Texas Journal of Chiropractic January/February 2013 Volume XXVIII, Issue 1 $10.00
In This Issue: TCA Appoints New CEO The ACA Files Class Action Lawsuit PQRS ACA To Celebrate 50 Years. Americans Live Sicker, Die Younger Insurers Request Steep Rate Hikes Oregon LBP Guidelines: Try Chiropractic First Algorithms for the Chiropractic Management of Acute and Chronic Spine-Related Pain Global Study on Disease and Disability
It is error alone which needs the support of government. Truth can stand by itself. --Thomas Jefferson
Chiropractic as First Option for Back Pain Relief, Surgery Avoidance Here We Go Again: HMO-Like Insurance Poised for a Comeback Only “We” Should Use “Doctor”
LOOK! 2013 MIDWINTER CONFERENCE IS IN LUBBOCK!
The Texas Chiropractic Association represents chiropractic professionals throughout the state. TCA serves to protect chiropractic professionals, their patients, and the right for Texans to choose chiropractic as one of their health care options. First formed in 1916, this historic association has existed for nearly 100 years representing the interests of Texans who desire safe and effective health care from chiropractic professionals. ABOUT OUR COVER “Good thing we've still got politics in Texas -- finest form of free entertainment ever invented. Better than the zoo. Better than the circus.� In honor of the 83rd Texas LegislatureThroughout this issue you will find various quotes pertaining to government and the importance of your involvement in it.
POLICIES Annual subscription to the Texas Journal of Chiropractic is included in TCA membership dues. The digital Texas Journal of Chiropractic is regularly published six times per year by the Texas Chiropractic Association under the supervision of the TCA Communications Committee. Opinions expressed are those of the contributors and do not necessarily reflect the policy of the Texas Chiropractic Association or the Texas Journal of Chiropractic. Publication of an advertisement does not imply approval or endorsement by the Texas Chiropractic Association. The association shall have the absolute right at any time to reject any advertising for any reason. For advertising rates contact the TCA Office, or check online at www.chirotexas.org. All advertising material must be in graphics ready format and submitted as a .jpg, .jpeg, .gif, .swf, or .png file type.
Texas Journal of Chiropractic Volume XXVIII, Issue 1
Inside
Texas Journal of Chiropractic The Official Publication of The Texas Chiropractic Association
1122 Colorado, Suite 307 Austin, TX 78701 Phone: 512 477 9292 Fax: 512 477 9296 E-mail: info@chirotexas.org www.chirotexas.org Executive Officers President: Jorge Garcia D.C. President Elect: Jack Albracht D.C. Secretary: James Welch D.C.
TCA Staff Membership Development: Amy Archer Editor: Chris Dalrymple D.C.
Board of Directors District 1! District 2! District 3! District 4! District 5! District 6! District 7! District 8! District 9! District 10! District 11! District 12!
Paul Munoz D.C. Nancy Hinders D.C. Jason Clemmons D.C. Mike McGarrah D.C. Dr. John Quinlan D.C. Cody Chandler D.C. Lorin Wolf D.C. Michael Henry D.C. Mark Roberts D.C. Shane Parker D.C. Max Vige D.C. Thomas Hollingsworth D.C.
January/February 2013
TCA Appoints New CEO: John Darby !
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The ACA Files Class Action Lawsuit!
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PQRS, Are You Adding the Correct Codes?!
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PQRS Slow to Catch On! !
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ACA To Celebrate 50 Years.!
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Americans Live Sicker, Die Younger!
Health Insurers Still Requesting Steep Rate Hikes!
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Heart Association Joins NSAID Risk Message! !
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Oregon LBP Guidelines: Try Chiropractic First! !
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TBCE Considers Requiring Documentation Comply with CMS Guidelines! ! ! ! ! ! 13 Algorithms for the Chiropractic Management of Acute and Chronic Spine-Related Pain! ! ! ! 24 Global Study on Disease and Disability ! !
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Chiropractic as First Option for Back Pain Relief, Surgery Avoidance! ! ! ! ! ! ! 27 HMO-Like Insurance Poised for a Comeback! !
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Only “We” Should Use “Doctor”! !
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Policies
Helping Chiropractors Help People
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Annual subscription to the Texas Journal of Chiropractic is included in TCA membership dues. Contact the TCA for subscription rates for non members. T h e p r i n t Te x a s J o u r n a l o f Chiropractic is published up to six times per year by the Texas Chiropractic Association under the supervision of the TCA Publication Committee. Opinions expressed are those of the contributors and do not necessarily r e fl e c t t h e p o l i c y o f t h e Te x a s
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Chiropractic Association or the Texas Journal of Chiropractic. Publication of an advertisement does not imply approval or endorsement by the Texas Chiropractic Association. The association shall have the absolute right at any time to reject any advertising for any reason. For advertising rates contact the TCA Office. All advertising material must be in graphics ready format and submitted as a .jpg, .jpeg, .gif, .swf, or .png file type. Copyright 2012 All Rights Reserved: Texas Chiropractic Association
Mid Winter Conference
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earned his Six Sigma Green Belt in Health Care from Villanova University.
TCA Appoints New CEO: John Darby
“The Texas Chiropractic Association is delighted to have a dynamic CEO who will help us to achieve our highest expectations,” stated Dr. Garcia, and “I look forward to helping Chiropractors help People,” added Mr. Darby.
“The Board of Directors of the Texas Chiropractic Association is pleased to announce the appointment of a new Chief Executive Officer,” reports Jorge Garcia D.C., President of the Texas Chiropractic Association. “The new CEO of the Texas Chiropractic Association is John Darby, IOM.
The American Chiropractic Association Files Class Action Lawsuit
This appointment comes after an intensive eighteen month search conducted by a boardappointed search committee,” Dr. Garcia announced.
The American Chiropractic Association has filed a class action lawsuit against American Specialty Health Inc. and American Specialty Health Networks Inc. (collectively, “ASHN”), and CIGNA Corporation and Connecticut General Life Insurance Company (collectively, “CIGNA”).
“The Executive Director search committee and the TCA Board of Directors felt that Mr. Darby was the best choice to assist the chiropractic profession on our selected path into the future,” said Dr. Garcia. “We considered Mr. Darby’s experience as a certified association executive and his extensive experience in business, nonprofit management, and government.”
The litigation alleges a litany of problems with the defendants, including arbitrary reductions of care, lack of communication to providers and patients resulting in coverage and payment errors, and interference with doctors’ duty to exercise professional clinical judgment in managing patients’ treatment plans.
Mr. Darby assumed his office at the TCA on January 7, 2013, just in time for the start of the Texas Legislative Session. He brings extensive training, experience and dynamic thinking to the Texas Chiropractic Association. Graduating from the University of Washington with a BA, he has attained certification as a Certified Association Executive. “I am excited about moving to Texas and undertaking the work of making chiropractic in Texas second to no other health care industry,” said Darby.
Filed on December 28, 2012, ACA’s litigation– which is being handled by the law firm Pomerantz Grossman Hufford Dahlstrom & Gross LLP–represents a nationwide class of health care providers and subscribers who were subjected to ASHN and CIGNA’s improper coverage and reimbursement practices. Furthermore, CIGNA allegedly failed to comply with terms and conditions of its plan to afford its subscribers or their health care providers an opportunity to obtain a “full and fair review” of denied or reduced reimbursement, and to make appropriate and non-misleading disclosures to subscribers or their health care providers–an alleged violation of the Employee Retirement Income Security Act of 1974 (ERISA), the
Over his career Mr. Darby has served as a Research Analyst in the Washington State legislature, the Executive Vice President of the Thurston County Chamber in Olympia, Washington, as well as serving eleven years in elected positions in local government. He www.chirotexas.org
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federal law governing private employee benefit plans.
as other state and federal laws and regulations.
