Texas Journal of Chiropractic March/April 2013
Volume XXVIII, Issue 2
$10.00
In This Issue: Customer Service for Chiropractic Business Success! Successful African-American Chiropractors–! New Patient Mastery! ! ! ! ! When Practices Fail – Warning Signs and Solutions! Back Pain Is #1 Cause of Disability Worldwide ! ! Modeling your Practice with “Practice “! ! ! To Be, or Not To Be; and the Use of “D.C.”! ! Mediterranean Diet Curtails Heart Troubles Watchful Waiting Best for Ear Infections! AAP Outlines Fetal Damage with Drug Abuse Walmart to Offer Health Screening Stations Legislation Pertaining Directly to Chiropractic
S E L ing C I ort T R ep A L lR A N nta I G me I OR ern v o G
Texas Journal of Chiropractic Volume XXVIII, Issue 2
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 CEO: John Darby CE Coordinator: Sterling Isdale Accounts Manager: Tracy Edwards Member Services: Abel Salazar 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. Dr. Jason Helton 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.
Helping Chiropractors Help People
March/April 2013
TCA Plans Second Legislative Day! ! ! Election Time!! ! ! ! ! ! TBCE Report!! ! ! ! ! ! Customer Service for Chiropractic Business Success! Successful African-American Chiropractors– Dr. Eric Snowden! ! ! ! ! Dr. Steve Minors! ! ! ! ! Which Road Leads to Spine Surgery?! ! ! New Patient Mastery ! ! ! ! ! When Practices Fail – Warning Signs and Solutions! Back Pain Is #1 Cause of Disability Worldwide! ! Modeling your Practice with Practice! ! ! TCA Takes to the Capitol! ! ! ! ! To Be, or Not To Be; and the Use of “D.C.”! ! ACA President Reports the “State of Chiropractic”! Too Many Pills in Pregnancy ! ! ! ! Mediterranean Diet Curtails Heart Troubles! ! Watchful Waiting Best for Ear Infections! ! ! AAP Outlines Fetal Damage with Drug Abuse! ! Walmart to Offer Health Screening Stations! !
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Policies 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 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 2013 All Rights Reserved: Texas Chiropractic Association
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 More than halfway through the 83rd Texas Legislature. The TCA has been HARD at work to promote and protect the profession from the over 5000 pieces of legislation. It takes a JOINT effort from the entire profession to insure that nothing sneaks into or out of legislation. Your support of the TCA helps us to better carry out that work.
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.
staff and legislators. Call 512-477-9292 or email: tca@chirotexas.org.
Texas Chiropractors Plan Second Legislative Day Thursday, April 11
The TCA has an aggressive legislative agenda this year and this second legislative day at the capitol demonstrates to our government that doctors of chiropractic and their staff offer real solutions and that we are continually present and available to answer their questions during this very busy legislative session. TCA representation is in the Capitol early, often, and constantly.
Due to the overwhelming success of the first TCA Day at the capitol, the Texas Chiropractic Association is planning a second legislative day for Thursday, April 11, 2013. Doctors of Chiropractic are urged to inform the TCA office of their availability to attend and to make available their massage therapists for chair massages for busy capitol
Once you have notified TCA of your availability our governmental affairs team will work to set key appointments where participants can meet with their local representative or senators to let them know which issues are of importance to the chiropractic profession and their constituents.
ELECTION TIME! The Texas Chiropractic Association will be holding its statewide election for executive officers this month.
For more information or details call 512-477-9292 or email: tca@chirotexas.org.
Ballots are going in the mail in late March and will be arriving in the mailboxes of eligible TCA members shortly. Candidates for the 2013 election are:
TBCE Report
TCA President -- Jack Albracht D.C. TCA President-elect -- James Welch D.C. TCA Secretary Candidates: ! Cynthia Vaughn D.C. ! Tom Hollingsworth D.C. Ballots received by mail can be returned by: Mail to TCA - 1122 Colorado St STE 307 Austin TX 78701
By: Chris Dalrymple D.C., F.I.C.C. On February 14, 2013 the House Appropriations Subcommittee on Articles VI, VII, and VIII met to hear appropriations requests from a number of government agencies. Among them was the Texas Board of Chiropractic Examiners. Excerpts of particular interest to our readers include: •
The TBCE requested an additional legislative appropriation of more than one-third of a million dollars.
•
The first request of TBCE is increased enforcement. “We do need to step up some enforcement efforts and make sure that the doctors in the state comply with that scope of practice,” said Yvette
Fax to (512) 477-9296 Or scanned and emailed to info@chirotexas.org Ballots must be postmarked or time stamped by 5pm April 30, 2013
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Yarbrough, Executive Director of the TBCE. •
•
towards the agency’s … receipts. It would drastically increase the agency’s … receipts which we could then fund more of our operating expense ….”
“The second item is a lack of administrative support for the Executive Director Position,” she said.
Representative Cecil Bell asked “out of the 5000-plus doctors, what percentage of those doctors have enforcement issues?” Ms. Yarbrough answered “our percentage of licensees with NO recent violations is about 95 to 96%.“
“The third issue is … compensation of key personnel. … I am requesting funding of $10,000 each per year for a merit pay increase.”
Said Ms. Yarbrough, “We are dealing with anything from standards of care issues, to insurance fraud; Doctors that are over charging for services … There are a number of ways that these services can be manipulated to increase payment.”
A State Representative stated: “At the same time the board is now saying that they want to increase the taxes, they call it a fee, on these small businesses, and they are saying that they also want to increase the salary of their employees $10,000 each, at the same time that our chiropractors are seeing a decrease in the amount of pay that they receive while seeing additional regulations being forced upon them, and being portrayed as 1 out of 20 being ‘bad apples.’ … I don’t think that is fairly portrays them … and I know that they are suffering greatly because of these cuts in their pay, yet at the same time we are now asking them to pay more fees, more taxes … I adamantly disagree with this.”
When asked by one state representative “You are making sure that they are actually delivering the services …,” Ms. Yarbrough stated: “Correct, that they are charging for services actually rendered. That they are coding the proper services, that they do not … create false documentation to insurance companies for payment.” When asked by a representative “Do you guys have armed peace officers that work for the organization?” Ms. Yarbrough responded “At this point we do not, however, it is part of our strategic plan to request that in the future,” and “if you are willing to give it to me I would love to have it. … it is something that we would like in the future.” “When I talk about the certified p e a c e o f fi c e r s , t h i s w o u l d a l l o w o u r investigators to have that status. Even though we have the statutory authority to inspect facilities sometimes we do meet some resistance on that. … and additionally in obtaining additional information especially related to insurance fraud.”
The TCA representative stated: “We oppose this increase. Number one because … we are taxed enough right now. … The agency, as far as their investigators, they have two now, and they’re going to add two more. That would be, out of 13 employees, 4, or almost 25% would be investigators.” The TCA representative also pointed out the truly exceptional nature of the request: “You are taking 30% of your employees and giving them a 25% pay raise.” The following are excerpts from the full testimony:
“One thing that we are developing,” Ms. Yarbrough notes, “is an online jurisprudence course that would be part of required continuing education for every licensee. … The development of this course … would become mandatory continuing education that would go Texas Journal of Chiropractic
A representative of the Legislative Budget Board presented the appropriations request to the subcommittee and reported that 92% of the income being generated by the TBCE is general revenue to the state. 7
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He further reported that “the recommendations for the 2014-2015 biennium are $1.1 million with the continuation of 11 FTEs [Full Time Equivalent Employees]” and reported that in addition to this recommendation the TBCE is requesting from the Legislature an additional $367,000 with the addition of three new Full Time Employees.
