Your readers should not be surprised by the AMA omitting chiropractic from its new book on back pain (Aug.15 issue).
Despite your professions' advances over the years, such as the positive view about manipulation expressed in the AHCPR guideline, the typical AMA leader and member has maintained a negative view of chiropractic. Most MDs are ignorant about research documenting benefits of manipulation.
In my dealing with AMA officials over the years, I have repeatedly heard derisive comments about chiropractors.
Preparing an article concerning the increased acceptance of chiropractic a few years ago for the Chicago Sun-Times, I spoke with the AMA's chief executive, who expressed the opinion that DCs were "glorified massage therapists." Another AMA leader told me she preferred to refer patients to osteopathic physicians or physical therapists.
Though the Wilk case should have ended it, the 100-year war between allopathy and chiropractic still appears to be smoldering. In fact, the Solla case in New York contends the conspiracy continues to this day (Aug. 15. issue).
Medical politics and education are part of the problem. The typical medical doctor of course is trained to look through MD eyes and does not see much benefit from non-allopathic approaches. They are carpenters who think the only solution to a problem requires a hammer.
Still, there is some cause for hope. Some younger MDs appear to be more open to alternatives. For that matter, not everyone at the AMA hold chiropractic in disdain. One very high-level AMA official, a non-MD, told me his mother has benefited from chiropractic care.
Both professions ought to put patient care first.
Chicago Sun Times
Co-author, The Serpent on the Staff: The Unhealthy Politics of the American Medical Association.
"... the non-DC professionals supporting this profession are often overlooked."
My sincere accolades on your excellent editorial "Chiropractic's Second Class Citizens" published in your August 15th Dynamic Chiropractic. As a six year member of the Palmer College administrative staff, and having the opportunity to travel extensively on behalf of this great profession, I concur that often the non-DC professionals supporting this profession are often overlooked.
Thanks for drawing the issue to everyone's attention and keep up the excellent work.
Darrell Slabaugh, CFRE
A Veteran Chiropractor Speaks
Congratulations on your excellent chiropractic newspaper. I am honored to be on your mailing list. I'm a veteran chiropractor (graduated February 1939) now in my 55th year of the profession. Following five years in the Air Force in WWII, I spent 15 years in Africa specializing in leprosy care. Returning home in 1959 because of illness in the family, I was briefly president of CMCC, going on to be the first DC elected as a member of parliament. In 1991 I was given the rank of officer in the Order of Canada, the only DC so honored. Now in my 82nd year with a serious heart defect, I am unable to attend the centennial celebration. I will be with the thousands of grateful DCs and patients in honoring chiropractic.
Thank you again for Dynamic Chiropractic which plays such a major role in unifying and promoting chiropractic.
Robert Thompson, DC
Fort Langley, British Columbia
Is there a Lexicographer in the House?
Meridel Gatterman made a plea in the July 17, 1995 issue of Dynamic Chiropractic for the profession to "get its act together" regarding nomenclature. To be precise, nomenclature means "a set of system of names or terms as in a particular science, art, etc." Terminology is defined as "the special words or terms used in a science, business, art, etc." Where do you find terminology and nomenclature? Most fields have a lexicon for easy reference. A lexicon is defined as "the vocabulary belonging to a certain subject, group, or activity" per definition 2. All of these definitions come from the World Book Encyclopedia Dictionary.
She has proposed a system for determining terminology. This system appears very thorough, but is it workable? Since lexicographers have been around for ages probably a lexicographer should be consulted in any approach taken at compiling a chiropractic lexicon.
Somewhere in the chiropractic news over the past year I saw an announcement that a group of well respected chiropractors were compiling a dictionary of chiropractic terms. Perhaps the job is well underway. It is no doubt true that our profession needs to get a lexicon put together, and that this would be an ongoing affair. Doing it is simply another game to played in the chiropractic world which hasn't been done yet.
A key to developing or codifying nomenclature is to realize that a single term may have more than one understanding associated with it. Several definitions each understood can give one a more complete multi-viewpoint perspective. There are few concepts that are one dimensional.