The litigation outlines various allegations, including: •
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“ACA was compelled to take this action against ASHN and CIGNA because their egregious practices are undermining patient care and Use of false and misleading Explanations doctor-patient relationships. Chiropractic of Benefits relating to chiropractic claims Doctors feel they have to choose between (required under ERISA for informing acting in the best interest of the patient, and subscribers of how their claims have adhering to the requirements imposed by ASHN been processed), which interferes with and payers they work with,” said ACA President the doctor-patient relationship Keith Overland, DC. “Since 2002 we have worked to try and improve these issues. It is Manipulating charge and payment data, now time for action and we will not rest until allowing ASHN and patients across the nation CIGNA to pass on receive all the care they need In a healthy nation there excessive costs to and have paid for through their subscribers, while insurance premiums.” is a kind of dramatic distorting the amounts balance between the providers actually Providers who believe they will of the people and r e c e i v e i n b e n e fi t and/or their patients have been the government, which payments affected by ASHN and/or prevents its CIGNA’s improper practices ASHN’s restrictions of can visit the Chiropractic degeneration into care via the preNetworks Action Center where tyranny. authorization process they will find instructions and --Albert Einstein and provider contract forms that can be used to provisions that prevent submit a complaint to ACA. patients from having access to the full breadth of their benefits and in contradiction to their certificates of coverage–a violation of ERISA
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ASHN and CIGNA’s imposition of excessive co-pay requirements on subscribers, another ERISA violation
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CIGNA’s improper prevention of doctors of chiropractic from providing services that fall within their scope of practice, in violation of state provider nondiscrimination laws
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ASHN and CIGNA’s violation of various state prompt payment laws
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ACA’s suit requests the court to award injunctive, declaratory and other equitable relief to ensure ASHN and CIGNA’s compliance with ERISA as well
Texas Journal of Chiropractic
PQRS, Are You Adding the Correct Codes? In 2006 the Congress of the United States passed a law that included the establishment of the Physician Quality Reporting System (PQRS). In 2015 PQRS will become a mandatory program. You need to be aware that YOUR PERFORMANCE WITH PQRS IN 2013 WILL AFFECT YOUR RATE OF MEDICARE REIMBURSEMENT IN 2015. In 2015 benefits will be reduced by 1.5% based upon 2013 reporting success. In 2016 the penalty will become 2% based upon 2014 reporting and will increase each year thereafter 4
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by some measure. THIS MEANS THAT YOU NEED TO SUCCESSFULLY CODE PQRS CODES ON YOUR MEDICARE PATIENTS IN 2013 IN ORDER TO AVOID AN ADDITIONAL 1.5% REDUCTION IN YOUR MEDICARE PAYMENTS IN 2015.
or did not have to do a pain assessment measure for that CMT visit. •
Fortunately there is no special registration, notification, or other action required to make use of the PQRS system, one merely starts correctly reporting PQRS required codes as soon as possible. It’s that easy. To “report satisfactorily” means that for every patient greater than or equal to 18 years of age report BOTH pain assessment and functional outcome assessment codes for every eligible visit (that is, every time you bill for a CMT) must be reported. Thus more than half of your Medicare visits where CMT is coded you need both a pain assessment “G-code” code and a functional Outcome assessment “Gcode.”
Pain Assessment and Follow up Category For this category the patient must be at least 18 years of age (a pretty safe bet for a Medicare patient, but there are exceptions, so be aware that a patient under 18 years of age is an exclusion to coding requirements). The pain assessment instrument must be a recognized standardized tool. Tools such as the visual analog scale, or the numerical analog scale qualify, though there are others as well. The assessment tool must document pain in terms of location, quality, intensity; and include a follow-up plan which must include a reassessment of the pain later.
Report the PQRS codes on as many Medicare patients as you can, ensuring that they are: •
Reported on the SAME claim as the spinal CMT code, with
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The SAME dates of service as the spinal CMT code, and
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Using the same National Provider Identifier (NPI) for the provider providing the CMT.
There are six possible “G codes” for use for pain assessment performance measurement: “Performance codes” include: G8730–for when a pain assessment instrument indicates positive findings and a follow up plan has been established (e.g. “numerical pain scale is 4 of 10 and will be evaluated at the next visit”). G8731–for when a pain assessment instrument has been performed but indicates no positive findings and a follow up assessment is not required (e.g. “numerical pain scale is 0 of 10”). “Exclusion codes” include:
The PQRS system is associated only with covered services. For chiropractors this is only spinal CMT manipulation codes–every time a CMT code is billed the PQRS codes are to also be reported. These PQRS codes, for chiropractors under Medicare, are a total of twelve numerical codes preceded by the letter “G.” •
G8442–No pain assessment is required (the patient is not eligible for a pain assessment e.g. the patient is less than 18 years old)
For the Pain Assessment category there are two “performance codes,” two “nonperformance codes” and two “exclusion codes” to report if you did, or did not do,
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For the Functional Outcomes Assessments category there are three “performance codes,” two “nonperformance codes,” and one “exclusion code.”
G8939–A pain assessment is performed, but there is no follow-up planned because the patient is not eligible (e.g. 5
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the patient will hospitalized and further assessments are not possible.)
assessment must be no more than 30 days old. There are six possible “G codes” for use with functional outcome assessment and treatment plan:
Reasons for exclusion may include Medical reasons such as mental or physical incapability to complete the assessment; that the patient refused the assessment; “insurance coverage or payer-related limitations”, or that resources to perform the assessment were not available.
The basis of our government is opinion of the people. --Thomas Jefferson
“Non-performance codes” include: G8732–No Pain Assessment was performed for no particular reason and no exclusion applies. G8509–There is a positive Pain Assessment but no follow up plan was made. Functional Outcome Assessment Category For this category a patient must be over 18 years of age and the assessment must be a normalized and validated tool. For spinal CMT there are some 12 to 20 possible assessment i n s t r u m e n t s a v a i l a b l e . Instruments such as the Oswestry or Roland Morris, or Headache Assessment questionnaires are included in t h i s c a t e g o r y . Each assessment must also have an associated treatment plan based upon the deficiencies revealed by the instrument. A common example might be “to return the patient to being able to walk without difficulty within 2 weeks.” Finally, a functional Texas Journal of Chiropractic
Call for Keeler Award Nominations Established in 1934 by Dr. Clyde Keeler, The Texas Chiropractic Association’s award designating the Chiropractor of the year, The Keeler Plaque, is Texas Chiropractic’s most prestigious award. Nominations for the Keeler Plaque should be sent to: Dr. Curtis McCubbin Secretary, Keeler Plaque Committee P. O. Box 272 Hunt, Tx 78024 All nominations will be held in strict confidence to assure that the recipient will be surprised when their name is announced. A candidate shall be: A member in good standing in the TCA Of good moral character A promoter of chiropractic advancement in at least one of the three years immediately proceeding the year in which the award is to be presented. Such advancement may be in research, public relations, school participation, promotion or support. The candidate’s main endeavor must be in the practice of chiropractic and must have promoted chiropractic throughout their career. Civic, church or community involvement, individually or within organizations or groups, and holding offices in local, state or national chiropractic organizations, chiropractic boards, and chiropractic college boards may also be considered.
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“Performance codes” include:
“And now for the future forecast.” The traditional fee for service system encourages the utilization of more services that results in more fees but has nothing to do with quality of care. This is evidenced by the high cost, but low quality of the outcomes of health care in the US medical system.
G8539–A Functional Outcome Assessment has been performed and there are positive findings and a treatment plan based upon those findings has been established (e.g. “Oswestry demonstrates a rating of X and will be performed again in 2 weeks”).
As a result the government and insurance industry are transitioning to a “quality measures based system” for the future. The PQRS is among the first steps in this transition. All of healthcare is expected to become more “outcomes based” and today’s “quality measures” will become “tomorrow’s medical necessity indicators.”
G8542–A Functional Outcome Assessment has been performed, but there is a negative result and no treatment plan is required (e.g. “Roland Morris demonstrates no incapacity”). G8942–There is a current Functional Outcome Assessment on hand that is less than 30 days old. (e.g. The last assessment is less than a month old and another assessment is scheduled for a later date).
Plans are already in the works for a website that will show to the world PQRS participation and eventually physician performance will be reported on the internet. A “value based modifier” will apply to all physicians by 2017 based on 2015/16 performances. It is expected that in the future PQRS will expand beyond Medicare and will eventually include third party payers.’’
The “Exclusionary code” is: G8540–There is no Functional Outcome Assessment, the patient is not eligible (e.g. The patient is younger than 18 years old, or is so mentally confused as to make any assessment invalid).
Our thanks to Susan McClellan and all of the work that she has done to bring this important development to the awareness of our profession.
“Non-performance codes” include: G8541–No Functional Outcome Assessment has been perform on an eligible patient, and there is not a current one on file.
PQRS Slow to Catch On Despite the requirements of the PQRS system, fewer than one in five medical physicians have m e t M e d i c a r e ’s n e w q u a l i t y r e p o r t i n g
G 8 5 4 3 – A F u n c t i o n a l Outcome Assessment has been performed, but no treatment plan has been established.
By definition, a government has no conscience. Sometimes it has a policy, but nothing more.
For every visit where CMT is performed on a Medicare patient, chiropractic doctors should be choosing one Pain Assessment Code and one Functional Outcomes Assessment PQRS code from the list above to add to the insurance claim. Stated again, for every treatment visit where a CMT code is used, two additional “G codes” should be added. www.chirotexas.org
--Albert Camus 7
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requirements and would be exempted from financial penalties starting in 2015.
ACA To Celebrate 50 Years.
A review of Medicare data showed; 23.7% of radiologists and 16.3% of nonradiology specialties met the reporting requirements under the Medicare Physician Quality Reporting System (PQRS) in 2010. If that situation remaines unchanged, 76.3% of radiologists and 83.7% of nonradiologists would be susceptible to penalties in 2015. In 2015, those bonuses for well-performing doctors will be replaced by a 1.5% penalty for those who don’t meet the standards, and it jumps to 2% in 2016.
The American Chiropractic Association (ACA) marks its 50th anniversary in 2013, an occasion that the association will use to honor the hard work of its dedicated volunteers and the support of its many valued members. ACA plans a gala event on March 7, in conjunction with the National Chiropractic Legislative Conference (NCLC) in Washington, D.C.