“We also sometimes have to request of local law enforcement to go out and check on facilities…sometimes they are just not cooperative with us in helping us out with these investigation. Therefore we are asking for two field investigator positions, two FTE positions to be authorized and funded for our agency to help us with these issues.“
Yvette Yarborough, TBCE Executive Director, presented testimony on behalf of the TBCE. She reported that “My President of the board, Dr. Cynthia Tays, could not be here today, she’s out of state this week dealing with a family issue. But under normal circumstances she would be here with me.“
Ms. Yarbrough explained “the second item is a lack of administrative support for the Executive Director Position. … I’m having to dedicate a large amount of personal time to purely administrative items, which means there is less time to develop and amend already existing policies and procedures that are in desperate need of updating. [There are] some management issues that we desperately need to address, however, time spent doing purely administrative items is taking away from that, therefore we are asking for one FTE position to help with that issue.“
“As of last week we are regulating over 6000 licensees, and over 4100 chiropractic facilities,” Ms Yarbrough reported. “Including that $200 professional fee, we raise nearly $2.5 million. We are appropriated back only about $600,000 … $497,000 of that general revenue goes towards salaries for my eleven FTE positions. Another $30,000 of that general revenue goes towards Texas Online payments. So, in effect, we are left with nearly $75,000 of general revenue for operations.” Later she reported “we are appropriated less than 25% of the revenue that we generate.”
Finally Ms. Yarbrough reported that “the third issue is … compensation of key personnel. … I am requesting funding of $10,000 each per year for a merit pay increase. So that way I can move them [three "key personnel] closer to the mid-point of their salary classification. Because right now they are woefully underpaid.“
Ms. Yarbrough explained the TBCE request for an additional amount in excess of 1/3 of a million dollars: “We feel that it is necessary to request this additional funding in order to get the agency to the point where we need to be in regulating and enforcing the Chiropractic Act for the protection of the public. Our three specific areas that we are looking at are a lack of FTE positions for field investigators currently. Right now we don’t have the manpower and we don’t have the resources to go out in the field and inspect facilities. This means we have close to 4100 facilities and I’m sure a large number of unregistered facilities that we have no idea are in existence operating across the state. We are heavily relying right now on insurance investigators … for claims of overcharging, claims of patient care issues.“ www.chirotexas.org
She reported to the subcommittee that “in 2009 the agency was able to hire for the first time ever an attorney. Previously we had been relying on the Attorney General’s office.” She noted that “unfortunately we do see a lot of people that are still practicing with an expired license.” When asked “what is the penalty for practicing without a license?” Ms. Yarbrough’s response was “it can range anywhere from a ‘cease and desist order’ to a monetary fine up to $1000 for a first offense. Usually what we see is if somebody is practicing without a license, us demanding $1000 from them usually remains unpaid; so it usually is a cease and desist order. Under our statute it is a criminal offense to practice without a license as well.” 8
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response was “if you are willing to give it to me I would love to have it. … it is something that we would like in the future.” “One thing that we are developing,” Ms. Yarbrough notes, “is an online jurisprudence course that would be part of required continuing education for every licensee. All too often we hear in enforcement … ‘well I just didn’t know that was the rule’ or ‘I didn’t know that was the law.’ So we are trying to educate our licensees more. The development of this course … would become mandatory continuing education that would go towards the agency’s … receipts. It would drastically increase the agency’s … receipts which we could then fund more of our operating expense out of.”
Representative Bryan Hughes asked “briefly what else would your enforcement work look like?” Ms. Yarbrough responded “We are dealing with anything from standards of care issues, to insurance fraud; Doctors that are over charging for services … where services are bundled, or unbundled, or up charged or down charged, up coded, down coded. There are a number of ways that these services can be manipulated to increase payment. We do see that unfortunately. The majority of our licensee population practices within the bounds. However, there are always going to be the few that create the work for us. When I am talking about over charging, those are the type of things I am referring to.”
Representative Cecil Bell asked “out of the 5000-plus doctors, what percentage of those doctors have enforcement issues?“ Ms. Yarbrough answered “our percentage of licensees with NO recent violations is about 95 to 96%.” The association, and chiropractors in Texas, have had some issues with our Board of Examiners. “We oppose this increase. Number one because … we are taxed enough right now. … The agency, as far as their investigators, they have two now, and they’re going to add two more. That would be, out of 13 employees, 4, or almost 25% would be investigators.”
Representative Hughes stated “it’s not that we regulate what they can charge, but you are making sure that they are actually delivering the services …“ Ms. Yarbrough responds “Correct, that they are charging for services actually rendered. That they are coding the proper services, that they do not … create false documentation to insurance companies for payment.”
A representative asked “with the new health care act, with all the changes in Medicaid and Medicare, are chiropractors receiving more money today than they were two years ago for the services that they perform?“ The TCA responded “No sir.”
The representative asks “the field investigators that we are talking about, are those positions certified Texas peace officers in their armed function, if not, do you have folks like that? Many of our agencies that you wouldn’t expect, do. … Do you guys have armed peace officers that work for the organization?“ Ms. Yarbrough responds “At this point we do not, however, it is part of our strategic plan to request that in the future.” The representative asks “But that would not be the case with these particular ones we are talking about in this request?” Her Texas Journal of Chiropractic
The representative continued: “At the same time the board is now saying that they want to increase the taxes, they call it a fee, on these small businesses, and they are saying that they also want to increase the salary of their employees $10,000 each, at the same time that our chiropractors are seeing a decrease in the amount of pay that they receive while seeing additional regulations being forced upon them, 9
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and being portrayed as 1 out of 20 being ‘bad apples.’ … I don’t think that is fairly portrays them … and I know that they are suffering greatly because of these cuts in their pay, yet at the same time we are now asking them to pay more fees, more taxes … I adamantly disagree with this.”
“The solution to this problem is for the agency to be given the authority and funding to hire two field investigator positions–one to operate out of Houston and the other to operate out of Dallas.” Why More Administrative Staff? “There is a critical need for the Executive Director to create and/or update agency policies and procedures, maintain compliance with required reporting and implement required programs such as stakeholder group meetings and peer review committees. However, time personally spent doing administrative items (such as preparing/making copies of board meetings materials, making room reservations for Board meetings, arranging parking for Board members, posting items on the Texas Register, filing/organizing documents, etc.) takes away from the time necessary for the Executive Director to complete critical items.”
In the document Written Materials A c c o m p a n y i n g Te s t i m o n y f o r H o u s e Appropriations Committee presented by Yvette Yarbrough J.D., the answers to questions regarding TBCE’s request for more money are found. Here are the answers as presented by the TBCE Why More Inspectors? “Complaints are often received by the agency involving patient care that would be best investigated by an inspection of the facility that is the subject of the complaint or where the chiropractor who is the subject of the complaint works. Chiropractors with disciplinary actions putting stipulations on their license often require in-person visits to monitor these stipulations. Also, complaints are often received stating an unlicensed facility is in operation or an unlicensed individual is practicing chiropractic at a facility. … all of these issues would best be investigated with a facility inspection [by a person with specific knowledge of the requirements of the Chiropractic Act]. However, because only two investigators are currently employed by the agency, the agency is unable to conduct these inspections.”
