish.  This belief begins with the fact we are the most educated users of manipulation and other forms of adjustments in the US (and probably the world).  As one compares the curricula of competing professions, especially the hours of study, this becomes very clear (3, 4, 5).  If we were to do direct comparisons of DC, PT and DO manipulations and other procedures we could evidence this.  But where is the money to do such things?  The federal government is one source.  The National Institutes of Health now provide approximately 100 million dollars per year to fund such research through their National Center for Complementary and Alternative Medicine (6).  All we need to do is access this money by writing high-quality grant proposals. The good news is we already have had a number of projects funded, which suggests that the interest is there and the internal expertise exists.  We just need to take more advantage of our knowledge by being very clear and consistent with the words we choose.  Language matters, especially when money is involved!

References

1. Gatterman, M.I. & Hansen, D.T. Development of chiropractic nomenclature through consensus. J Manipulative Physiol Ther 1994;17:302-9.
2. Bronfort, G., Haas, M., Evans, R., Leiniger, B., & Triano, J. Effectiveness of Manual Therapies: The UK Evidence Report. Chiropractic & Osteopathy 2010, 18:3.
3. University of Bridgeport College of Chiropractic website accessed on 09Oct2011 at http://www.bridgeport.edu/academics/graduate/chiro/curriculum/curriculumbreakdown
4. Boissonnault, W., Bryan, J.M., & Fox, K.J. Joint manipulation curricula in physical therapist professional degree programs. J Orthop Sports Phys Ther. 2004, 34(4):171-8.
5. H. Shubrook, Jr & Dooley, J. Effects of a structured curriculum in osteopathic manipulative treatment (OMT) on osteopathic structural examinations and use of OMT for hospitalized patients.  JAOA , 2000, 100(9): 554-558.
6. National Center for Complementary and Alternative Medicine website accessed on 09Oct2011 at http://www.nccam.nih.gov/

Christopher Good, DC, MA(Ed) is a Professor of Clinical Sciences at the University of Bridgeport College of Chiropractic.  He teaches courses in clinical biomechanics and chiropractic technique, extremities technique, and chiropractic principles and practice. He can be reached at [email protected].

:dropcap_open:I:dropcap_close:n 1847, the American Medical Association adopted the world’s first national code of professional ethics in medicine. For the more than 160 years, the AMA’s “Code of Medical Ethics” has been the authoritative ethics guide for practicing physicians. Currently, the AMA has 200 ethical opinions. The chiropractic profession needs to learn from the AMA and, in the end, further protect our patients and doctors from fraud and abuse. In this case, I make the argument in order to protect against IME and peer review abuse.

The AMA’s Code of Medical Ethics, Opinion 10.03, is titled “Patient-Physician Relationship in the Context of Work-Related and Independent Medical Examinations” and outlines a cogent relationship that should exist between both IMEs (independent medical examiners) and IEPs (industry employed physicians). The AMA writes:

Despite their ties to a third party, the responsibilities of IEPs and IMEs are in some basic respects very similar to those of other physicians. IEPs and IMEs have the same obligations as physicians in other contexts to:

(1) Evaluate objectively the patient’s health or disability. In order to maintain objectivity, IEPs and IMEs should not be influenced by the preferences of the patient-employee, employer, or insurance company when making a diagnosis during a work-related or independent medical examination.

(2) Maintain patient confidentiality as outlined by Opinion 5.09, “Industry Employed Physicians and Independent Medical Examiners.”

(3) Disclose fully potential or perceived conflicts of interest. The physician should inform the patient about the terms of the agreement between himself or herself and the third party as well as the fact that he or she is acting as an agent of that entity. This should be done at the outset of the examination, before health information is gathered from the patient-employee. Before the physician proceeds with the exam, he or she should ensure to the extent possible that the patient understands the physician’s unaltered ethical obligations, as well as the differences that exist between the physician’s role in this context and the physician’s traditional fiduciary role. (http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion1003.page)

Although the AMA worked hard to protect patients and doctors from improper IME and IEP examinations, they are a labor organization and neither a regulatory body, nor a court of law.

However, upon joining, members have to agree to abide by the Code of Ethics, which is a contractual obligation and has legal precedent in tort (trial) proceedings. In addition, many regulatory bodies seek counsel from state organizations to determine if a doctor is practicing within the current standard of care and ethics for his/her particular state.