The PQRS is run by the Centers for Medicare and Medicaid Services and is an indicator that healthcare is moving away from fee-forservice payment models to more outcome-driven arrangements. The PQRS system will result in substantial cuts in Medicare reimbursements. For example, if more radiologists don’t meet the reporting requirements, the specialty as a whole will face estimated fines up to $111 million. The average penalty would be at least $2,600 by 2016, the second year Medicare will penalize for not meeting the reporting standards.
Click to
“ACA’s golden anniversary offers the profession as a whole the chance to reflect on the many achievements of the past 50 years and how they have moved the profession forward, expanding awareness and access to chiropractic, improving insurance reimbursement, and defending and protecting DCs against discriminatory treatment in many settings,” notes ACA President Keith Overland, DC. “Our forefathers were correct that the profession needed a strong national voice to act as its advocate in Washington and other federal arenas. ACA has been that voice for chiropractic.” contribute
In addition, the January/ February issue of ACA Good government is no News, the association’s substitute for selfflagship member magazine, government features a cover story that Some practices have already chronicles the birth of ACA in become frustrated trying to --Mahatma Ghandi 1963 with an agreement comply with PQRS between members of the requirements. Some former National Chiropractic radiologists have reported that their perceived Association and several members of the incremental efforts far outweigh program International Chiropractors Association, who rewards. believed the profession needed one strong national voice in order to succeed.
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The establishment of today’s ACA was one of the most important unifying events in the history of the chiropractic profession and would lead to the formation of several other research- and education-related organizations that together created a solid foundation for advancement.For more information about the 50th Anniversary Gala Event and NCLC, visit www.acatoday.org/ NCLC.
primary care providers than its peer countries and greater problems coordinating care, the study found. For the report, the blue-ribbon panel compared health outcomes in the U.S. to 16 comparable high-income or peer countries. It found a consistent pattern of higher mortality and poorer health in the U.S. for every 5-year age group starting from birth. Researchers were surprised by the disparities and couldn’t pinpoint a cause to a specific disease. Poor health results also could not be blamed on a single racial, ethnic, or socioeconomic group. The disparity found between the U.S. and 16 comparable countries showed itself in all ages, from birth to 75. And while the U.S.’s mortality rate has been lagging for some time, the report found poor comparable health status cuts across income, education levels, and health insurance status.
Dr. Fabrizio Mancini to Host New Chiropractic Radio Show Former Parker University President Fabrizio Mancini, DC, will host a weekly radio show that sheds light on the power of chiropractic care. The weekly program will feature Dr. Mancini and various guest health care professionals who will discuss health, wellness, prevention tips and much more. Click here to watch Dr. Mancini’s special announcement, and to find out how you can listen to the new show.
Americans Live Sicker, Die Younger A recently completed study demonstrates that despite spending more on healthcare, Americans die sooner and experience more illness than people in other high-income countries. Lung disease was more prevalent and associated with higher mortality in the U.S. compared with other countries, and American children were less likely to live to age 5.
Since the 1990s, U.S. adolescents have had the highest rate of pregnancies and have been more likely to acquire sexually transmitted infections; The U.S. has the highest prevalence of HIV infection for ages 15-49; Americans have lost more years of life to alcohol and other drugs than people in peer countries; For
Call for Nominations for Young Chiropractor of the Year Established over half a century ago, this award is for the purpose of recognizing doctors who have shown outstanding dedication and who have made longlasting contributions to the profession and their community, and who are under 40 years of age at the time of the award’s receipt. Send nominations to 2010 recipient: Dr. Tyce Hergert, D.C. 1500 W. Southlake Blvd #120 Southlake TX 76092
There are many possible causes for this outcome, one leading factor is that the U.S. has a smaller number of www.chirotexas.org
or via email at www.chirocaresouthlake.com
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decades, the U.S. has had the highest obesity Antihypertensives and NSAIDs are often corate among high-income countries; From age prescribed, although little is known about the 20 onward, U.S. adults have among the highest potential risks when they are used together. prevalence of diabetes among peer countries; Americans reached age Clinicians must advise 50 with a less favorable patients who are cardiovascular risk profile If people let government decide prescribed diuretics, ACE than their peers in inhibitors, or angiotensin what foods they eat and what Europe. receptor blockers of the medicines they take, their bodies risks associated with Americans who do reach will soon be in as sorry a state as NSAID use and they must age 50 generally arrive at are the souls of those who live also be vigilant for signs this age in poorer health of drug-associated acute under tyranny. than their counterparts in kidney injury in all --Thomas Jefferson other high-income patients. countries, and as older adults they face greater morbidity and mortality from chronic diseases that arise from risk factors that are often Health Insurers Still established earlier in life.
Requesting Steep Rate Hikes
Americans also rely on cars for transportation more and eat food generally prepared in a less healthy way. And the U.S. has a smaller number of primary care providers than its peer countries and greater problems coordinating care, the study found. “This study would suggest we need to think about the way we spend our money,” the nation’s recent immigrants are generally in better health than native-born Americans, the study found.
Although one goal of the Affordable Care Act (ACA) was to rein in the high cost of health insurance, dozens of health plans continued to implement double-digit rate hikes. For instance, in California, premiums on separate UnitedHealth plans rose 12.3% and 14.3%, according to the state’s Department of Insurance. An Aetna plan covering more than 76,000 people jumped 20.4% and another covering 21,000 people shot up nearly 19%. Celtic Insurance Company in Ohio requested a 39% increase for some of its plans in the state, according to the Department of Health and Human Services (HHS).
NSAID, BP Med Combo Tied to Kidney Risk
So far, 44 states have programs to review rate increases in their states. For states that don’t have such programs, HHS reviews the proposals. Insurance companies seeking to increase premiums by 10% or more in the individual or small-group markets are required to submit justification for their rate increases to either the affected states or to HHS for review. “By requiring insurance companies to further document, submit for review, and publicly justify rate increases above a certain level, consumers are able to better understand their premiums
Researchers have found that adding a nonsteroidal anti-inflammatory drug (NSAID) to an antihypertensive regimen that includes a diuretic and either an ACE inhibitor or an angiotensin receptor blocker may increase the risk of acute kidney injury. Those who were taking an NSAID had a 31% greater risk of acute kidney injury. The risk was highest within the first 30 days of using the antihypertensive-NSAID combination. Texas Journal of Chiropractic
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and shop for health insurance,” HHS said in its annual rate view report.
to treat the patient’s pain over the shortest period of time.”
Of the proposals reviewed by HHS or the states for more than a 10% rate hike, 26% were deemed unreasonable or were rejected. H o w e v e r, 3 6 % w e r e c o n s i d e r e d n o t unreasonable and had no forced reduction in the rate increase.
“Many patients don’t realize there is the potential for adverse events associated with NSAIDs,” “In particular, people can get into trouble when they unknowingly combine NSAIDs, such as an over-the-counter flu medication, on top of a known NSAID.
Heart Association Adds Its Weight to NSAID Risk Message
Oregon LBP Guidelines: Try Chiropractic First The new State of Oregon Evidence-Based Clinical Guidelines for the Evaluation and Management of Low Back Pain recommend spinal manipulation as the only nonpharmacological treatment for acute lower back pain.
The American Heart Association (AHA) has joined the newly formed Alliance for the Rational Use of NSAIDs, a public health coalition that aims to bring more awareness to the health risks associated with nonsteroidal anti-inflammatory drugs (NSAIDs).
The guidelines, which have been adopted by the Oregon Health Authority, are a collaborative effort between the Center for Evidence-Based Practice, Oregon Corporation for Health Care Q u a l i t y, O r e g o n H e a l t h a n d S c i e n c e s University’s Center for Evidence-based Policy, and the new Oregon Health Evidence Review Commission.
About 98 million NSAID prescriptions were filled in 2012 and about 23 million people in the U.S. use over-the-counter NSAIDs on a daily basis. But these drugs are not benign; they can harm the kidneys, gastrointestinal tract, and cardiovascular system. For example, patients with a first heart attack who took NSAIDs had a 41% increased risk of a second heart attack that persisted out to 5 years, compared with similar patients who did not take NSAIDs.
The Oregon Chiropractic Association (OCA) repeatedly gave written and oral testimony that the original draft guidelines placed too much emphasis on drugs and surgery. The OCA responded with scientific clinical journal articles validating the efficacy of chiropractic spinal manipulation for lumbar radiculopathy and stenosis, with an emphasis on Dr. James Cox’s flexion-distraction technique research.
All NSAIDs carried a cardiovascular risk, but some were less harmful than others. In particular, naproxen had the lowest risk for myocardial infarction, while Rofecoxib (Vioxx) topped the list. Rofecoxib was taken off the market in 2004.
Next, the OCA gave input relative to the original draft that emphasized pharmacological over non-pharmacological interventions, not the least of which was spinal manipulation as demonstrated here in its original form.