“The solution to this problem is for the agency to be given the authority and funding to hire one administrative assistant to assist the Executive director.” Why More Staff Salaries? “The agency’s Director of Licensure, Director of Enforcement and Chief Financial Officer are three key positions within the agency’s staff that ensure a successful and efficient agency. These three individuals have been with the agency long enough to possess institutional knowledge that is invaluable to agency operations. However, their pay is not commensurate with their levels of responsibility and their job performance. Currently, none of these three key personnel earn even the midpoint salary for their position classifications.”
“The agency would like to become more proactive about finding facilities operating without a registration, individuals practicing chiropractic without a license, and chiropractors advertising and practicing outside the scope of practice, as well as monitoring licensees [who have already been disciplined by the board]. However to do these things, additional enforcement resources are needed.”
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“The agency’s Director of Licensure runs a flawless licensing program. Initial licenses and facility registrations are issued within one week of the time a completed application is received by the agency. License and registration renewals are processed the next business day. During FY 2012 alone, she processed over 5700 license renewals and over 3600 facility 10
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registration renewals, in addition to issuing 325 new licenses and nearly 800 new facility registrations. However, presently she earns … less than the midpoint salary for her position classification.”
The agency now meticulously ensures that all appropriations are spent correctly and that all revenue is collected. The agency recently underwent an audit by the Comptroller’s Office (travel, payroll, and purchasing/procurement) in August 2012. Due to the CFO’s diligent work, only minimal findings were recorded. However, she currently earns … less than the midpoint salary for her position classification.”
“The agency’s Director of Enforcement manages a busy enforcement section, dealing with the investigation of and resolution of over 250 complaints per year. He manages the investigation of complaints from the time they are received in the agency office, reviews all investigative reports, presents cases to the Board’s Enforcement Committee, oversees the Informal Settlement Conference program, monitors cases pending resolution and refers cases for litigation to the Settlement Conference program, monitors cases pending resolution and refers cases for litigation to the agency General Counsel, testifies at t h e S t a t e O f fi c e o f Administrative Hearings, and monitors completed d i s c i p l i n a r y a c t i o n s . Currently the Director of Enforcement earns … the minimum salary for his position classification.”
“If any of these three individuals were to leave the agency for a higher-paying job, agency operations would greatly suffer. The solution to this problem is for the agency to be given the funding to provide these three key personnel a merit pay increase of $10,000, thereby bringing their salaries closer to the midpoint salary for their position classifications.” Show Me the Fee Increases
Click to “The agency’s Chief Financial Officer is the agency’s first full-time accounting staff member since 2006, when the agency was in financial shambles. At that time, the agency previously had been placed on prepayment audit status by the Comptroller, meaning that all vouchers had to be approved in advance by the Comptroller’s office before they could be paid. Finally, the agency’s payroll and those bills that were being paid were being processed by the staff of the Board of Nursing because the agency lacked the necessary expertise. A parttime accountant was hired in 2006, which helped the agency’s financial situation some. However, when the CFO was hired in 2009, the agency’s financial situation improved drastically.
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“If it becomes necessary to increase fees to cover some or all of the cost of the exceptional items, the agency would consider increasing fees.” The proposed fee increases recommend are as follows: ADDITIONAL REVENUE FOR 2014-15
1. Implement online Jurisprudence Course for Applicants and Continuing Education Credit; Agency revenue (appropriated receipts) from fee would be $20 per course--Income generated $212,000 2. Increase Continuing Education Course Approval Fee by $35; from $165 to $200-Income generated $47,250 3. Increase D.C. Initial Application Fee by $10; from $398 to $408--Income generated $5,800 www.chirotexas.org
4. Increase Original License (prorated) by $10; from $86 to $96--Income generated $5,600 5.Increase D.C. License Renewals by $5; from $362 to $367 (this includes the $200 professional fee)--Income generated $54,000
positions were contingent upon us raising that additional revenue, which is why we sought the increase in licensure fees this biennium in 2012.” When asked “so what happens if you don’t hit that number?” she reported “then I don’t receive a portion of my appropriation and I can’ t meet the cost of operating the agency.”
6.Increase Facility Registration fee by $5; from $73 to $78 (includes Texas Online and collection of required “patient protection” fees)-Income generated$40,000
When asked “so the fees [of the licensees] will remain the same for 2013?” Ms. Yarbrough responded “they are the same for 2013, yes, for 2014 and 2015 that remains to be seen.”
7. Increase initial Facility Registration fee by $5; from $75 to $80; including patient protection fees--Income generated$5,000 TOTAL AMOUNT OF ADDITIONAL REVENUE GENERATED: $369,650
Licensees Ms. Yarbrough reported on the number of Texas licensees. She reported “as of January 1, we have issued 103 new D.C. Licenses, 17 new RadTech licenses, and 190 new facility registrations. We issued a little bit over 2400 license renewals and little be over 1400 facility registrations. There are currently 5176 actively licensed D.Cs., 700 inactive D.C.s, 252 expired D.C.s, and 174 retired D.C.s as of February 19th. There are a little be under 3900 registered facilities and 230 expired facilities.”
Total cost of TBCE requested additional funding--$366,800 Total estimated gain or loss anticipated-$2,850 As part of the agenda of the February 21, 2013, TBCE Board meeting Executive Director Yvette Yarbrough reported on the following items: Agency Financials “For finance you’ll see that the agency has collected a little over one-million dollars in total revenue in the first five months of this fiscal year. … in the first five months of the fiscal year the agency has spent approximately $255,000 in operating expenses.”
Enforcement Concerning enforcement Ms. Yarbrough reported: “as of January 31st we have 344 complaints open. A large number of these were do to the address change cases that were opened due to the high volume of mail being returned to the board and the high volume of licensees not providing the board with a current address. We will track at the conclusion of the fiscal year those cases separately from the other cases so that we can report accurately on the complaints. During the first five months of the fiscal year we closed 117 jurisdictional complaints and 2 non-jurisdictional complaints. Of the jurisdictional complaints 19 were closed with discipline. … as of January 31, there were 10 cases scheduled for SOAH hearings with 39 cases remaining to be set.”
When asked “you are under mandate to raise so much money?” Her explanation was “yes, we are given what is called a biennial revenue estimate that is the baseline amount that we are required to collect by the legislature that goes into the general revenue fund. Additionally, for 2012-2013 we were given what is called a contingent revenue rider requiring us to raise certain amounts above and beyond our baseline revenue estimate in order to receive a c e r t a i n p o r t i o n o f o u r a p p r o p r i a t i o n s . Additionally two full time equivalent employee www.chirotexas.org
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Appropriation Request
management of the organization at the agency. There are numerous procedures that need to be updated–we have not had a substantial update of the policy and procedures of this agency in a number of years. We’re looking at sunset in the next few years and this desperately needs to be done.”
Regarding the status of the TBCE’s appropriation request Ms. Yarbrough reported “we submitted our legislative appropriations request earlier in this biennium regarding our funding for the FY 2014-15 biennium. ..We pass [all the funds we collect] to the general revenue [fund] and then we are appropriated back a small percentage of that. Right now for 2012 we are looking at being appropriated back approximately 24.82% of the general revenue that we generate, including the $200 professional fee. In 2013 we are looking at being appropriated back 23.58% of the general revenue that we bring in for the state. We were instructed by the legislative budget board that our baseline request had to remain the same as what it was for this biennium, meaning that I had to request exactly what we had been given in this biennium. Any additional moneys to be requested needed to be requested as exceptional items.”