It is here where every national and state chiropractic organization has the ability to level the playing field in protecting both patients and doctors by having a code of ethics outlined and agreed upon by all of their members. This creates a standard of practice in the state and should an improper IME, IEP or peer review be performed, then there are guidelines to justify recourse. Although some states have ruled that IME, IEP and peer review doctors are not subject to state licensure disciplinary boards as a result of their interpretation of “duty of care” or the legal obligation of the doctor to the patient because they believe no doctor-patient relationship exists, many states do hold the IME or IEP doctor to the same standard as the treating doctor. This dichotomy creates a problem in those states where a doctor can tell half-truths, report only snippets of research or do only a partial examination for a desired conclusion and not be subject to losing his/her license. Courts in New York, Maryland, The District of Columbia, Arizona, Michigan, West Virginia, Montana, and The United States Court of Appeals, Fifth Circuit, among others, have ruled that these doctors are responsible in a doctor-patient relationship.

Should an independent examining doctor do an improper or fraudulent examination in any of those states, the code of ethics will weigh heavily against them. In states  like Alaska, Missouri and Colorado where there is no “duty of care” and it has been determined there is no doctor-patient relationship for independent examining doctors, the Code of Ethics then helps litigators, to some degree, in creating justice for the injured. Furthermore, it can help give direction to creating legislation to overturn the court rulings that currently protect the licenses of IME, IEP and peer review abusers. We must never lose sight of the fact that independent examining doctors have a tremendous personal financial gain to render a desired diagnosis and conclusion and there have to be checks and balances in place to ensure an honest opinion is rendered.

I strongly suggest that every state and national organization adopt a version of the following language as a code of ethics standard for all of their members:

Chiropractic Code of Ethics:

A. Conduct of Independent Examiners

(1) Evaluate objectively the patient’s health or disability. In order to maintain objectivity, independent chiropractic/medical evaluations should not be influenced by the preferences of the patient-employee, employer, or insurance company when making a diagnosis during any type of independent chiropractic/medical examination, including, but not limited to, sequellae from auto accidents, on-the-job injuries and pre-employment physicals.

(2) Maintain patient confidentiality as outlined by the State of [add your state].

(3) Disclose fully potential or perceived conflicts of interest. The doctor of chiropractic should inform the patient about the relationship between himself or herself and the third party as well as the fact that he or she is acting as an agent of that entity. This should be done at the outset of the examination, before health information is gathered from the examinee. Before the doctor of chiropractic proceeds with the exam, he or she should ensure to the extent possible that the patient understands the doctor of chiropractic’s unaltered ethical obligations, as well as the differences that exist between the treating doctor’s role and that of the independent examiner.

(4)The examining doctor shall:

1. Include all pertinent and related diagnostic findings and test results in his/her report(s).
2. Consider all pertinent and related diagnostic findings and test results when rendering a diagnostic conclusion.
3. Include complete pertinent and related research, when applicable, in rendering a conclusion.
4. Perform examinations to the same standard as he/she does for all other patients with similar diagnoses.
5. Note in his/her report(s) the absence of any diagnostic or test findings when he/she is aware he/she does not have possession of said reports or results.

Adopting these standards is taking the first step towards leveling the playing field to help ensure that our patients get the care they need and that doctors receive the payments they are entitled to for rendering necessary services.

References:

1. American Medical Association. (n.d.). History of AMA ethics.  AMA Code of Medical Ethics, Retrieved from http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/history-ama-ethics.page?
2. American Medical Association. (1999). Opinion 10.03 – Patient-physician relationship in the context of work-related and independent medical examinations. AMA Code of Medical Ethics, Retrieved from http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion1003.page

:dropcap_open:M:dropcap_close:y mantra for many years was “Chiropractors adjust and osteopaths and physical therapists manipulate.” I had a dogmatic philosophical belief that anything else was blasphemy and that sentiment was and is shared erroneously by many. Over the years, I have felt that nomenclature was more of a philosophical issue that served to divide the profession and I was of the opinion “Who cares about words? Let’s call it a left elbow to the spine and move on together.” I was wrong!

The nomenclature utilized in a healing, regulated profession cannot be based upon belief. It must be based upon standards taught in our teaching institutions and verified both by research and in the field daily as practiced by clinicians and evidenced by their results. Having spent the last few years researching chiropractic and related topics and having spoken to many in our teaching institutions, it has become “crystal clear” as to why we have gravitated towards the label “manipulation” as a descriptor of what we do rather than “adjusting.” Until you “read between the lines” and see how we are being seen as a result of the lines being blurred, you will not understand the dilemma the dichotomy of language has created.

If we look at a Barnes, Bloom, and Nahin (2008), we see that 2002 findings revealed that chiropractic had a 7.5% utilization rate among Americans 18 years of age and over. In 2007, the results for chiropractic read “xxx,” meaning the category was not applicable because there were no chiropractic statistics. Our utilization was placed under the banner of “manipulation” and lumped together with osteopaths. The formal heading is “chiropractic or osteopathy manipulation.”  Some may see this as progress, as we are now being considered equals in the eyes of the government with doctors of osteopathy. However, based upon the facts we are no longer being quantified for utilization as a separate and distinct profession.