In 2007, the AHA published an update for clinicians on the use of NSAIDs. The key message of the scientific statement was for clinicians to use an NSAID that is “associated with the least risk — from a cardiovascular perspective — in the lowest dose that is needed www.chirotexas.org
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We vehemently opposed the emphasis on drug therapy, citing the considerable downside to all the pharmacology currently in health care. A close look at this original draft chart’s far left column reveals that after the listed “Self-care,” the chart originally listed “Pharmacologic therapy” ahead of “Nonpharmacologic therapy.” Following our input, the chart was significantly changed, placing nonpharmacologic therapy ahead of pharmacologic therapy, with an additional note of the greater risk for NSAIDs, benzodiazepines, and opioids.
hospitalizations at an estimated $2 billion in additional health care costs and 17,000 deaths yearly in the U.S. – NSAID use is also associated with cardiovascular mortality, particularly in the elderly. These associations exist for both COX-2 inhibitors such as Celebrex and non-selective NSAIDs such as ibuprofen and naproxen.
We noted that Oregon’s narcotic statistics reveal that between 1997-2007, hydrocodone sales increased by 280 percent, oxycodone by 866 percent and methodone by 1,293 percent, and For in reason all government resulted in 700 poisoning deaths from 2003-2007, without the consent of the with the increasing governed is the very availability of opioids closely definition of slavery. paralleling increased --Jonathan Swift m o r t a l i t y f r o m o p i o i d overdoses.
We made our suggestions in consideration of the risk versus benefit favoring spinal manipulation over the use of pharmacologic therapy including “first-line medications,” e.g., acetaminophen or nonsteroidal anti-inflammatory drugs. We referred to the landmark Agency for Health Care Policy and Research (AHCPR) acute low back pain guidelines (1994), which have not been refuted by any subsequent research or guidelines; and which state that spinal manipulation both relieves pain and restores function, while pain medications (NSAIDs and analgesics) relieve pain but do not restore function.
Fifty-three percent of drug overdoses in Oregon are associated with prescription opioids, an overall increase of 540 percent since 1999 and a 1,500 percent increase in deaths from methodone alone. Prescription drug overdoses account for the most drug-related deaths in Oregon and the opioid methodone is the leading cause of those deaths. We explained that in regards to increased costs to Oregon’s health care system, the number of treatment admissions for opioid use increased 130 percent between 1999-2005. As a consequence, the OCA stood strong stating that for the State of Oregon to recommend the use of dangerous narcotics ahead of proven spinal manipulation conflicts with the stated goals of the Oregon Health Policy Board to “lead Oregon to a more affordable, world-class health care system.” To “set standards for safe and effective care” was nonsense.
We also pointed out that the risk-to-benefit ratio favored less invasive spinal manipulation over drug therapy, including the recommended firstline medications acetaminophen and NSAIDs, and most certainly over narcotic medications. We did so using the following sobering facts: Acetaminophen (e.g., Tylenol) is the leading cause of acute liver failure in the United States, resulting in approximately 140,000 poisoning cases, 56,000 ER visits and approximately 100 d e a t h s e a c h y e a r. O r e g o n i a n s w e r e unknowingly taking more than one product that contained acetaminophen, increasing the likelihood of unintentional overdoses and poisoning. Non-steroidal anti-inflammatory drugs (NSAIDs) are the second leading cause of peptic ulcers, resulting in more than 100,000 Texas Journal of Chiropractic
The OCA stood strong for our profession and our patients, demanding that based on the scientific evidence, safer spinal manipulation must be placed in a first-tier status ahead of any recommendations for narcotics. 12
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We are a nation of “pill poppers” and are quickly approaching the 4 billion annual prescription purchase mark, which will result in an estimated annual cost of $500 billion by 2015 when Oregon’s universal health care system comes fully online. We explained that this represents only the direct drug costs and does not include the indirect cost of treating consumers who suffer the estimated 2.2 million adverse drug side effects, resulting in over 700,000 ER visits and 1 million hospitalizations each year; nor does it include the economic costs of lost work capacity or lost work days due to these adverse drug events.
our philosophy and by so doing changed a significant piece of health care reform here in Oregon.
TBCE Considers Potential Rule to Require Documentation to Comply with CMS Guidelines The Texas Board of Chiropractic Examiners has posted on Facebook: “The Board needs your input! What do you think the minimal requirements for documentation should be for chiropractors? “
We pointed out that recently the Centers for Disease Control and Prevention (CDC) reported that nine out of 10 poisonings are related to the abuse of prescription drugs, 40 percent being related to pain medications alone. We concluded with the reality that chiropractic physicians have a proven track record of providing overall health promotion and wellness while also treating an individual’s particular health care needs – without all the harmful synthetic pharmacology. There are so many evidence-based natural remedies that work and so many drugs that don’t; it’s time to make a change here in Oregon and the Oregon Chiropractic Association made a difference. I am proud of our state association, which stayed resoundingly true to
“The Board is collecting stakeholder input for a possible amendment to Board Rule 80.5 to state all chiropractic patient records must conform with the Centers for Medicare and Medicaid Services (CMS) Documentation Guidelines for Evaluation and Management Services.” “Let us know your thoughts on Facebook or Twitter or via email to tbce@tbce.state.tx.us.”
The business of government is to keep the government out of business -- that is, unless business needs government aid. --Will Rogers
Sherman College Names New President Edwin Cordero, DC, has been named the fifth president of Sherman College of Chiropractic, effective Jan. 1, 2013. He succeeds Dr. Jon Schwartzbauer, who announced in May 2012 that he would be stepping down from the position.
The government is us; WE are the government--you and I. --Theodore Roosevelt
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“My vision as president is to lead Sherman College in becoming the preeminent chiropractic school in the U.S. and the world, 13
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and to strengthen its cultural legacy of outstanding academics, chiropractic philosophy, excellent faculty, technique and research,” said Dr. Cordero upon being named to lead the college.
Of 164 studies included in the review, 54 (32.9%) had positive results that were not based on the primary endpoint, which was not statistically different. Spin (considered a form of bias) involves use of reporting strategies that emphasize the benefits of an experimental treatment, even when the primary outcome is nonsignificant. Spin might also be used to distract readers from nonsignificant results, the authors continued. Authors of the reports “used spin in an attempt to conceal bias,” The frequency of biased reporting increased to 59% when the analysis was limited to 92 studies that produced nonsignificant differences in primary endpoints.
A 1993 graduate of Life University’s College of Chiropractic, Dr. Cordero practices in Boynton Beach, Fla. He was the Florida Chiropractic Society’s Chiropractor of the Year in 2011. In choosing Dr. Cordero, the Sherman board of trustees reviewed 20 applications, ultimately narrowing the field to three applicants in October before making their final selection.
“Bias in the reporting of efficacy and toxicity remains prevalent,” Clinicians, reviewers, journal editors, and regulators should apply a critical eye to trial reports and be wary of the possibility of biased reporting.
It is not the function of our government to keep the citizen from falling into error; it is the function of the citizen to keep the government from falling into error.
Study Shows ID Errors in Prostate Biopsies As many as 3.5% of prostate biopsy specimens were contaminated or inadvertently switched with that of another patient, according to a review of 13,000 samples from 54 laboratories. The overall error rate was less than 1%, but rates among different types of labs ranged as high as 3.51%. No laboratory included in the study had an error-free performance record.
Study Reports Reflect Researchers’ Bias A third of randomized clinical trials (RCTs) in breast cancer had published results that showed bias in the reporting of endpoints, and two-thirds showed bias in reporting toxicity, authors of a literature review concluded. Because RCTs represent the gold standard for evaluation of a new therapy’s efficacy and toxicity, appropriate trial design and objective reporting of results are essential. Bias in reporting can create false impressions about a therapy’s safety and efficacy, and clinical decisions may be influenced by the reports.
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“The fact remains that … a diagnosis was assigned to the wrong patient with no knowledge or even suspicion of the error that had occurred.”
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days, and harm to the provider and hospital reputation.”
FDA Lowers Ambien Dosages–Driving Can Be Impaired the Morning After Makers of sleep drugs containing zolpidem, including Ambien and Ambien CR, must cut the recommended dosages for women by half — to 5 mg for immediate-release products and 6.25 mg for extended-release formulations — to reduce morning drowsiness, the FDA has announced.
Women’s College to Focus on Wellness Spelman College in Atlanta, the oldest college for black women in the U.S., is embarking on an initiative to improve the lifelong well-being of its students, sacrificing its participation in intercollegiate athletics for a program that emphasizes wellness for its entire student body.
Next-morning impairment is a common side effect of all insomnia drugs, and alertness can be impaired even when people The Will of the people is the don’t feel sleepy. New data The college has belonged to only legitimate foundation suggest that the drugs can a traditional NCAA division 3 of any government leave levels high enough the athletics program, but about morning after use to impair --Thomas Jefferson a year ago their conference activities such as driving. decided to disband, which led The issue is especially acute to a rethinking of the role of in women. physical activity in an institution of higher learning for African-American women. The FDA is continuing to evaluate other sleep medications, The college’s president, Beverly Daniel Tatum, PhD states: “In our mission statement, we say that we are educating the whole person — mind, body, and spirit. As a distinguished liberal arts college we certainly put a lot of emphasis on developing the habits of the mind, in terms of Billions Paid Out for Surgical critical thinking, and there are plenty of Errors opportunities to develop the spiritual life. In the past, however, we had less emphasis on Surgical “never events” — such as leaving a encouraging beneficial habits for the body,” sponge in a patient — cost healthcare professionals a minimum of $1.3 billion in “Many of our students already are overweight or malpractice payouts from 1990 to 2010, obese and are enrolling with diabetes or high researchers found. blood pressure,” Tatum said. “This initiative is intended to help our students educate In an analysis of such surgical mishaps, a mean themselves about how to maintain their health of $133,055 per event was paid out for 9,744 both at school and beyond, and to become “never events” that resulted in permanent injury ambassadors for change in their local in 32.9% of patients, communities,” she said. “It makes little sense to invest as much as we “These [malpractice] payments do not capture do in preparing young women for leadership the even greater financial burdens of legal fees, additional inpatient and disability care, lost work www.chirotexas.org
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only to have them lead unnecessarily shortened lives,” she added.