“The merit pay increases–currently these three key staff personnel … when looking at other agencies these individuals are underpaid and overworked, and if any one of them leaves for a higher paying job, the agency would be crippled due to the lack of institutional k n o w l e d g e . Therefore the agency feels that it is in it’s best interest to request these merit pay increases. This is not anything that is unique to our agency. There are a number of other health care agencies … requesting salary increases. In fact, it is my understanding that … the state is considering an across the board pay raise for all state employees because it hasn’t been addressed in so many years. They do recognize the fact that our workforce is working for a lot less money than they should be.”
“The exceptional items that the agency requested were for three additional [full time equivalent (employee)] positions and some merit pay increases for our director of licensure, our director of enforcement and our [chief financial officer]. The two field investigator positions are just that … they will be living in Houston and Dallas and have the ability to travel within those regions. The other staff position would be an admin[istrative] assistant. Currently the executive director … is doing all of my own copying, every time the board members need parking, anytime anything administrative in nature needs to be done I have to oversee that or personally do it. It is taking a large amount of time away from the actual Texas Journal of Chiropractic
Peace Officer Status “Finally, I’ll address some misinformation that I alluded to about the request for peace officer status and the investigators. There is currently no pending request in front of the legislature, and there has been no request to the legislature for peace officers for this agency. There will be no armed guards, there will be no one beating down doors, there will be no one drawing guns on doctors. During the House Appropriations Subcommittee testimony I was asked by a representative if our investigators had armed 14
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peace officer status. I responded no, very clearly in the testimony, I said that ‘it was something that we would like in the future. That the agency was considering in the future.’ This does not mean that it is currently pending or that we could get it if we wanted to right now. There is a moratorium on new agencies being granted peace officer status as of the 80th legislature. So even if we had ask for it … it would not have been granted, but this agency did not request that status.”
as well, however it is no intention of me as Executive Director or any of my staff, and I believe not the intention of the board, to ever draw a gun on a chiropractor, to ever beat down the door of a facility or ever to ever intimidate a chiropractor. Any insinuation that I or my staff would do otherwise is reprehensible.” “Also I would like to shed light on the fact that I am not requesting a pay raise for myself, as has been insinuated. I am not requesting a pay raise across the board for all of my staff. This is something for three individuals who are the backbone of this organization, who dedicate tireless hours and who are very much underpaid for their positions.”
“The purpose of that status and why it is considered a possible request in the future is for investigators to be given the status of law enforcement. Not to go kick down doors of facilities, or demand information from doctors at gunpoint, as has been insinuated in these emails. There are a number of outside organizations that conduct fraud investigations and other investigations that will only share that information with law enforcement. Currently our investigators do not have that status, meaning that there are times when we find out about the arrest or conviction or indictment of a chiropractor by reading it in the newspaper, the same as you. And usually in those articles it explains ‘the Texas Chiropractic Board of Examiners reports on their website that ____________ is actively practicing and has no stipulations on their license.’ To become more a part of the investigation’s process that is where the peace officer status comes into play. It is also an asset to our investigators IF they encounter any resistance in trying to inspect a facility. This does not mean that they would draw a weapon to gain entrance to that facility. This means that they have the status to be able to request admission more so than just pointing to a piece of paper on a statute saying ‘you have to let me in because of this.’”
Ms. Yarbrough concluded her remarks stating: “Our agency is proud of the work that it does and we hold ourselves to a high standard of conduct, and any insinuation otherwise is, as I said, reprehensible. … I remain committed to the board and to the agency. … I am a [chiropractic] patient. I am the daughter of two chiropractic patients who have been patients since before I was born, and I am the one that referred my husband personally to a chiropractor.” “If anyone has any questions about any of the request about any of the operations of this agency I always welcome them. I have an open door policy, as many of our licensees will attest to. I answer my phone and I’ve given out my personal cell phone number on many occasions, and I am always available by e-mail. If you choose to stop by the office to see how we operate we will welcome you with open arms.”
Helping Chiropractors Help People
“Most of the time when we do encounter resistance some of the e-mails that I’ve seen say that we should just call local law enforcement and leave it at that. We have had instances where there has been aggression by doctors. There have not been a lot, but there have been some. The status would be considered in order to protect our investigators www.chirotexas.org
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The most important but overlooked issue in business is customer service. Today, patient-topatient influences are stronger than ever. With the proliferation of the Internet and instant connectivity, patients relate instant information about chiropractors and their offices. It is not necessary to react to every patient issue but it is vital to indulge in a culture of service.
Customer Service for Chiropractic Business Success By: Drew Stevens, PhD all rights reserved. © 2012. Drew Stevens transforms struggling chiropractors into wealthy chiropractors. For more information visit www.stevensconsultinggroup.com
With over 25 years of research and consultancy in the field, I have found that success for the chiropractor is achieved with a focus on three functional areas 1) Mindset 2) People and 3) Differentiation.
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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Mindset During my collegiate business studies, I discovered a quote t h a t p e r s o n i fi e s t h e achievement of every business. Peter Drucker stated, “Every organization is in business for one reason--the customer [patient]”. All activities and internal functions rely on acquiring and retaining clients. This imperative concept is needed to ensure that chiropractors focus on the area of acquiring patients. Simply put, chiropractors require a laser like focus on marketing and service. It also presupposes that those hired will also focus on these business attributes. Second, chiropractors also need to understand that upon graduate they are entrepreneurs. Doctors become involved in a myriad of tactical issues that can alter focus and create stress. Doctors therefore need to be c o n fi d e n t a b o u t t h e i r achievements. And, they must continually maintain confidence www.chirotexas.org
with staff even during volatile times. This also includes operating the business using prudent risk. Removal from the comfort zone is always difficult for habitual business owners.
professionalism. Finally, when patients are serviced appropriately they inform others of their positive experience. Such feedback assists with decreasing marketing and advertising costs while also retaining current patients.
People Property - Individuals always judge books by their covers and patients are no different. On a recent appointment with a supplier, I could not find a spot to park my car. All employees were in visitor spots. On another visit, I entered the main lobby of a potential client to what seemed like a hurricane. These images leave a certain perception of company operations. Simply put pictures say a thousand worlds. The reception area must be tidy, organized and exemplary of the service you provide. Smiling staff and signage drawing attention to the practice’s location. Staff should dress professionally and preferably have name tags. It took five trips to my current chiropractor (Yes I do use one) before I even knew the name of his receptionist!
Customer service simply comes down to proper communication and implication to patients. When doctors and staff poorly communication; service fails. While conducting research for chiropractic practices, three functional areas help and hinder doctors. People -- There is nothing more prevalent to business then internal employees: they are the frontline to the organization. Failure to exemplify a patient culture only diminishes a firm’s ability to communicate and collaborate with prospects. Working for a chiropractor many years ago, I was greeted by a receptionist that could have passed for an Undertaker. I do not suggest that receptionist require effervescence however, empathy works better for customer care. Service culture needs to run throughout the practice and not just reception. Everyone from the CA to the PT needs to be empathetic to patient needs.
Service Suggestions:
More importantly, people know people. Doctors need take full advantage of referrals and testimonials. Patients are always enamored in hearing of other patient cures. Such stories become more beneficial than any four-color brochure.
Patients are the most important people.
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Patients are not dependent on us.