Cerritelli et al. (2011) published research findings revealing that “…among patients affected by cardiovascular disorders, osteopathic treatment is significantly associated to an improvement in intima-media and systolic blood pressure after one year” (p. 69). They went on to detail what osteopathic treatment or osteopathic manipulative technique (OMT) is. “OMT is characterized by different techniques, i.e. myofascial release, craniofacial, High Velocity Low Amplitude (HVLA) manipulation, Balanced Ligamentous Tension (BLT), Muscle Energy Technique, biodynamic, strain-counterstrain, etc. This wide range of techniques permits the operator to choose the more appropriate to apply on a patient in a given moment. During scientific studies, OMT can be used as an approach, as was done in this study, or as an isolated technique” (Cerritelli et al., 2011, p. 69). The published definition of an OMT is not close to a chiropractic manipulation, it is identical.

Chevan and Riddle reported in 2011 that “physical therapists and chiropractors are similar because both provide manipulative and corrective care. The conceptual and philosophical basis of care for physical therapists and chiropractors does differ, and 2 older studies conducted in the UK and Sweden indicate that chiropractors use more manipulation and physical therapists provide both manipulation and mobilization, as well as exercise, modality-based treatment, and education” (p. 467). The literature clearly reflects that both physical therapists and chiropractors do the same thing, manipulate, but physical therapists offer more by adding “mobilization, exercise, modality-based treatment, and education.”

While everyone within the chiropractic world knows this to NOT be true, the scientific community has reported this and our regulators, payors and referrers (primary care physicians who treat 95% of the population and control 95% of the referrals in America) have accepted this. We, as a profession, have validated their arguments and research findings by exclusively using the tag “manipulation” for chiropractic in too many venues and publications. Conversely, Welsh and Boone reported in 2008 on the sympathetic and parasympathetic responses to specific adjustments to chiropractic vertebral subluxations. The metric that was being analyzed was blood pressure and pulse rate. They reported, “Diastolic pressure (indicating a sympathetic response) dropped significantly postadjustment among those receiving cervical adjustments, accompanied by a moderate clinical effect (0.50). Pulse pressure increased significantly among those receiving cervical adjustments, accompanied by a large effect size (0.82). Although the decrease in pulse pressure for those receiving thoracic adjustments was not statistically significant, the decrease was accompanied by a moderate effect size (0.66)…It is preliminarily suggested that cervical adjustments may result in parasympathetic responses, whereas thoracic adjustments result in sympathetic responses.

Furthermore, it appears that these responses may demonstrate the relationship of autonomic responses in association to the particular segment(s) adjusted” (Welsh & Boone, 2008, p. 86). The clear conclusion is that a specific chiropractic adjustment is the reason for the positive outcome.

Rochester reported in 2009 that “The data supports the alignment model’s predictive validity by suggesting that a threshold of altered atlas alignment toward the orthogonal configuration following the first adjustment was associated with a better outcome inc 2-weeks for disability from neck pain” (p. 173). Again, the conclusion is clear that a specific chiropractic adjustment is the reason for the positive outcome and cannot be used to validate physical therapy or osteopathy under the generic banner of manipulation. In addition, physical therapists and osteopaths do not perform adjustments, therefore precluding them from laying any claim to the successes of chiropractic.

Cifuentes, Willets and Wasiak (2011) compared the treatment of recurrent or chronic low back pain. They considered any condition recurrent or chronic if there was a recurrent disability after a 15-day absence and return to disability. Anyone with less than a 15-day absence was excluded from the study. 

The study concluded that chiropractic care during the health maintenance care period resulted in:

• 16% decrease in disability duration of first episode compared to physical therapy

• 6.6% decrease in opioid (narcotic) use during maintenance care compared to physical therapy care

• 32% decrease in average weekly cost of medical expenses during disability episode compared to physical therapy care

The study concluded that chiropractic care during the disability episode resulted in:

• 24% decrease in disability duration of first episode compared to physical therapy

• 5.9% decrease in opioid (narcotic) use during maintenance care compared to physical therapy care

• 19% decrease in average weekly cost of medical expenses during disability episode compared to physical therapy care

In essence, Cifuentes, Willets and Wasiak (2011) verified through statistical outcomes that all manipulation is not alike because what chiropractic offers is a specific type of manipulation/adjustment or simply a chiropractic spinal adjustment that is not taught, performed or offered by either physical therapists or osteopathic doctors. These outcomes certify chiropractic to be a superior form of treatment for this specific type of condition and impairment, yet we leave open the ability for disparate professions to falsely lay claim to chiropractic successes by following the chiropractic treatment plan of manipulation. This has occurred because the chiropractic profession has not remained unique in the nomenclature in describing what we do.