You can’t give the government the power to do good without also giving it the power to do bad -- in fact to do anything it wants.
A small wellness program was already in place and used by about 300 students each week. This included activities such as yoga and Pilates, but often took a back seat in facility usage to the intercollegiate activities. The decision to shift the emphasis away from intercollegiate athletics reflected the fact that out of a student body of 2,100, only about 80 young women were involved in the competitive program.
Although 70% of children were getting at least 60 minutes of moderate-tovigorous exercise each day and 54% were sitting in front of a screen for no more than 2 hours a day, only 38% met both criteria.
Thirty-nine New Drugs in 2012 Last year saw the most new drug approvals in the U.S. since 1996, with 39 new chemical entities cleared for marketing. More new drugs won FDA approval last year than in more than 15 years, with 39 new chemical entities (NCEs) cleared for U.S. marketing in 2012. It's the highest total since 1996, when 53 new drugs were approved.
The school had the option of joining another athletic conference, which would involve more extensive travel for participants. Tatum and her team considered whether better use could be made of their athletic dollars and facilities, and found that many of their alumnae continued with noncompetitive physical activities, such as golf and swimming. They decided that their new focus would be on long-term wellness and fitness enhancement.
The 2012 total was also nearly double the number OK'd in 2010, when the number of NCE approvals was only 21. In 2011, the FDA approved 30 new medicines.
Black women overall represent a highly vulnerable population, with high rates of many ailments related to obesity and a lack of physical activity. Large numbers also have diabetes, stroke, and breast cancer, and “Black women also tend to die younger from those diseases,” Tatum observed.
Sid Williams, Founder of Life University, Dies
Many Kids Not Meeting Physical Activity Goals
Sid Williams, 84, suffered a stroke a year ago and had more recently battled pneumonia, said Jean Riley, his personal secretary for more than 40 years. He died early December 27, 2012.
Only two out of five U.S. children in elementary school met both the physical activity and screen-time recommendations from the federal government and the American Academy of Pediatrics, researchers found.
Dr. Sid E. Williams along with his wife, Dr. Nell Williams, started Life Chiropractic in 1974, which became Life College and is now Life University.
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Though he was eventually forced to leave the school 10 years ago after an accreditation controversy, Williams dedication to his field never changed.
No man is good enough to govern another man without that other’s consent. --Abraham Lincoln
Dr. Lassiter Elected Parker University Board Chair Parker University’s Board of Trustees elected Dr. Wright L. Lassiter, Jr., Ed.D., D.CE, as board chairman during its recent December meeting. Dr. Lassiter will serve a two-year term in the position. He was first appointed to the board in 2007 and previously served as treasurer.
Physician Update Fixed through December 2013 On Wednesday, January 2, 2013, President Obama signed into law the American Taxpayer Relief Act of 2012. This new law prevented a scheduled payment cut for practitioners who treat Medicare patients. The new law provides for a zero percent update for such services through December 31, 2013. This provision guarantees seniors have continued access to their doctors by fixing the Sustainable Growth Rate (SGR) through the end of 2013.
“I’m honored to serve as chairman of the board of trustees for the university,” said Dr. Lassiter. “Parker is a growing university that has many exciting developments ahead, which I’m glad to be a part of.” Dr. Lassiter’s appointment comes at an exciting time for Parker University. With a five-year strategic plan that calls for twelve new degree programs and 2,500 total students by 2017, Parker University is growing to meet the needs of an expanding health care industry. In 2013, Parker plans to launch an associate’s degree in Radiological Technology, a bachelor’s degree in Health Information Management, and an MBA with a concentration in Health Care Management. Parker University currently enrolls approximately 850 students in their doctor of chiropractic and massage therapy programs.
The Centers for Medicare & Medicaid Services (CMS) is currently revising the 2013 Medicare Physician Fee Schedule (MPFS) to reflect the new law’s requirements as well as technical corrections identified since publication of the final rule in November. Given the new legislation, CMS is extending the 2013 annual participation enrollment period through February 15, 2013. Therefore, participation elections and withdrawals must be post-marked on and before February 15, 2013. The effective date for any participation status changes elected by providers during the extension remains January 1, 2013.
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“With my experience in education and the recent hiring of a new president for Parker University, Dr. Brian J McAulay, the institution now has the leadership in place to offer allied health degrees to students with a strong desire 17
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to work within health care,” said Dr. Lassiter. “The demand for qualified professions to fill these roles within health care is great and Parker is at the cutting edge of health care education.” Chancellor of the seven-college Dallas County Community College District, which currently enrolls over 104,000 students and is the largest community college in Texas, Dr. Lassiter, holds numerous years of experience in higher education. He has previously held positions as president of El Centro College of the Dallas County Community College District, president of Bishop College in Dallas, president of Schenectady County Community College in New York, vice president of finance and management at Morgan State University in Baltimore, business manager of Tuskegee University of Alabama, and more.
University-Bloomington, a doctor of education degree (Ed.D.) from Auburn University, and a doctor of christian education degree (D.CE) from Andersonville Theological Seminary.
Dr. Brian J. McAulay D.C., PhD Chosen to Lead Parker University
“Dr. Lassiter is a great fit for this role,” said Dr. Gery Hochanadel, provost of Parker University. “He not only has an extensive background in higher education, but he’s also an esteemed leader in the DFW education community. He brings a wealth of experience and knowledge to the Board of Trustees and Parker University will benefit greatly from his leadership.”
The Board of Trustees of Parker University and Parker Seminars is pleased to announce the appointment of their new president, Brian J. McAulay, DC, PhD. This appointment comes after an intensive three month search conducted by a board-appointed presidential search committee of nine members, headed by Wright L. Lassiter, Jr., PhD, chair of the Board of Trustees.
In addition to serving on the board of trustees of Parker University, Dr. Lassiter also serves on the board of trustees of Dallas Baptist University and is a past board chairman. His service in Dallas also includes serving as chairman of the board of trustees of the African American Museum and on the boards of the University of Texas Southwestern Medical School Foundation, the Dallas Housing Authority Advisory Board, the North Texas Commission, the Texas Association of Community Colleges, and the State Fair of Texas.
“The presidential search committee and Board of Trustees felt that Dr. McAulay was the best choice to lead Parker into the future,” said Dr. Lassiter. “In the search for a new president, the search committee was mindful of the expansion in the role and mission of the institution as a university. In that regard, Dr. McAulay has a PhD in business and management, the doctor of chiropractic degree, and further professional education at the Harvard University Institute for Educational Management, and was awarded a post-doctoral fellowship in educational administration by the American Council on
He is also a distinguished adjunct professor of management at Dallas Baptist University and holds an honorary doctor of humanities degree from that institution. He holds a bachelor’s degree from Alcorn State University, a master’s in Business Administration from Indiana Texas Journal of Chiropractic
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Education. In addition, a noteworthy aspect of his professional experience is service as a chiropractic department chair and teaching experience in business and management at Philadelphia University and Temple University.”
president/provost for Life University. Each of these institutions experienced growth and success under Dr. McAulay’s leadership.