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Patients are not an interruption of our practice. Differentiation
The deterrent to practice growth is a lack of focus on simple things. While working with chiropractors I typically ask them to identify their value proposition. I also inquire if patients can repeat it. The rationale is if patients understand the value provided they repeat it, thus becoming marketing avatars. The largest compliment received by a doctor is the referral and testimony of current patients informing others. However, customer service must be part of everyday living stemming from holding doors during shopping excursions, smiling when meeting others in public, and general posture and attitude. Introversion is no excuse; chiropractors are part of communities. Empathy and excitement must be in everything you do. I
Finally, ensure you spend time and get to know your patients and their families. Individuals do business with those they know and trust. When chiropractors are rushing from treatment room to treatment room this illustrates inward focus. Processes – Patients and prospects are enamored by increased communication. The more you tell them, the more comfortable they become with information. Remember they are investing in your sage advice on health. Communicate the rationale for paperwork, procedural issues, signatures, etc. Ensure the phones are answered promptly and with rapt www.chirotexas.org
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know of one chiropractic associate that is so shy, some take him as being aloof. Hence their portion of the practice produces negative results. Ensure inclusion in everything you do.
practice he realized that his chiropractic schooling did not prepare him to run a successful business practice. He knew how to treat spinal subluxations, to manage a patient’s healing, and all the other things included in a chiropractic education, but what he did not know was how to run a business.
The cacophony of competition is too strong to avoid the power of customer service. With many practices and many patients having the power to influence other patients, service is the marketing differentiator. Ironically, many chiropractors look at how many patients they see per week. Curious how many patients don’t you see because of your customer service?
Determined to be successful in his business and professional life, Dr. Snowden educated himself on how to better serve patients and to receive the compensation due from insurance companies for the services he provided. He notes that receiving correct payment for services rendered is a direct function of knowing how to bill correctly. Learning how the billing system works is absolutely critical for a chiropractor, their office staff and billing departments. Not understanding the proper and expected billing methods for services rendered will result in not receiving correct payment for those services.
Successful AfricanAmerican Chiropractors– Dr. Eric Snowden
Over the course of his career, Dr. Snowden has become wiser in the ways of running a business. Staying up on the latest healthcare laws and insurance changes are how Dr. Snowden keeps his practice running with optimum performance. He believes that chiropractors need more than just schooling in treating patients. They also need to be taught
Dr. Eric Snowden–a Doctor of Chiropractic, a businessman By Mary Clark, TCA Journalism Intern I recently spoke with Eric Snowden D.C. who runs a highly successful chiropractic practice in the Dallas area. Since beginning his practice, Dr. Snowden has expanded his services to not only help patients but to also help other chiropractors build their own successful practices. In chiropractic practice since December 2000, Dr. Snowden was inspired to become a doctor of chiropractor after three years of service with the U.S. Air Force in Japan. While there he learned of natural medicine and holistic philosophy. After returning to the United States a chiropractor inspired him to pursue a career that focused on natural healthcare alternatives. I asked him how he managed to become so successful in such a short period of time. He told me that after starting his chiropractic Texas Journal of Chiropractic
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how to run their businesses. His consulting services help chiropractors with restructuring, compliance with laws and learning how to properly bill insurance companies for their services.
application of chiropractic healthcare in the business world is the key to being successful; it is not what we think THEY think that is of vital importance. It is what WE think in our own minds that is the most important factor.
In the last thirteen years, Dr. Snowden has witnessed many changes in the healthcare industry. The biggest yet is the Affordable Care Act. He worries doctors unfamiliar with all the provisions in the act will find themselves in trouble for waiving copays and deductibles for patients, when many doctors should actually be using discount programs. Dr. Snowden feels it is of utmost importance that chiropractors know and understand the Affordable Care Act and how it affects their practice and billing departments.
Which Road Leads to Spine Surgery?
In regards to being an African-American chiropractor, Dr. Snowden said, “When it’s all said and done, you are paid for your knowledge.” Race does not matter to people who are pain and want relief, if you respect your clients they will respect you and your office. He encourages chiropractors of all races to do their homework, and know the demographics of the neighborhood where they are looking to operate their practice; but most importantly, to do business where they want to do business. Patients will come if you show them you can help relieve their pain.
Yes, while back pain is rampant, surgery is rarely required; even the Mayo Clinic admits that while “back pain is extremely common … surgery often fails to relieve it.” However, chiropractic is glaringly absent from the nonsurgical recommendations, despite ample research evidence supporting chiropractic care for back pain and increasing reliance on chiropractic as a first-line treatment option.
According to the Mayo Clinic, “back surgery is needed in only a small percentage of cases. Most back problems can be taken care of with nonsurgical treatments, such as antiinflammatory medication, ice, heat, gentle massage and physical therapy.” Accurate on face value, but missing an important piece of the puzzle, of course.
So, what determines whether a patient undergoes spinal surgery? A recent study endeavored to answer that very question and came up with several predictive variables, perhaps the most interesting of which is the type of health care provider – namely a surgeon or a doctor of chiropractic – the back pain patient sees first.
Growing up in Alabama, Dr. Snowden’s mom experienced, first hand, the effects of racism. She was very concerned when her son told her he was moving from California to Texas. Dr. Snowden said he told his mother that the current era was not the same as the 1950s, and that people are not as closed-minded anymore when it comes to race. His thriving practice in Dallas is a clear testament of race being a nonissue if you are good at what you do. Dr. Snowden has this message for up and coming African-American, other minority chiropractic students, and indeed the profession as a whole: “The biggest blocks we have are in our own mind and how we THINK people will perceive us.” Overcoming this mental obstacle and learning how to get paid for the effective www.chirotexas.org
A recent study notes that “there is little evidence spine surgery is associated with improved population outcomes, yet surgery rates have increased dramatically since the 1990s,” found that Washington state workers with an occupational back injury who visited a surgeon (orthopedic, neuro or general) first were significantly more likely to receive spine surgery within three years (42.7 percent of workers) than workers whose first visit was to a DC (1.5 percent of workers). 19
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This association held true even when controlling for injury severity and other measures.
a thorough intake, you can bill for a more appropriate—and often higher—EM code, with the accompanying higher fee. Time spent early on with new patients allows you to increase your efficiency as the relationship develops, and continues to pay off over time.
New Patient Mastery By Dr. R. A. Foxworth, FICC, MCS-P
Ask ten chiropractors what would most transform their practice, and nine of them will say New Patient Mastery. It makes sense. New patients are the life’s blood of a growing, thriving practice—but they also require more time and attention, education, and salesmanship from you and your staff. How can you streamline and secure new patient procedures so that this vital process flows easily and organically from the point of first contact?
New Patient Payments Sometimes front desk staff dislike fielding the question, “How much does it cost to see the doctor?” because new patients aren’t always happy with the answer. You can make this problem virtually disappear by becoming a ChiroHealthUSA provider. ChiroHealthUSA allows you to legally set up your own routine initial visit with a capped fee. Imagine what a relief it will be to your front desk staff to be able to tell uninsured, underinsured or partially insured new patients, “Your initial visit with the doctor will be no more than $125” (or whatever amount you choose—with ChiroHealthUSA, you, the doctor, set the fee schedule). For that matter, imagine the relief prospective patients will feel upon hearing they can afford such valuable care!
New Patient Phone Procedures The first, and possibly the most critical, procedure for your staff to master is the new patient phone call. A great way to start is to establish specific appointment blocks for scheduling new patients. Some offices like to cluster these in the middle of each shift; other practices prefer to place new patients at the bottom of each hour (9:30, 10:30, etc.). Still others hold by a looser, “We Accept New Patients Any Time” policy. It doesn’t really matter which you pick. The key is to be c o n s i s t e n t , a n d t o p r o v i d e a n e a s y, standardized scheduling procedure for your front desk staff. Take the time this week to decide upon and set a standard for your practice. And clearly communicate this to your team.