The next challenge is billing. CPT codes 98940, 98941, 98942 and 98943 are labeled “chiropractic manipulative therapy,” forcing all doctors of chiropractic to utilize the manipulation label to get paid. The primary difference in this “carve out” code is that the word “CHIROPRACTIC” comes first. If all chiropractic research and literature and arguments used “chiropractic manipulation” and not just “manipulation,” it would be better. However, this is not the best solution that would ensure our separation and distinct position among other healthcare professionals because the words and lines still blur.

A literature search for “chiropractic adjustment” rendered 596 results without all of them being peer reviewed journals. However, all were specific to chiropractic and each is a building block to grow on. A literature search for “spinal manipulation” rendered 8,145 results, but only 3,518 had “chiropractic manipulation” in the text. There is so much overlap in what we do versus what others do that others often lay claim to chiropractic manipulation results to certify non-chiropractic care. We are empowering other professions that manipulate and the regulators, payors and referrers who utilize the research must get a clearer message for chiropractic to flourish. The results are: we get reimbursed at the lowest level or none at all (i.e. Medicaid), there is ongoing legislation further limiting chiropractic care, we are prevented from participating in too many local, state and Federal programs and we are bypassed in the referral process by well meaning but misinformed referral sources such as primary care physicians who rely on literature for verification of the best referral pathway.

Organized medicine controls the purse strings of everything related to healthcare in government, locally and nationally, and we do not have enough money to fight them because we have not centralized as a profession like physical therapists have with the American Physical Therapy Association. Who does organized medicine control? Physical therapy, osteopathy or chiropractic? The answer is obvious and armed with literature that erroneously states that DCs, PTs and DOs all do the same thing, individual outcomes will be overlooked for politics, power and money as they have been for the last 116 years by those that significantly control our destiny. It cannot be business as usual or we will keep being homogenized, as the US Census Bureau already has done, to the point where no one will recognize the power of a chiropractic adjustment. For proof, see the history of osteopathy, and if we take that pathway, realize that unfortunately today virtually no one says “I need to see my osteopath for a manipulation.”

References:

1. Barnes, P. M., Bloom, B., & Nahin, R. L. (2008). Complementary and alternative medicine use among adults and children: United States, 2007. National Health Statistics Reports, 12, 1-23.
2. Cerritelli, F., Carinci F., Pizzolorusso, G., Turi, P., Renzetti C., Pizzolorusso, F.,…Barlafante, G. (2011). Osteopathic manipulation as a complementary treatment for the prevention of cardiac complications: 12-months follow-up of intima media and blood pressure on a cohort affected by hypertension. Journal of Bodywork & Movement Therapies, 15(1), 68-74.
3. Chevan J., & Riddle, D. L. (2011). Factors associated with care seeking from physicians, physical therapists, or chiropractors by persons with spinal pain: A population-based study. Journal of Orthopaedic & Sports Physical Therapy, 41(7), 467-476.
4. Welch, A., & Boone, R. (2008). Sympathetic and parasympathetic responses to specific diversified adjustments to chiropractic vertebral subluxations of the cervical and thoracic spine. Journal of Chiropractic Medicine, 7(3), 86–93.
5. Rochester, R. P. (2009). Neck pain and disability outcomes following chiropractic upper cervical care: A retrospective case series. Journal of the Canadian Chiropractic Association, 53(3), 173-185.
6. Cifuentes, M., Willetts, J., & Wasiak, R. (2011). Health maintenance care in work-related low back pain and its association with disability recurrence. Journal of Occupational and Environmental Medicine, 53(4), 396-404.

:dropcap_open:I:dropcap_close:f your practice isn’t exactly the well-oiled machine that it should be, it’s time for some serious maintenance. But you need the right tools – and the best place to look is in the toolkits of practices with proven operations records.

Experts advise that becoming a practice leader means adopting the following strategies to make your office run more smoothly: 

1. Take care of your staff. Practices with low turnover are places where employees are valued and where there’s a climate of mutual respect. “You can’t just be nice to the patient. You have to be nice to the people who work there. Be nice to your neighbors, your landlord, and your co-tenants; be nice to yourself, to one another before you can be nice to the patients.”

Invest in your employees and you’ll reap financial rewards, it’s rare to see a practice where you get that good feeling and find that they’re not doing well financially.  Keep your office happy and your patients and practice will prosper.