“I am very proud to become a part of the Parker family and I look forward to helping the Dr. McAulay replaces Fabrizio Mancini, DC, institution maintain its reputation as one of the who has retired after serving as president for premier schools in chiropractic education.” said just under fourteen years. During his tenure Dr. McAulay. “While Parker’s history is rich with with Parker, Dr. Mancini had a significant impact tradition and success, it’s the future that is so on both Parker and the chiropractic profession, intriguing to me. raising the visibility of the profession by This is an exciting time for Parker as the participating in media efforts that reached institution looks to expand into new degree millions of people never exposed to the programs that complement and support chiropractic message. In chiropractic. I believe my addition, he oversaw the experience in balancing renaming of the institution to program expansion and Government even in its Parker University in April foundational chiropractic best state is but a 2 0 11 a n d g u i d e d t h e programs will certainly be a necessary evil; in its worst institution through a benefit to Parker in the successful SACS coming years.” state, an intolerable one. reaffirmation in 2012. From a global perspective, Dr. Last year, Parker University --Thomas Paine Mancini oversaw the developed a strategic plan development of internship that called for the introduction programs in foreign cities of twelve new allied health such as Bogota, Colombia and Mexico City, programs by 2017. The first three degree Mexico and instituted Parker Seminars events programs, slated for introduction in January in countries including Japan, Greece and 2013, include an associate’s degree in Australia. Radiological Technology, a bachelor’s degree in Health Information Management and a master’s Dr. McAulay brings experience in both the degree in Business Administration with a chiropractic profession and higher education to Concentration in Health Care. All three degrees Parker University and Parker Seminars. Dr. were carefully selected for introduction based McAulay’s education is extensive with a PhD on criteria including how well they support and from Temple University, a doctor of chiropractic complement chiropractic, the job forecasts for degree from Pennsylvania College of each degree program and the higher than Chiropractic and a bachelor’s of commerce from average expected salaries for each profession the University of Toronto. In addition, Dr. these degrees serve. McAulay participated in the American Council on Education (ACE) Fellows program and the “Program expansion calls for a president with a Institute for Educational Management (IEM) unique set of skills and talents.” said Dr. Gery program through the Harvard Graduate School Hochanadel, PhD, provost of Parker University. of Education. “I am very pleased with the board’s decision to hire Dr. McAulay as the next president of Over the past thirteen years, Dr. McAulay has Parker. His experience in maintaining served as executive vice president/provost and chiropractic as the foundational program while interim president for Sherman College, viceexpanding degree offerings will be critical to the president for academic affairs at Palmer future of Parker University and the students we College, and provost and executive vice serve.” www.chirotexas.org
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In addition to his role with Parker University, Dr. McAulay will also serve as president of Parker Seminars. With over sixty years supporting the chiropractic profession, Parker Seminars continues to serve the profession as the premier professional seminar dedicated to helping chiropractors and chiropractic assistants build successful practices. Parker Seminars has four North American seminars planned for 2013, with the largest gathering taking place in Las Vegas January 10-12, 2013.
Making a Case for the Checkup A recent analysis from The Cochrane Collaboration, an international group that reviews scientific evidence, concluded that general health checkups for adults did not help patients live longer or healthier lives. The study was a meta-analysis, in which the authors scoured the literature and came up with 16 randomized trials in which one group of patients had general checkups and the other group did not.
“I am very aware of the impact Parker Seminars and Dr. Parker had on the chiropractic profession and I consider it a great honor to oversee this effort. Parker Seminars is the meeting place for the profession and I intend to continue positioning Parker Seminars as a global resource for the chiropractic profession,” said Dr. McAulay.
Patients in the checkup group received many more new diagnoses; one trial found a 20 percent increase. But they did not live longer. They died from cancer and heart disease at the same rates as their peers who did not have checkups. What the meta-analysis can’t quantify, of course, is the value of establishing a doctorpatient relationship before one gets sick. Treatment is immeasurably easier when it’s not taking place between strangers. It’s hard to place a numerical value on that.
Vitamin D No Help for Arthritic Knees Vitamin D supplements had no impact on the pain of knee osteoarthritis (OA), researchers reported. In a randomized, placebo-controlled trial, serum 25-hydroxy vitamin D supplements also had no effect on disease progression in patients with symptomatic knee OA.
Aging Is Easier with Endurance Exercise
The 2-year trial contradicts observational studies that had suggested higher levels of vitamin D might slow the progression of the disease.
Endurance training such as that done for track competitions may protect against the effects of aging in older individuals, a study of telomeres -- the caps on chromosomes that include repetitive, noncoding DNA sequences -suggested.
The notion that vitamin D might help was based on its role in bone health, combined with the importance of bone changes in OA and epidemiologic observations that hinted at slower disease progression among patients with higher vitamin D levels, the authors said.
Texas Journal of Chiropractic
Among individuals ages 66 to 77, endurance athletes had significantly longer telomeres compared with their less active counterparts, a relationship that was not seen among individuals in their 20s. 20
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The results "suggest that endurance exercise training may regulate the telomeres in old age and results in slowing of [the] aging process by maintaining telomere length," the authors wrote. Findings "provide further support to the hypothesis that long-term exercise, higher aerobic fitness, and longer telomeres all are part of same phenotype expressed in some older adults," the authors wrote..
Know Your Scope: Chiropractic, What Is It? What is “chiropractic” in Texas? In Texas “chiropractic” is the “use of objective or subjective means to analyze, examine, or evaluate the biomechanical condition of the spine and musculoskeletal system of the human body; or the performance of nonsurgical, nonincisive procedures, including adjustment and manipulation, to improve the subluxation complex or the biomechanics of the musculoskeletal system.” Rule 75.17– Scope of Practice Rule. (a) Aspects of Practice. (1) A person practices chiropractic if they: (A) use objective or subjective means to analyze, examine, or evaluate the biomechanical condition of the spine and musculoskeletal system of the human body; or
Telomeres shorten over time as cells continue to reproduce. Telomere length has been related to both cellular age and the physical aging process. Studies examining the association between telomere length and exercise training and capacity have yielded inconsistent results.
No Extra Death Risk Seen for Moderate Obesity Only people with body mass index values of 35 or higher face a significantly higher risk of early death than normal-weight individuals, a large meta-analysis suggested.
(B) perform nonsurgical, nonincisive procedures, including adjustment and manipulation, to improve the subluxation complex or the biomechanics of the musculoskeletal system.
Among nearly 3 million participants in 97 studies with good data on BMI and all-cause mortality, death rates were similar in those of normal weight (BMI 18.5 to 24.9), the simply overweight (BMI 25 to 29.9), and the moderately obese (BMI 30 to 34.9) The findings highlighted the limitations of BMI as an indicator of unhealthiness. "Sole use of BMI as a health risk phenotype aggregates people with substantial differences in nutritional status, disability, disease, and mortality risk together into similar BMI categories." They argued that, for individuals who appear overweight but not severely so, "traditional risk factors, including blood pressure, blood lipid levels, and fasting blood glucose level" should be considered along with BMI or waist circumference in assessing their risks.
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Know Your Scope: What is NOT Chiropractic? What is “not chiropractic” in Texas? “The practice of chiropractic does not include: incisive or surgical procedures; the prescription of controlled substances, dangerous drugs, or any other drug that requires a prescription; or
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the use of x-ray therapy or that exposes the body to radioactive materials.” Rule 75.17– Scope of Practice Rule. (2) The practice of chiropractic does not include: ( A ) incisive or surgical procedures;
“(3) That our AMA lead a specific lobbying effort and grassroots campaign in cooperation with members of the federation of medicine and other interested components of organized medicine to repeal the provider portion of PPACA’s ‘Non-Discrimination in Health Care’ language; and”
(B) the prescription of controlled substances, dangerous drugs, or any other drug that requires a prescription; or
“(4) That our AMA Board of Trustees report back at our 2013 AMA Annual Meeting.”
(C) the use of x-ray therapy or therapy that exposes the body to radioactive materials.
Boards Agree on Social Media ‘Never’ Events Fact Not Fiction–They ARE Coming After YOUR Livelihood.
Posting drunken pictures on social media could get a physician in trouble, the same as other “online” behaviors that would spark an investigation if done offline, a survey of state medical boards suggested.
Why does chiropractic need to be so active in the legislative arena?
The biggest consensus on Web no-no’s was around misrepresenting credentials or treatment outcomes (81% of respondents said this would spark an investigation) and inappropriately contacting patients or using their photos (79%). “These violations clearly parallel common offline violations, as well as established statutory and professional codes” and should be considered “never” behaviors for physicians.
The American Medical Association has STATED that they intend, and its offspring the Texas Medical Association stands ready, to seek discriminatory practices in health care:
At the AMAs most recent meeting of their house of delegates in November 2012 Most state boards said they they published the The difference between golf would look into depictions following in their of alcohol intoxication and government is that in golf meeting minutes: (73%), violations of patient you can’t improve your lie. “(2) That our AMA confidentiality (65%), and create and actively discriminatory speech pursue legislative (60%).”Physicians should and regulatory opportunities to repeal the be aware of the potential consequences for so called ‘Non-discrimination in Health online behaviors … and apply the same high Care’ clause in Public Health Service Act ethical and professional standards in their Section 2706, as enacted in the Patient online actions as they would in their actions Protection and Affordable Care Act offline.” (PPACA);”
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When asked specifically about 10 hypothetical scenarios, there was a high degree of consensus that an investigation would be “likely” or “very likely” for the following:
TBCE Now on Facebook and Twitter
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Misleading claims about clinical outcomes posted to a physician’s website (81%, 39 of 48)
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Patient images posted to a website without explicit consent (79%, 38 of 48)
www.facebook.com/TxChiroBd
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Misrepresentation of credentials on a medical practice website (77%, 37 of 48)
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Use of an online dating service to interact with a patient (77%, 37 of 48)
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www.twitter.com/TxChiroBd
Know Your Scope: Can Chiropractors Use Needles?
Simply showing alcohol use without clear intoxication was likely to trigger an investigation for just 40% of the medical boards, which was considered low consensus.
Can chiropractors make use of needles in their practice in Texas?
Some medical board respondents suggested that posting content indicating intoxication on social media was a gray area that would be decided by the context, perhaps if there were past issues with alcohol or a physician was on probation or already under investigation for alcohol or substance abuse.