Removing the dread from answering that allimportant financial question will make your front desk staff’s job so much easier. And let’s face it, when your front desk is happy, odds are good that everyone else is, too! Use this month to improve your efficiency and outcomes as a team by committing to refining your New Patient procedures. Go to www.ChiroHealthUSA.com to attend a webinar to learn more about how we can help you in this essential process.
New Patient Examination Process Dr. Foxworth is a certified Medical Compliance Specialist and President of ChiroHealthUSA. A practicing Chiropractor, he remains “in the trenches” facing challenges with billing, coding, documentation and compliance. Dr. Foxworth is a 1984 Honors Graduate, (Cum Laude), of Cleveland Chiropractic College in Kansas City, MO. He served as Staff Chiropractor for the G.V. Sonny Montgomery VA Medical Center 4 years and is a member of the American Chiropractic Association and a 3 term past-president of the Mississippi Chiropractic Association. He was voted by his peers as
It’s easy for busy doctors like us to fall into a routine and overlook the obvious, such as maximizing the intake process. Obviously, this is less than ideal from a diagnostic perspective —but it’s also bad business. Spending the time to take a thorough patient history and perform a thorough exam will, not only leave you betterinformed about your new patient’s issues, but it will also boost your bottom line. How? By doing Texas Journal of Chiropractic
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Chiropractor of the Year for several years and is currently a Fellow of the International College of Chiropractic. He was appointed to the Mississippi State Board of Health by Governor Kirk Fordice and again by Governor Ronnie Musgrove and served 12 years, two of them as C h a i r m a n . Yo u c a n c o n t a c t D r. F o x w o r t h a t 1-888-719-9990, info@chirohealthusa.com or visiting the ChiroHealthUSA website at www.chirohealthusa.com
Successful African-American Chiropractors– Dr. Steve Minors
Dr. Steve Minors–Educate, Help, Inspire By Mary Clark, TCA Journalism Intern Steve Minors D.C. has been in the practice of chiropractic in Austin, Texas, since 1996. His clinic, Rehabfx, is located on Lake Austin Boulevard in a welcoming limestone house that he has converted into an office. I sat down with Dr. Minors during his lunch hour and we discussed a variety of things–from his past experiences with the Texas Board of Chiropractic Examiners and the Texas Chiropractic Association, to how the world of chiropractic is evolving and what he believes the future will hold. Dr. Minors told me that his time spent working within the political world has helped him to better understand the inner workings of government and the thought processes of policy makers. He urges other chiropractors to become politically involved, to learn how things work within our government and, more especially, to make sure that their voices are heard by the makers of governmental policy. The future of chiropractic care is going to be shaped by government policies and elected officials, Dr. Minors believes. The general public is starting to wise up to the n e g a t i v e e ff e c t s o f m e d i c a t i o n - b a s e d healthcare, and are starting to lead better, health-focused lives. These attitudes are impacting how and whom they vote for. People are starting to focus on improving their overall health and paying attention to what they are putting into their bodies. People want natural, chemical free pain relief options, and they are www.chirotexas.org
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looking to chiropractors and other alternatives to medicine for the answers. Dr. Minors says this can only be a positive for the chiropractic community.
“Don’t be afraid to tell the truth,” Dr. Minors reminds us.
When Practices Fail – Warning Signs and Solutions
Now is the best opportunity for chiropractic doctors to step up to the plate to educate people about their nervous system. Dr. Minors feels that this is the moment for chiropractors to go beyond the common perception of just treating a patient’s musculoskeletal system. Patients want truth. They want an explanation about their condition and how to help it get better. They deserve an answer that goes beyond just a “take this pill and call if it doesn’t get better in a few weeks.” Chiropractors can offer patients the answers about why their back hurts and provide a holistic, natural approach to treatment.
By: Drew Stevens, PhD Television programming has changed in recent years and as you know reality television is exceedingly popular. There is a fairly new show known as “Hoarders” where individuals or couples are featured for hoarding intense amounts of household materials. The one fascinating concept from these shows is that all individuals seem stupefied by how quickly and how intense the hoarding. Unfortunately many chiropractic practices suffer similarly. Doctors and their staff leave one day and return wondering how on earth the practice suffers. Suffice to say many practices fail. In according to the Bureau of Labor and Statistics, 98% of most small businesses fail within the first 5 years. Just because one is a chiropractor does not mean that the odds are not against you.
Dr. Minors has this message for his fellow chiropractors: “we have to be what the public wants.” The public wants answers, wants help, and wants ways to improve their lives, he says. Patients want to improve their lives and feel good. They need a doctor that cares, listens, offers answers, and treats them with respect.
What becomes necessary is to look for warning signs and know when to turn it around quickly. Before I get into cause-and-effect, when I visit many chiropractic colleges and speak with the soon-to-be graduates there is a notion that they will never fail. Ironically, many believe that their Established over half a century ago, this award is for practices will be an instantaneous success and that they will never fail. the purpose of recognizing doctors who have shown All chiropractors young and old will outstanding dedication and who have made longhave volatility in the practice therefore lasting contributions to the profession and their it is necessary to understand where community, and who are under 40 years of age at the you might have issues and how to time of the award’s receipt. quickly resolve them. Send nominations to 2010 recipient: Cause-and-effect Number One Dr. Tyce Hergert, D.C. Awareness 1500 W. Southlake Blvd #120 Southlake TX 76092 Jeff Foxworthy the American comic has an act that typically begins if or via email at this…than that! The same can be www.chirocaresouthlake.com said about your chiropractic practice
Call for Nominations for Young Chiropractor of the Year
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when it is failing. If you are beginning to see less volume in the business and your expenses are higher than your income, then you might have a huge problem. The rationale for low patient volume includes but is not limited to poor marketing activities, lack of patient referrals and most of all a lack of activity that creates awareness in the local community.
even writing articles in regional periodicals. The more intense you are about activities the more capability to bring back patients into your waiting room. Cause-and-effect number 2 - Measurement Many of you reading this article right now might say in standard conversation that you know of how many patients you service weekly or even monthly. However, when I engage certain chiropractors in conversation I typically ask about expenses or I even ask about account receivables and unfortunately they do not know the answer. Chiropractors that do not stay close to the numbers do not have a successful practice. Chiropractic operates in one of 2 ways cash or co-pay. Yet no matter what every patient must pay for service. Unfortunately, too many chiropractors are shortsighted and see the
Chiropractors must remember that there are three conditions for chiropractic marketing: A) patients have no idea who you are, B) patients are already with another chiropractor and C) patients don’t have a want or need for chiropractic. Therefore, when the practice begins to fail the very first remedy for any chiropractic practice is to intensely begin activities that create awareness and help build local community. Many of these include patient referral systems, networking, speaking and www.chirotexas.org
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money coming in and quickly buy material goods forgetting to invest back into the practice or more importantly even save for the future. Therefore, the effect of not saving money or investing back into the business will deeply impact your practice in years to come. The solution to this issue than it is to measure every inflow and outflow so that you are close enough to the numbers and understand how to run a profitable practice.
everything, this only leads to business failure because one cannot be a jack of all trades. Cause-and-effect number 4 - Customer (patient) service Ron is a chiropractor who after 8 years built a practice of approximately 100 people per week. Currently he is only seeing 22. After some mystery shopping it was found that patient service is not top of mind. In fact, it is patient service that has dropped his volume by over 80%. The reason why practices fail is the front desk, the operations and even the doctor. him or herself. If you want your practice to fail, then simply fail to provide proper patient service.