Let employees know you value their input, give them respect and you will get respect.  One way to accomplish this is to hold in-service meetings with staff to set mutual goals for the week and month ahead.  This is why I put such an emphasis on statistics.  For every doctor that sends them I look at them, if they don’t, I know their practice; their success level is not up to their potential.  Practices where management and staff don’t share common goals suffer lots of infighting. We need to be constructive, not destructive, in these meetings.  These are not gripe sessions; they need to be happy and beneficial.  In my office we brought in pizza and made it a fun environment. 

2. Re-strategize, Re-energize your practices. Once you’re clear about the kind of office environment you’re creating, you can employ people who can carry out that vision.  One office, one vision.  For instance, physicians who want to run everything, micro managers, need to hire people who are comfortable with that management style.  However you need to delegate, offer trust to get the maximum from any person.  Otherwise you will always be the one holding the bag.

Whether your practice succeeds can depend on you and your management style.  When hiring always look for candidates with previous health care office experience who are both collegial and proficient as office assistants. It’s nice to have someone who can work with people and who can bring physicians and staff together, but it’s also critical to have someone who understands budgeting and reimbursement issues. 

Rather than sticking to conventional interviewing tactics, I recommend asking potential managers how they would respond to specific incidents that come up in the practice. Create vignettes based on real occurrences to evaluate their judgment and expertise. 

3. Emphasize orientation for new patients. Physicians give lots of lip service to patient satisfaction, but in reality satisfaction levels are very low.  After so many years in practice, why do so many chiropractors need so many new patients?  If patients were happy, if they understood chiropractic, then they should still be coming in once per month.  How many patients do you have on this type of schedule?  We often give one report of findings and expect the patient to stay forever.  No one is that good a salesperson.  The key is not being a salesperson at all.  One way to set a friendlier tone is for the receptionist to take the time to explain procedures and answer basic questions when a patient calls for a first appointment.

Don’t rely too heavily on your automated answering system. Patients want to speak with someone, not always leave voice messages and wait for calls to be returned. Service is the key to keeping patients and getting referrals.  How many referrals did you get last month?  Referrals are your barometer of patient results and satisfaction. 

:dropcap_open:Find out why you are not getting paid, and you will find the map to payment.:quoteleft_close:

4. Refine records management methods. Don’t let work pile up. Stay current with bills and reports.  You must complete your notes or dictation on the same day you see a particular patient, and have the information transcribed within a day of receipt. Billing people should file all loose papers on the same day they receive them and return every record to the file by the end of the business day. These are simple things that you can do that will make the practice run more smoothly.

5. Streamline data collection procedures. Some physicians think that more is better when it comes to notes, but this is not the case.  Don’t hesitate to call Perry or myself to discuss your note system.  Good notes keep you compliant and help collections.

Doctors should ask the billing people to collaborate and conduct a presentation for the office on what they actually need in the notes and develop templates for doctors to use when charting procedures.  Find out why you are not getting paid, and you will find the map to payment.

6. Consult insurance companies for advice. Take advantage of outside resources, including cozying up to your malpractice insurer. Malpractice insurers have legal departments that can be a tremendous help in providing free consultations on such matters as documentation practices and consent forms.

Dr. Eric S. Kaplan, a former President COO of  a NASAQ traded public company, which included Nutrisystem, Currently he is CEO of Concierge Coaches, Inc., www.conciergecoaches.com,  a comprehensive coaching firm with a successful, documented history of assisting doctors create profitable practices nationwide, providing over 30 New Patient marketing Programs. Teaching doctors nationally how to develop a successful business in the health care industry of today. . Dr. Kaplan is the best selling author of Dying to be Young, and Lifestyle of the Fit and Famous and Co-developer and President of Discforce and Palm Beach Massage Centers, www.pbmassage.info, the next Generation Chiropractic Practices, massage and Spinal decompression   For more information on coaching or spinal decompression, call 1-561-626-3004.

:dropcap_open:W:dropcap_close:hat is the minimal time per session for successful traction/decompression? Do we need to deliver 15-plus minutes of mechanical traction to have a clinically important outcome…could we instead use just 1-3 minutes and have a similar clinical result?

Over the last sixty years the application of traction (to create decompression) has been perceived as a time-dependant therapy, i.e. the minimal effective dose tends to be seen as durational, or time-dependant. Like manipulation, massage and other passive interventions, several sessions (of whatever duration used) are probably necessary to be most effective and most studies suggest from 3-12 sessions. However, how long those sessions need to be is perhaps open to debate and this article is simply a discussion of that possibility. Few if any research studies have undertaken a minimum-dose control.