“Needles may be used in the practice of chiropractic under standards set forth by the Board but may not be used for procedures that are incisive or surgical.” You will need to check elsewhere in the Rules to determine when the use of needles are appropriate or inappropriate, but generally the use of acupuncture needles or the drawing of blood samples are permitted by law. Rule 75.17– Scope of Practice Rule.
Whenever the people are well informed, they can be trusted with their own government; that whenever things get so far wrong as to attract their notice, they may be relied on to set them to rights.
(3) Needles may be used in the practice of chiropractic under standards set forth by the Board but may not be used for procedures that are incisive or surgical.
--Thomas Jefferson
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Algorithms for the Chiropractic Management of Acute and Chronic SpineRelated Pain
Remember that a government big enough to give you everything you want is also big enough to take away everything you have. --Barry Goldwater
The complexity of clinical documentation and case management for health care providers has increased along with the rise of managed care. Keeping up with the policies of different insurers and third party administrators can be a daunting task. To address these issues for doctors of chiropractic (DCs) and policymakers, the Council for Chiropractic Guidelines and Practice Parameters (CCGPP) developed three consensus documents. Each of these documents was the outcome of a formal consensus process in which a multidisciplinary Delphi panel consisting of experts in chiropractic and low back pain treatment came to agreement on terminology and treatment parameters for the chiropractic management of spine-related musculoskeletal pain.Their recommendations were based on a combination of consideration of the current evidence and their clinical judgment.
of care. They do not dictate the type of treatment procedures provided. These algorithms are designed to assist in the management of spine-related pain. They were designed for the chiropractic profession, but other provider types may also find them useful, since the algorithms do not specifically address the components of the treatment visit. The algorithms are not designed for the management of other clinical objectives, such as non-painful functional or structural spinal care. They are also not appropriate for wellness care or other types of prevention and/or health promotion. If the algorithm suggests the release or referral of a patient, then the patient has either recovered or the clinical objective is outside the scope of this algorithm.
In order to make the recommendations in these three documents more accessible to users, the CCGPP created a set of algorithms based on these consensus recommendations. Clinical algorithms essentially provide a map to guide the practitioner in case management, especially for complex and multifactorial conditions. Using evidence-based clinical algorithms supports effective standardized care. To ensure that the algorithms accurately represented the consensus recommendations, they were reviewed by a group of experts and then revised as per the experts’ comments.
For detailed information on the consensus projects from which these algorithms were derived, the reader is referred to the original papers. via Algorithms for the Chiropractic Management of Acute and Chronic Spine-Related Pain.
These algorithms are only a guide, and are not appropriate for all patients and conditions. In particular, it should be noted that they relate specifically to spine-related pain, so are not applicable to other chiropractic treatment objectives. Furthermore, these algorithms are designed to guide the DC in planning the stages Texas Journal of Chiropractic
“Take Two Aspirin…NOW!” Say Medics More than half of cardiovascular patients who could benefit from aspirin for secondary prevention were not prescribed the drug, 24
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researchers found. Aspirin or other antiplatelet drugs were prescribed for secondary prevention in only 47% of outpatient visits in 2007-2008, a rate “virtually unchanged from the 2005-2006 period,”
but other studies have yielded conflicting findings. These results create a quandary for the many patients using aspirin, particularly those taking the drug as secondary prevention of CVD.
These data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey of the CDC “are sobering” in light of the evidence that aspirin can reduce recurrent major cardiovascular events such as stroke, heart attack, or peripheral arterial disease. “[E]veryone without a contraindication should receive [aspirin],” study authors said.
NSAIDs Use Common Source of Child Kidney Injury
Exposure to nonsteroidal anti-inflammatory drugs (NSAIDs) is a common cause of acute kidney injury in children and teens, researchers The best government rests found.
Outreach efforts need to be made to educate clinicians about initiatives, on the people, and not on programs, registries, and the few, on persons and not The most common agent used technological solutions on property, on the free i n t h e c a s e s o f N S A I D geared toward improving development of public associated acute kidney injury the use of aspirin to reduce was ibuprofen (67%). Naproxen o p i n i o n a n d n o t o n and ketorolac were also used, the risk of cardiovascular events, they said. authority. and most patients for whom “There is an important and dosing information was urgent opportunity to available (75%) received doses engage all healthcare providers, particularly within the recommended limits. primary care providers, in a singular, simple intervention with the potential to prevent heart The age of the patients with NSAID-associated attacks and strokes and save lives,” they acute kidney injury ranged from 6 months to concluded. 17.7 years (median 14.7 years). Children younger than 5 fared worse than their older counterparts. The younger children were more likely to require dialysis (100% versus 0%), admission to the intensive care unit, and had a longer median length of stay of 10 days versus Aspirin Use Linked to 7 days.
Macular Degeneration
Regular aspirin use was associated with an elevated risk for neovascular age-related macular degeneration, an Australian study suggested, but actual causality remains uncertain.
Know Your Scope: To Whom do the Chiropractic Rules NOT Apply?
A recent cross-sectional study suggested a possible link between neovascular age-related macular degeneration and routine aspirin use, www.chirotexas.org
Do the Chiropractic Scope of Practice Rules apply to everyone? 25
Texas Journal of Chiropractic
The Chiropractic Scope of Practice Rules do NOT apply to “a health care professional licensed under another statute of this state and acting within the scope of their license, or [to] any other activity not regulated by state or federal law.”
Allen G. Wyche was the son of Dr. Clifford Allen and Georgia Wyche. Doc, as he was affectionately called, was born in San Antonio and raised in Dublin, where his father started his chiropractic practice. Doc followed in his father’s footsteps and became a chiropractor himself in 1948. Doc married Sarah Louise Kiper in 1956 and started what became an inspiration to all.
No, these rules do not apply to other licensed health care professionals or to any unregulated activities. But they certainly do apply to TBCE licensees! Rule 75.17– Scope of Practice Rule.
Doc was admired for his dedication to his field. He was given many awards by his peers and colleagues, one of which was the esteemed Keeler Plaque in 1987, given for an outstanding career in the chiropractic field. Doc was a member of the Briar Oaks Congregation of Jehovah’s Witness in Burleson.
(4) This section does not apply to: (A) a health care professional licensed under another statute of this state and acting within the scope of their license; or
Doc’s hobbies were few but he really enjoyed traveling, spending time with his extended family, friends and his patients. He would often meet them after hours or on his days off. Doc obtained a license to become a private pilot and enjoyed the freedom of being in the air whenever possible. Keep flying, Doc!
(B) any other activity not regulated by state or federal law.
Dr. Wyche is survived by His wife of 56 years, Sally Wyche of Burleson; his close nephews, Ralph and Linda Blackwell of Harrisburg, Pa., Danny and Anita Blackwell and Ronnie and Renee Blackwell of Burleson; and many great nieces and great-nephews.
Global Study on Disease and Disability
Obituary: Allen G. Wyche D.C.
The American Chiropractic Association (ACA) urges health care systems everywhere to find ways to effectively reduce the toll of musculoskeletal conditions, which are the second leading cause of disability worldwide according to a new global study published in The Lancet this month.
Dr. Allen G. Wyche of Burleson, Life Member and Texas Chiropractic Association Keeler Award recepient, passed away peacefully on Tuesday, Jan. 22, 2013. Memorials: In lieu of flowers, please consider contributing to the Worldwide Work of Jehovah’s Witness. www.jw.org. Texas Journal of Chiropractic
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The Global Burden of Disease 2010, authored by an international group of experts assessing the world’s biggest health challenges, finds that the primary contributor to the world’s health burden has shifted from premature mortality to chronic diseases such as musculoskeletal disorders and mental health conditions. The study identifies low-back pain in particular as one of the major contributors to disability worldwide.
Chiropractic as First Option for Back Pain Relief, Surgery Avoidance The Foundation for Chiropractic Progress (F4CP), a not-for-profit organization dedicated to educating the public about the value of chiropractic care, cites the results of a new study as further documentation of chiropractic care as a first option for back pain relief and surgical avoidance. “Early Predictors of Lumbar Spine Surgery after Occupational Back Injury: Results from a Prospective Study of Workers in Washington State,” (Spine; 12.12.2012) observed reduced odds of surgery for those under age 35, women, Hispanics and those whose first provider was a chiropractor.
“Chiropractic physicians know how dramatically overall health and quality of life can be improved by successfully treating low-back pain and other musculoskeletal conditions,” said ACA President Keith Overland, DC. “We are hopeful that this major global study will spur greater efforts to address the burden and disability caused by musculoskeletal ailments. We advocate starting with conservative, non-drug approaches before moving to drugs and surgery. Research has shown that this approach is not only clinically effective but also cost-effective.”
“In total, 42.7 percent of workers who initially visited a surgeon underwent surgery, in contrast to only 1.5 percent of those who first consulted a chiropractor,” reports Gerard Clum, D.C., spokesperson, F4CP, who indicates the important study was conducted by a collaboration of prestigious institutions, including Geisel School of Medicine at Dartmouth College, University of Washington School of Public Health, University of Washington School of Medicine, Ohio State University College of Public Health and the Washington State Department of Labor and Industries. “Back injuries are the most prevalent occupational injury in the U.S., and care is commonly associated with one of the most costly treatments – spine surgery. Chiropractic is clearly the most appropriate first treatment option for patients with back pain, and this study confirms the value.”