The best methods of measurement include spreadsheets that illustrate the number of patients that you’re seeing per week and the amount of payables and receivables. Additionally, breaking down your receivables by insurance carrier and type will help you to understand how quickly or slowly money arrives. Additionally and returning to the point made earlier on marketing activities, one should also monitor the amount of activities conducted each week to illustrate how those activities assist in producing more income. Ultimately chiropractors are best off reviewing profit and loss statements and producing sales forecasts so that the practice runs in the black.
No matter what patient service has got to be the pinnacle part of every practice. Patient services must be enculturated into the entire practice. This begins with hiring the right people as well as having a doctor that is concerned with total patient care from the inside and out. Therefore, telephones must be answered on the second ring, e-mails must be answered within 6 hours and finally staff understands that patients are not an interruption of the practice, but the purpose of it! If patient service is not part of the culture he practice will fail.
Cause-and-effect number 3 - Delegation One of the biggest problems with any small business including chiropractic is learning how to delegate. Chiropractic much like any other business especially when starting out tends to use a “poor man’s syndrome.” In other words, many chiropractors will say they do not have money to pay for particular services. This has them treating less patients because they are busy with coding, billing, scheduling and a myriad of other responsibilities. Chiropractors can’t do it all and a poor man’s mentality will make the practice fail.
Additional recommendations include websites that have proper contact information and speak of results and outcomes for the patient. Also included are testimonials and case studies from former patients. Further, confirmation of appointments, handling of insurance claims and ensuring that all paperwork is submitted timely is all part of the patient experience. Finally, your patient experience begins with the ROF, so make certain that patients know how much you care from the moment of the first treatment.
Chiropractors must learn to delegate. They must learn whether part-time or virtually to find the right people to assist them. Even for just a few hours a day delegating tasks allows the doctor to focus on one of the most important assets of the practice-patients. When chiropractors do not delegate they control Texas Journal of Chiropractic
Cause-and-effect number 4 - Appointments Without sounding too fundamental every practice is built on the number of patients scheduled and examined. However, much like any businesses there are many rescheduled or canceled appointments. Yet I often find that if the chiropractor is busy or the staff lacked 24
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proper protocols patients are never called to reschedule. This is one of the easiest things to miss in any chiropractic practice. John recently had 22 appointments in a week canceled and none of them were rescheduled. Realize that this is missed income.
Back Pain Is #1 Cause of Disability Worldwide A series of studies emerging from the Global Burden of Disease 2010 Project clarifies the worldwide health burden of musculoskeletal conditions, particularly back and neck pain, in crystal-clear fashion. This project is a massive collaboration between the World Health Organization, the Institute for Health Metrics and Evaluation (the coordinating center), the University of Queensland School of Population Health, Harvard School of Public Health, Johns Hopkins Bloomberg School of Public Health, and the University of Tokyo, Imperial College London. Low back pain is identified as the number-one cause of disability worldwide and neck pain the number-four cause. Overall, musculoskeletal conditions represent the second leading cause of global disability.
The only way to mitigate this issue is to ensure that patients are called immediately so that missed appointments are rescheduled. There is technology available that allows you to confirm appointments with the use of text messaging, emails or even voicemails to remind patients. There is less labor on your part and less opportunities for patients to miss appointments. Further, many chiropractors should install a canceled appointments policy. This is highly recommended because your time is valuable and when a patient misses an appointment it is as if 2 patients cancel because someone else may have called for that same time. And, it dismisses the value of your time and expertise.
Findings emphasize the shift in global health that has resulted from disability making an increasingly larger footprint on the burden of disease compared to a mere 20-30 years ago. In addition, while more people are living longer, the flip side is that they do so with an increasing risk of living with the burden of pain, disability and disease compared to generations past.
Practices need not fail if the proper protocols and procedures are installed. Chiropractors today must be more proactive. This includes installing good strategies that provide enough foundations so that the practice is protected during good and bad times. The only way to ensure that your practice never fails is to remain on top of it. The practice is not an avocation but an occupation that must be protected daily. Never should any chiropractor walk into a situation and say “how did I get here?” With the proper systems your practice should never have to worry about any warning signs. Rather than just survive you will thrive no matter what!
Dr. Scott Haldeman, provides an analysis of the Global Burden of Disease 2010 findings, highlighted as follows: Musculoskeletal conditions such as low back pain, neck pain and arthritis affect more than 1.7 billion people worldwide and have a greater impact on the health of the world population (death and disability) than HIV/AIDS, tropical diseases including malaria, the forces of war and nature, and all neurological conditions combined.
© 2012. Drew J Stevens, all rights reserved. Drew Stevens is the author of Practice Acceleration and over 700 articles on chiropractic practice strategy. For additional information visit his website at www.Stevensconsultinggroup.com or call him at 877-391-6821.
When considering death and disability in the health equation, musculoskeletal disorders cause 21.3 percent of all years lived with disability (YLDs), second only to mental and behavioral disorders, which account for 22.7 percent of YLDs.
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“Analyze, Examine, or Evaluate”--ONLY OR Properly “Diagnose” TEXAS MEDICAL ASSOCIATION
2006 -- ROUND 1
TEXAS CHIROPRACTIC ASSOCIATION
TMA vs TBCE Win TEXAS CHIROPRACTIC ASSOCIATION
Loss
2009 -- ROUND 2
TEXAS MEDICAL ASSOCIATION
TCA APPEAL Win TEXAS CHIROPRACTIC ASSOCIATION
Loss
?
2013 FINAL ROUND Texas Supreme Court Win or
Loss
TEXAS MEDICAL ASSOCIATION
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Going, Going, Gone? In#2006#the#Texas#Medical#Associa5on#sued#the#Texas#Board#Chiroprac5c#of#Examiners# challenging#Texas#Chiropractors’#ability#to#render#any#diagnosis.#The#District#Court# ruled#that#while#Chiropractors#are#allowed#to#diagnose,#the#Board#rule#allowed# Chiropractors#to#diagnose#too#much,#so#it#was#overly#broad.#The#District#Court#struck# down#the#rule#but#maintained#the#chiropractors’s#right#to#diagnose#for#a#limited# purpose.# The#TCA#appealed#the#rule#invalida5on#on#behalf#of#TBCE.#TCA#successfully#argued#that# the#rule#was#valid#because#it#allowed#Chiropractors#to#diagnose#for#purposes#within#the# scope#of#their#prac5ce.#The#Appellate#Court#agreed. TMA#appealed#to#the#Texas#Supreme#Court.#On#January#18,#2013,#the#Texas#Supreme# Court#agreed#to#hear#the#appeal.##This#means#that#the#ability#to#diagnose#is#again#in# ques5on#and#the#scope#of#that#diagnos5c#ability#will#also#be#considered! Without#the#ability#to#diagnose,#ul5mately#chiroprac5c#physicians#would#be#required# to#acquire#a#referral#from#an#MD#or#DOQQthe#ul5mate&medical&victory.&&Chiroprac)c,%as% we%know%it%would%disappear!% Unfortunately#what#happens#in#Texas#won't#stay#in#Texas.#We#believe#that#if#TMA#wins# here#the#AMA#will#bring#the#fight#to#courts#all#over#the#United#States.# Texas’#legal#team,#led#by#a#former#Supreme#Court#Jus5ce,#is#“the#best#that#money#can# buy!”#Now#we#need#the#money#to#do#that!##But#we#can't#do#it#alone!#We're#desperately# fundraising#here#in#Texas.##Please%consider%joining%our%fight%by%sending%a%contribu)on% to%our%Chiroprac)c%Defense%Ini)a)ve.#
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Musculoskeletal conditions represent the sixth leading cause of death and disability, with only cardiovascular and circulatory diseases, neonatal diseases, neoplasms, and mental and behavioral disorders accounting for more death and disability worldwide.