Interestingly, the CPT have never imposed a time frame to traction application. 97012, unlike every other modality traction, has no minimal time. If it lasts twelve hours or twelve seconds it’s the same price. And the reimbursement hovers around $12-16.00 nationally, substantial for two minutes, paltry at thirty.

When we examine the research of traction comparisons of session-duration, we find it has never been undertaken with any sense of precision or focus. With the myriad of disagreements it appears that everyone tends to be in agreement that traction must be done over a relatively extended time frame, at least 20 minutes (often up to 45 minutes). Initially “hospital traction” was done for days or weeks at a time; however, that was the era of seven days of post partum bed rest as well. In a 1996 study by Shealy et al., albeit biased on the nascent DRS system (which eventually spawned the infamous DRX9000), they conclude: “sessions less than 45 minutes tended to give inconsistent results.” Having treated hundreds of patients on a DRS I found that suggestion dubious. Quite the contrary, as patients approached 45-minute sessions (typically at 50% bodyweight plus 10-20 pounds) iatrogenic pain and dysfunction followed almost linearly. Often, sessions would need to be skipped due to an increase of pain.

It is no coincidence that the more expensive the decompression system the longer the manufacturer suggested the sessions last. Leasing a $50,000-125,000.00 system required a defined patient management solution: high patient cost and elongated sessions.

Recently published trials tend to follow a “new” standard approach of approximately 10-15 minutes (the observation that 45 minutes was a necessity was not compelling to those actually using the units). An ongoing University of Colorado study involving 140 patients is also following these shorter parameters. This in my estimation is a good thing; as the old saying goes: “Tradition is what you rely on when time, money and new ideas are unavailable.” Anyone having suffered through a HNP or similar disc-related pain can attest that the traction cure can sometimes be worse than the disease. Many times when trying to arise after having been treated for 30 minutes on either our VAX-D or DRS I questioned the wisdom of lying for that long. I ignored the suggestion in those early years from many patients that less would be preferred (I refused to lose faith in the non-clinicians who sold me the magic machine and admonished me to stick with the program).

When we examine the how and why of axial traction we are faced with several ineffable physiological and anatomical considerations. Why can’t the disc react to unloading in just 1-3 minutes with a substantive, clinically relevant benefit?  Since we have no definitive answers we’re left with speculation (and future research), but clinical experience can give us some insight. Presently clinicians practicing the Kennedy Technique have been observing patient responses to very short duration sessions and the preliminary results are not disappointing (unless you really love keeping patients on your table).

What can’t be ignored is the fact that many traction studies often show little real benefit anyway, and often show more negative reactions than other modalities. Clearly too much force and too much time could be the culprits. As to the pain-gate relief achieved with any joint ‘motion’ therapy the durational component may not be ultimately important.

Anatomically, decompression is osmosis, i.e. fluid moving from high pressure to low pressure through a semi-permeable membrane. Changes in gravitational stress alter fluid inflow, assuming the proteoglycans matrix of the nucleus is intact (not degenerative). Any recumbent posture begins the process (both hyper-extension and flexion decompress the disc and restore height).

The process is potentially expedited dramatically with the addition of (dis)traction. Flexion tends to raise intradiscal pressure, linear distraction reduces it. Less forced flexion and more distraction leads to the most mechanically feasible means of rapid reduction of IDP. However, a decreased IDP then leads to an increased osmosis and fluid in-flow pressure, especially after arising.

This begs the question: Where does the fluid diffused via osmosis go once it has entered the nucleus? Doesn’t it then in fact act as an annular-distender, pressurizing the damage zone and increasing pain when upright? It would seem the negative IDP of the initial few traction pulls would achieve this effect, with further pulls possibly being superfluous.

This is the confusion of traction. Wouldn’t it be more reasonable to distract the spine once or twice (for 45-60 seconds) and release, then arise? We speculate that collagenazation and movement of nutrients occurs during decompression (and this is likely true). What actually happens internal in the disc is only speculative. Bogduk has maintained that any elongation is lost within 20 minutes after arising and thus the effect from traction must be a “phasic phenomena”, i.e. momentary and not from any resultant effect post (though the tissues and the CNS may continue to react over time, enhancing the initial benefit as well). 

The relevant clinical question is whether these effects occur immediately and need not require redundant application over 10-20 minutes. I’ll keep you posted as to any new findings, but as for now we suggest (like the SAID principal): Use the lowest time/force necessary to achieve an effect (“first do no harm”), further imposition of time and force may be unnecessary or possibly, in some cases, detrimental.