The Lancet study shows that while people around the world are living longer, they are spending more years with illnesses–and musculoskeletal disorders are causing a large share of the disease burden. In every region studied, low-back pain and neck pain ranked high on the list of causes of years lived with disability (YLDs). Low-back pain is the leading or second leading cause of YLDs in 17 of the 21 regions examined. According to the researchers, poor musculoskeletal health and poor mental health (including substance abuse) are major contributors to health loss, and monitoring progress in reducing the impact of these nonfatal ailments is as important for improving health as monitoring progress against the leading causes of death (heart disease and stroke). In addition, creating effective and affordable strategies to deal with the rising burden of non-fatal health outcomes should be an urgent priority for health care providers around the world. www.chirotexas.org
An additional study, “Health Maintenance Care in Work-Related Low Back Pain and Its Association with Disability Recurrence,” (Journal of Occupational and Environmental Medicine; 4.1.2011) also examined chiropractic care for occupational 27
Texas Journal of Chiropractic
back injuries and found similar outcomes. The study reported for work-related nonspecific low back pain, chiropractic care was associated with a lower disability recurrence, when compared to treatment by other medical interventions. Overall, chiropractic patients illustrated consistently better outcomes, less use of opioids, and had fewer surgeries, with lower medical expenses. “As more data continues to surface touting the benefits of chiropractic care — lower costs, less risks and higher satisfaction rates — I expect that patients and practitioners will move toward considering chiropractic first, medicine second and surgery last,” says Dr. Clum, who closes with praise of the University of Pittsburgh Medical Center (UPMC) Health Plan for already adopting this approach.
Insurance companies also benefit from offering such policies because they are less attractive to those with medical problems, who can no longer be turned away beginning in January 2014. Plans will say they can minimize their risk by creating narrow networks State or federal regulators, who must review the plans sold in the online markets, are unlikely to permit them to exclude an entire class of doctors, but there might be more subtle ways to discourage consumers with medical problems. They might have too few of a class of doctor.
Here We Go Again: HMO-Like Insurance Poised for a Comeback
The federal health law requires the policies to include a standard set of essential benefits, from emergency room and hospital care to prescription drugs, but the law is less prescriptive about the size of the policies’ networks of participating doctors and hospitals.
If there may be few or no specialists available for certain conditions, patients may have to seek care outside of the networks. If the policy doesn’t cover non-network care, they may end up footing the bill themselves. Even if policies allow for outside-the-network coverage, patients can incur large copays or other costs. Their financial exposure could be high.
Insurers plan to sharply limit the choice of doctors and hospitals in some policies marketed to consumers starting next Fall.
In March, the Obama administration issued rules stating that insurers must “maintain a network of a sufficient number and type of providers, including providers that specialize in mental health and substance abuse, to assure that all services will be available without unreasonable delay.” The administration noted, however, that “nothing in the final rule limits an exchange’s ability to establish more rigorous standards.”
Such plans, similar to the HMOs of old have begun a comeback among employers looking to slow rising premiums. They are expected to play a prominent role in new online markets, called exchanges, where individuals and small businesses will shop for coverage starting Oct. 1. Because such policies can offer lower premiums, insurers are betting they will appeal to some consumers, especially younger and healthier people who might see little need for more expensive policies. Insurers, who are currently designing their plans for next fall, “will start with as tight a network control as they can.”
Texas Journal of Chiropractic
Insurers are already rolling out narrow network policies that have shaved premiums 10% or more, 23 percent of large employers offered such plans this year, usually among a choice of plans, up from 14 percent in 2011. Each State rules on what makes an insurance network. Some states, California, specify that specialists available within a certain driving 28
adequate including must be time or
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distance. Others simply say insurers must have “There are no coordinated efforts by medical sufficient numbers of providers. Some states organizations to educate patients and the don’t have any requirements. Some public.” recommend that states should consider “For example, chiropractors and Optometrists adopting the rules that now apply to Medicare refer to themselves as ‘Doctors of Chiropractic’, Advantage, the private market alternative to ‘Chiropractic Physicians’ and ‘Doctors of Medicare. In that program, the federal Optometry’, respectively. Now, even allied government requires networks to include health professions who are not authorized to primary care physicians and more than 25 types practice independently seek to use the term of specialists, and sets county-level ‘Doctor’.” requirements on both the minimum number of doctors This Resolution directed the A society of sheep must in required in each category FMA to seek legislation and how far patients might time beget a government of prohibiting use of the word have to travel to see one. “doctor” by individuals other wolves. than MD’s, DO’S, DDS’s, “There’s no escaping that and DPM’s, in the clinical we’re going to see” setting. insurance policies that include networks both wide and narrow. “That can be OK if there are Florida Medical Association Memo [emphasis much better tools to reveal to consumers how added]: RECOMMENDATION N0. 7: adequate those networks are and how much it might cost to go outside of them.” IN COLLABORATION WITH SPECIALTY SOCIETIES, THE FMA WILL WORK TO via HMO-Like Plans May Be Poised for a ENHANCE AND STRENGTHEN EXISTING Comeback. LAW PROVIDING FOR TRUTH IN ADVERTISING FOR NON-PHYSICIAN PROVIDERS, AND EXPLORE WAYS TO E D U C AT E T H E P U B L I C T O H E L P INDIVIDUALS IDENTIFY AND DISTINGUISH THE TRAINING AND QUALIFICATIONS OF Florida Medical Association: THEIR HEALTH CARE PROVIDER.
Only “We” Should Use “Doctor”
Patients and members of the public are often unaware of the differences between physicians and allied health professionals. Patients should be able to make informed choices about who is treating them.
The following memo, reported to be from the Florida Medical Association, illustrates that the monopolistic attitude of “organized medicine” is “alive and well and living in Florida. The FMA wants exclusive ownership of a word! Says the FMA:
Presently there are no coordinated efforts by medical organizations to educate patients and the public. Lack of knowledge and education make consumers vulnerable to unscrupulous advertising and businesses practices, and ultimately could be harmful to patient safety. This is not a new problem. For years, the lines of professional credentials have grown increasingly blurred as terminology becomes less distinctive and exclusive For example, chiropractors and Optometrists
“THE FMA WILL WORK TO ENHANCE AND STRENGTHEN EXISTING LAW PROVIDING FOR TRUTH IN ADVERTISING FOR NONPHYSICIAN PROVIDERS…” “Patients and members of the public are often unaware of the differences between physicians and allied health professionals.”
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refer to themselves as “Doctors of Chiropractic”, “Chiropractic Physicians” and “Doctors of Optometry”, respectively. Now, even allied health professions who are not authorized to practice independently seek to use the term “Doctor”. We are seeing this with ARNPS who obtain a “Doctor of Nursing” degree. The problem is further compounded by state and federal policymakers and others who repeatedly include MDS and DOS Within the generic term “health care provider”‘. This issue is pervasive, growing, and relevant to all physicians and specialty groups. The FMA should build on its success in 2006 with the passage of HB 587. HB 587 provided that it was grounds for disciplinary action for a practitioner licensed by the Department of Health to fail to identify through Written notice (such as by Wearing a name tag) the type of license under which the practitioner is practicing. The bill placed similar requirements on advertisements. The bill directed individual boards to develop rules for implementation and compliance by licensees. Unfortunately, the efficacy of the law is limited because enforcement is left to the discretion of the individual licensing boards, and the requirements do not apply in a hospital setting. Much debate ensued on this issue at the 2012 FMA Annual Meeting. While there was general agreement about the need to act, there was little Consensus on the mechanics of a solution.
Governor′s may Wish to direct FMA staff to consult and coordinate with specialty societies on possible legislative remedies. This recommendation was unanimously adopted by the Task Force with no abstentions.
Let us never forget that government is ourselves and not an alien power over us. The ultimate rulers of our democracy are not a president and senators and congressmen and government officials, but the voters of this country. --Franklin D. Roosevelt
Government is not reason; it is not eloquent; it is force. Like fire, it is a dangerous servant and a fearful master. --George Washington
Ultimately the FMA House of Delegates adopted Substitute Resolution 12»303, which directed the FMA to seek legislation to reinforce current law regarding license identification. in addition, the House of Delegates referred Resolution 12-316 to the Board of Governors. This Resolution directed the FMA to seek legislation prohibiting use of the word “doctor” by individuals other than MD’s, DO’S, DDS’s, and DPM’s, in the clinical setting. Finally, the Task Force notes the FMA has several existing policies opposing “Doctor of Nursing” degrees and supporting legislation to penalize persons who misrepresent themselves as physicians (MD/DO). See, eg, P 340-O02; 450.025. In Sum, the Board of Texas Journal of Chiropractic
Helping Chiropractors Help People 30
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Texas Chiropractic Association www.chirotexas.org 1122 Colorado, Suite 307 Austin, TX 78701 Phone: 512 477 9292 Fax: 512 477 9296 E-mail: info@chirotexas.org