The beauty of a compiled lexicon is it puts down for all to see in an organized, easily accessed way all the concepts of a profession. In other words, a lexicon is a warehouse of the points of agreement of a profession. To be novel in the world of dictionaries and lexicons we could even record areas of disagreement in a chiropractic lexicon. The real power of a lexicon is it puts each of us in better communication with what's going on in the profession. Currently one has to do a study on the literature or go to a seminar to find out anything. Oops, did I step on the toes of the seminarists? Well, so be it. New terminology will always go through a seminar and popularization phase before it would go into the next addition of the lexicon. For a profession which wants to be leader in 21st century health care we should do something about our intracommunication system which looks something like 18th century politics between European kingdoms. A lexicon will open the door to cooperation between warring states.
Semantics is the study of the evolution of language. a lexicon remains current by changing with time. For example, my 1989 Collier's Unabridged Dictionary of the English Language fails to mention the word "computer" in its listings. So while my old tome is still very useful, new version show change as it occurs. The point is that compiling a lexicon is not something to fear. It is something to rejoice in!
A Centennial Idea
September 18, 1995 is a very special day that we all need to recognize. In honor of the chiropractic centennial day, I hereby call on all chiropractors worldwide to provide all services on that day free of charge. This very simple act will demonstrate unity, and will show the respect and love that we all have for our profession and our patients. Please join us in this honoring of chiropractic.
Jonathan Luscomb, DC
The Rest of the PPO Story
In your column of July 3, 1995, you write of the new problems associated with managed care such as forcing doctors to underutilize. You praise a chiropractic PPO (and if I'm correctly identifying the entity you write of, it's actually a Seattle-area based, independent practice association, an IPA) for improvising, overcoming, and adapting to these trying times.
"Now," as Paul Harvey says, "the rest of the story." To become a member of this IPA, a doctor must be credentialed, i.e., board eligible, board certified, or undergoing the training at a minimum of 72 hours/year in orthopedics, sports medicine, applied chiropractic sciences, etc. (although in the first few years there was only orthopedics). The cost of this credentialing is between $4,500 and $6,000, not to mention 320 hours of prime weekend time.
The membership fee is $1,500, however, under strong pressure from contracting insurance companies to expand the network of DCs, the fee has recently been lowered to $400 and credentialing has been eliminated, much to the chagrin of credentialed doctors who paid $1,500. Two tiers of providers now exist, the uncredentialed lower tier members paying an annual membership fee, a higher percentage administration fee per service, and are subject to a higher degree of utilization scrutiny. Yes, it's true that we "elite tier" members no longer have to justify every service provided, but should our "quality credential" (their euphemism for utilization profile) exceed the 70th percentile, a warning is issued in the form of threat of being placed in the lower tier.
A reasonable person may read this and think that overutilizers should be penalized. Consider this: in 1994, I provided 9.26 services (a service includes each set of films, each exam, adjustment and re-exam) per network patient at an average cost of $288. This places me in the 81.4 percentile, and on notice! I am expected to bring this blatant overutilization under control or face a $200/year "fee," a 33 percent increase in administration fees, a minimum decrease in end-of-the-year withhold disbursement that will now be contingent upon performance (again read: utilization profile), addition to the necessity of treatment plan pre-approval. What a strong incentive to cheat the patient by providing service based on a statistical profile rather than the true needs of the patient.
In part, the chiropractic oath states: "I will at all times consider the patients under my care as of supreme importance." I refuse to compromise this oath, or my patients' welfare to remain in good standing with an organization that uses a legal form of extortion to manage patient care. Apparently they have indeed improvised, overcome, and adapted.
Rick Louis LaMarche, DC
A Provider's IPA Experience
In reading your "Report of My Findings" in the latest issue of Dynamic Chiropractic I noticed your reference to a PPO organization with some very familiar figures (see "130 members" and "750,000 covered"). I am a member of an IPA (Independent Practice Association) that boasts these same figures operating in the Seattle area.