References

1. Adams, M., Bogduk, N., Burton, K., & Dolan, P. (2006). The Biomechanics of Back Pain. 2nd ed. Edinburgh: Churchill Livingstone. p. 177-194.
2. Fritz, J.M., Thackeray, A., Childs, J.D., Brennan, J.P. (2010). A randomized clinical trial of the effectiveness of mechanical traction for sub-groups of patients with low back pain: study methods and rationale.  BMC Musculoskeletal Disorders, 11, p. 81.
3. Shealy, C.N., & Leroy, P.L. (1998). New concepts in back pain management: Decompression, reduction and stabilization. Pain Management A Practical Guide for Clinicians, Vol. 1, Fifth Edition. St. Lucie Press: Boca Raton, FL.

Kennedy is a 1987 graduate of Palmer Chiropractic College and maintains a full time practice in western Pennsylvaina. He is the principal developer of the Kennedy Decompression Technique. Dr. Kennedy teaches his non-machine specific technique to practitioners who want to learn clinical expertise required to apply this increasingly mainstream therapy.

Kennedy Decompression Technique Seminars are approved for CE through various Chiropractic Colleges.  The author can be contacted @ [email protected]

:dropcap_open:W:dropcap_close:hen you developed your yearly marketing program, you probably thought about how to attract more children or geriatric patients to your office. Have you ever considered trying to attract more athletes, especially runners? There is a large, growing population of runners that could use your expertise and care. According to Running USA’s “State of the Sport” report, from 2008 to 2009 the running population increased 18 percent to more than an estimated 35 million people. There was also a 15 percent increase in trail runners (almost 5 million people). While the overall sports industry’s growth declined or remained flat in 2009, retail sales dollars of the running/jogging category of footwear were up 5 percent (to $2.3 billion). (1)

We are great at spreading the word about chiropractic: about how healthy eating habits, regular exercise and chiropractic adjustments will help you live a healthy lifestyle. We are great at educating our patients about how subluxation complexes can lead to degeneration, restricted ranges of motion and pain, just to name a few. It is second nature to educate the patient that neurologically it is “above, down and inside out,” and biomechanically it is from the ground up. That is simple anatomy, physiology and biomechanics. But what if a runner asks you how asymmetrical biomechanics of her gait cycle can cause symptoms of low back pain, mid back pain, neck pain, plantar fascitis, chondromalasia, iliotibial band syndrome, tibial stress syndrome or greater trochanteric bursitis? Or better yet, if she has no signs or symptoms, could you tell her why she needs chiropractic care?

Let’s consider developing a wellness-based practice and the time it takes to educate a patient on the importance of wellness. Who do you think is easier to educate and take hold of the principle: the couch potato, whose life revolves around going to work, eating and watching television, or the runner who eats healthy and exercises regularly? I think the answer is quite clear – THE RUNNER. Want to attract excellent wellness patients? Attract those runners!

Case Study

Mary Jane is a 38-year-old female who has changed from what she calls the “boring runs on pavement” to the unlevel, changing of surface thrill of the trails. She previously notes a history of mild tibial stress syndromes, but changing of shoes and more stretching has helped. Since switching to trail running, she has noticed an increase in her tibial stress syndrome. She again has tried several types of shoes, more stretching, and self medications with the thought process that it will go away. In addition, she gives mention to several falls from tripping over tree roots, but nothing that caused her to discontinue her running.

:dropcap_open:Or better yet, if she has no signs or symptoms, could you tell her why she needs chiropractic care?:quoteleft_close:

Orthopaedic and neurological exams showed no significant findings. Functional examination did note decreased strength of the abductor muscles on the left. Gait appeared normal with symmetrical heel-to-toe transition. Radiographs demonstrated mild lumbar degenerative changes with mild axial rotation in the lumbars. A-P pelvic view shows a left leg insufficiency of 12mm at the iliac crest and 15mm at the femoral heads. Foot scan shows asymmetry or an imbalance of the three arches. Her Pronation/Stability Index™ number is 110, indicating moderate pronation. Body assessment screen indicates Mary Jane’s left foot as 57 percent, while her right foot indicates 43 percent. These findings are also supported by the left leg insufficiency noted on the A-P pelvic film, indicating more weight bearing on the left leg.

Since Mary Jane is a runner, we performed a video gait analysis that included walking and running. Findings from the gait analysis showed a decreased stride on the left leg compared to the right. The video analysis also pointed out excessive pronation on midstance of the gait cycle, which was more pronounced on the left. All findings are consistent with previous ones noted.

Comparing all our clinical findings, the recommendations for Mary Jane included:

1. Stabilizing orthotics to create symmetry and balance of the foot and the rest of the kinetic chain.
2. Rehabilitation exercises to strengthen her core with special focus on the weak abductors.
3. Soft tissue techniques to help reduce pain in the anterior and posterior compartments’ musculature (tibial stress syndrome).
4. Chiropractic manipulative therapy to reduce subluxation complexes and restore joint integrity.

Runners are a growing section of the population that could benefit from your care. They can turn to you for treatment when they are injured, or they could just be looking for help to stay healthy and fit. How do you find more runners? Contact your local running clubs and do a lecture on proper gait biomechanics. Explain how asymmetry of the normal movement patterns of the gait cycle lead to overuse injuries, resulting in subluxation complexes and the other common injuries that are experienced by runners. Reaching out to your community to help runners is one more way that you can help serve others with chiropractic.

Reference:

1. Running USA: “State Of The Sport 2009.” Published: Jul 15, 2009. www.running.competitor.com/2009/07/news/running-usas-state-of-the-sport-2009_3711.

A 1980 graduate of Palmer College of Chiropractic, Dr. Kirk Lee is a member of the Palmer College of Chiropractic Post Graduate Faculty and Parker College of Chiropractic Post Graduate Faculty. He has lectured nationwide on sports injuries and the adolescent athlete, and currently practices in Albion, Michigan.

A simple true or false would be nice. Unfortunately, it depends on who you ask, what state you are in, if the patient is federally insured, AND their particular circumstances. So much for straight answers to a simple question!

When consultants do answer questions about discounting , it is usually followed by “consult with your health care attorney before offering any type of discounts”. This would be great advice , except most of us do not have a health care attorney.  Others will tell you discounting is perfectly legal, as long as it is done consistently and in accordance with your written compliance program. More  great advice, but the reality is many of us still haven’t put a full compliance plan in place.

So who cares if the answer is True or False?

What’s all the fuss about discounting anyway? Can’t you charge what you want to whomever you want? Can’t you just down code your adjustments, exams or X-rays  to save a patient some money? What’s the big deal in charging more for PI, Workers Comp and insurance patients than you do for cash? All you are doing is trying to help a patient right? It’s no big deal…right?

WRONG!

In the days before insurance, third party reimbursement, state and federal payers, things were simpler. When someone else is paying part or all of the costs for health care, especially the government, rules change and regulations apply. This is when discounting the wrong way can cost you.  It’s called doing the right thing the wrong way.

You may be trying to help an uninsured or underinsured patient by offering discounts, but many doctors end up putting themselves at risk in the process.

Dual fees schedules, (charging more to insurance companies than you do to your cash patients), improper time of service discounts, (reductions that are really MORE than a reasonable bookkeeping reduction), are illegal in most states . Offering discounts that do not fall into one of Medicare’s safe harbors can cause an inducement and is absolutely a violation of federal regulations in EVERY state, subject to a $10,000 fine PER OCCURRENCE!

Violation of state and federal regulations against inducements or triggering anti-kickback statutes can lead to serious fines and career ending penalties as well.

So what is the right answer to the True or False question?

Discounting your fees CAN be illegal, if you do it the wrong way! Keep reading and find out how to offer discounts the RIGHT way, in every state and for any patient group.

Follow the rules.

1. Document correctly. The rules in this area are quite clear and there are many resources and guidelines to follow.

2. Code correctly. Again, follow the rules. Do not up code for more reimbursement when insurance is available and do not down code to reflect lower charges as a means to offer discounts. It is just as improper and illegal as up coding.

3. Discount correctly. That is a new one for most doctors.

Here is how you offer discounts the RIGHT way. Hire a health care attorney if you’d like, put your compliance plan in place…AND, if you don’t do anything else, consider joining, and encourage your patients to join a Discount Medical Plan Organization (DMPO). DMPO’s are regulated by the Department of Insurance in most states and have been around for years.

Why a DMPO? Simple. These plans use the contract model similar to what you use now, which  allow you to contract with multiple insurance companies for different rates on the same codes  without it being a “dual fee schedule”. Using a DMPO, you can still bill your UCR fees and have the protection of a “contract” that allows you to offer network-based discounts to your cash and underinsured patients. Most all patients are familiar with “buying clubs” such as Sam’s Club  and they are familiar with networks. Experience shows they do not hesitate to join these network plans to save money!

Using a DMPO really is one of the most logical, legal, and ethical ways to allow you to accept a lower fee than your normal UCR clinic fees. It helps you help your patient, and it does not put you at risk!  A good cash discount plan solves so many of the potential problems for you and really helps the patient…the RIGHT way!

Article submitted by ChiroHealthUSA.

Dr. Ray Foxworth is a certified Medical Compliance Specialist and is President of ChiroHealthUSA.