I feel a strong urge to inform you of this provider's experience with the IPA. I would also like you to know that I'm not alone in my opinion. A recent survey of this network's providers, which over half responded, rating their overall pleasure/displeasure with the IPA. On a 1 out of 10 scale, 1 being extreme displeasure and 10 being very pleased, the average was less than 3 (2.898). Also this survey showed 75 percent disagreeing with the necessity of their administrative procedures, and utilization management, and 95 percent feeling they're not being reimbursed fairly in relationship to other PPOs they are part of. Nearly 40 percent are ready to forfeit membership currently, 41 percent will bill the insurance company out of the managed care network, and 19 percent will not accept new patients from the IPA or just treat them at no charge. Granted this is an unscientific survey (which is how the IPA responded when approached with the response figures), but certainly it shows a pattern of discontent to say the least.
This same IPA has now imposed new regulations in order to increase the percentage withheld and to bill each doctor $200 per year if we do not fall within their standards for practice utilization profile. This by the way being an average of seven visits or less per patient per year (including x-ray and exam procedures), and a $219 per patient average per year. Along with the myriad of paperwork, forms, billing procedures, and authorization to treat protocol I find it nearly impossible to practice chiropractic the way I feel is responsible to insure the patient gets well.
The U.M. manager and co-owner of this organization has stated to me personally, point blank that they will only pay for symptom care and not one visit more, yet when anything is billed that does not accompany an objective finding to justify it, then it's denied. Double standards? I think so. On several occasions patients have gotten better, informed of their coverage for symptomatic relief only, quit care only to flare up two weeks later. They then either start corrective care again or quit chiropractic altogether and probably think it a short term, pain relief manipulation therapy that has nothing to do with health or prevention unless convinced otherwise. I even had patients quit and refuse to pay deductible or co-pays because they thought they had chiropractic coverage would help solve their problem. Considering this, the contracts being made with the insurance companies are not what the patients needs for health or the doctor needs to practice responsibly. This brings up the question, would these insurance companies be offering a more open ended comprehensive plan had not the IPA stepped in and offered their watered down version of cut rate pain relief care? And what kinds of standards is this setting for other payers? Who's responsible if the doctor bends under the scrutiny and fails to practice responsibly and the patient doesn't get better or a serious problem goes undetected (i.e., not x-raying area of pain due to lack of objective findings and knowing the IPA won't pay for them)?
Many DCs who got on board in the beginning thinking this was the answer to practicing in the '90s, now have sour grapes. Thousands of dollars spent on credentialing requirements and the $1,500 initial fee to join is not being recouped by most members. Because of the high withhold (30 percent) of the already discounted fee and the capitation of care, much of the charges are written off. An example of an actual case: $476 in billed charges for nine visits including exam and x-rays. Doctor gets $150 deductible paid by patient, $10 co-pays ($90) and $47.60 from IPA, IPA keeps $127.40. The chiropractor ends up writing off $188.40 and has an upset patient who's still in pain but has been denied visits covered because his symptoms diminished for a period. This plan agreed to allow 12 visits per year (including visits billed under deductible) at $20 a visit. This $20 was all inclusive no matter the procedure on that visit, such as $179 first visit fees. Who needs these kind of contracts? Are they attracting patients? Maybe a few but certainly no provider is flooded with them. I saw 40 new patients within this network last year. Many who were personal referrals anyway and would have paid cash had they not been on the plan. Granted we get a portion of the withhold back at the end of the year but only a small percentage, especially if you're not within their unrealistically tight utilization figures.
The ultimate insult, however, was when the IPA decided they needed to expand to include more doctors. The IPA board decided to drop the recredential requirements from 72 hours per year (up to board eligible, 36 hours after that) to the state-required 25 hours and the initial fee from $1,500 to $400. This along with the new administration regulations and the $200 a year and the select status program that will punish doctors even further with higher withholds who practice their conscience has pushed many of us over the edge.
As you can see, the IPAs, MCOs, PPOs and other groups can certainly paint a pretty picture, but the rank and file practitioner many times is very discouraged thinking there must be a better way to practice than within these networks.
W. Lance Eblen, DC