“The Global Burden of Disease Study provides indisputable evidence that musculoskeletal conditions are an enormous and emerging problem in all parts of the world and need to be given the same priority for policy and resources as other major conditions like cancer, mental health and cardiovascular disease,” said Dr. Haldeman.
Low back pain is the most dominant musculoskeletal condition, accounting for nearly one-half of all musculoskeletal YLDs. Neck pain accounts for one-fifth of musculoskeletal YLDs.
The seven studies from Global Burden of Disease 2010, as well as accompanying commentaries, appear in The Lancet. To review the studies and all relevant material, click here.
Low back pain is the sixth most important contributor to the global disease burden (death and disability), and has a greater impact on global health than malaria, preterm birth complications, COPD, tuberculosis, diabetes or lung cancer.
Modeling your Practice with “Practice” By: Drew Stevens PhD
When combined with neck pain (21st most important contributor to the global disease burden including death and disability), painful spinal disorders are second only to ischemic heart disease in terms of their impact on the global burden of disease. Spinal disorders have a greater impact than HIV/AIDS, malaria, lower respiratory infections, stroke, breast and lung cancer combined, Alzheimer ’s disease, diabetes, depression or traffic injuries.
I recall running into a prospective client for my coaching services. Paula was struggling like mad with over nine patients per week! I immediately asked to see her business plan and model. She did not have one. I asked to see a list of her marketing and promotional activities. She did not have one. Then I asked to see her invoices and she did not have time to find them because she was busy trying to find a code for her new patient. The time… 7 hours! When you do not have a plan, then plan to fail.
Current estimates suggest that 632.045 million people worldwide suffer from low back pain and 332.049 million people worldwide suffer from neck pain.
Similar to the manner in which you use a map or compass to hike or drive to a destination, you need the model to ensure success. According to the Bureau of Labor and Statistics, 96 percent of small businesses (1–99 employees) that enter the marketplace survive for 1 full year. Unfortunately, data for physician practices are difficult to find, but the data weigh heavily against a positive outcome. What I suggest is using the PRACTICE METHOD to aid in the success of your practice. Since chiropractic is an intangible service, the only thing binding the chiropractor and staff to the patient is a culture of unbridled service. Building these relationships takes much time
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and effort. Athletes practice, students practice, musicians practice, physicians practice… but do they really? If you desire the proper relationships and the proper method to developing a great business model for your practice, perhaps now is the time to treat your profession like an athlete does. Therefore,you must practice it.
about poor products and services; it is simply a poor culture.
T
Treatment Plans Know whom you will treat and why. Always have a picture of your perfect patient and how you treat them. The more specific you are, the easier it becomes to create a culture, conduct your billing and then ultimately your marketing.
I frequently use mnemonics to make items memorable. For this I use “practice”:
I
Invite Others The more individuals you meet, the larger the pipeline and this always needs to be full so that you can create constant streams of incomes.
P People Make a Difference Remember that, at all times, people are the front and center of your practice. When you treat them correctly, people will inform others. This helps to build awareness of the practice and the community that will support the practice. Additionally, your office staff is part of the promotional process. Staff become marketing avatars with the use of exceptional customer service and treating patients like royalty.
C
Consider Delegating and Help The doctor cannot treat, bill, code, book appointments, etc. There needs to be a time when practice procedures are delegated to others. A contributor to the lack of productivity is the inability to delegate.
R
Relationships Inside and Out It is necessary for you to build relationships wherever, however and whenever you are with someone. Your patient base only increases with the ability to extend your network. This requires that you, your patients and your office staff work synergistically to continually build your community.
E
Evaluate Consistently No practice survives without using benchmarks and plans for evaluation and improvement. The best practices always adjust when presented with new opportunities and better methods for success.you do the same for your patient? Building your practice requires that you focus on 5 things everyday to ensure nothing goes awry. These include:
A Attention to Retention An absolute must for any doctor. Retention helps develop the practice. It is one thing to treat immediate care and get the patient out of pain but another to keep them on a healthy maintenance schedule. Therefore, you should always be thinking and have the patient thinking about the future.
· Find new customers in an economical way · Keep them coming back time after time · Keep your operating costs low · Manage the cash flow · Continually innovate
C Culture Is King The manner of dress, the
These however, are not possible unless a proper business model helps to support the practice.
code of ethics, the office procedure, the manner in which patients are greeted, rescheduled, billed, etc., is all part of the practice culture. This stops and starts with the doctor. There is a reason why so many businesses fail. It is not www.chirotexas.org
The model for a chiropractor is much like the GPS or OnStar© unit for your automobile. 29
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These tell you where you are going, how you are going to get there and what obstructions to avoid.
TCA Takes to the Capitol
When you model your practice with PRACTICE, you begin to implement a course of actions that turns your fantasy into reality, eliminates obstacles and streamlines your success toward a healthy and wealthy practice.
For the staff and TCA members arriving at the Texas Capitol on February 6, 2013, the morning began as a rainy and overcast day. Even so, by eight-thirty in the morning the lower level conference room in the Capitol Extension had filled with chiropractors mingling over coffee and preparing themselves for a day of visiting, greeting, and presenting the chiropractic profession to the legislators and their staff.
© 2013. Drew Stevens PhD. Drew Stevens transforms struggling chiropractors into wealthy chiropractors. And he operates one of the leading practice management firms in the country. His knew book “Practice Acceleration” is available through Greenbranch Publishing. He can be reached through his website at www.stevensconsultinggroup.com
By Mary Clark, TCA Journalism Intern
TCA President Jorge Garcia, D.C. began the work of the day. Dr. Garcia welcomed everyone and introduced John Darby, the TCA’s new CEO. John spoke briefly introducing himself and then welcomed the TCA’s lobby team. Mr. Jeff Heckler and Mr. Ray Allen of GovBiz spoke to the assembled doctors about speaking with their legislators and presenting the prepared content outlining how they can support chiropractors. Ray encouraged everyone, explaining that there was no need to feel intimidated about talking to their representatives. He pointed out that a comfortable and positive social interaction with staff by asking them to review the chiropractic legislative goals and ask them for their support for chiropractors would lead to a positive effect. Ray went on to review current legislative goals that GovBiz is pursuing during this session. Following review of the twelve legislative goals, the doctors of the TCA dispersed to keep appointments and make office calls on the nearly 187 offices in the state capitol. Doctors visited various representatives and senators, not just those of their own district. This made the day a truly social event of personal interaction.
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I had the privilege of accompanying Tyce Hergert D.C., and Michael McGarrah D.C. on one of their visits. Dr. Hergert and Dr. McGarrah paid a visit to Representative Tan P a r k e r o f F l o w e r M o u n d , T e x a s . Representative Parker was very receptive to their visit and discussed the concerns of the 30 www.chirotexas.org
chiropractors. As chiropractic patient himself he expressed understanding of the value of chiropractic care.
As part of the TCA Day at the Capitol, a BBQ lunch was served in the conference room and hundreds of legislative staffers attended to learn more, to visit with the chiropractors, and to enjoy a delicious plate of BBQ with all the trimmings. During lunch, I had an opportunity to talk with many of the doctors about their visits with representatives. Most had positive experiences to share. I also had a chance to discuss issues such as student loan debt and the importance of chiropractic networking in the healthcare community.
I next caught up with several doctors and observed Chad Blackwell D.C., and Jack Albracht D.C., and several others conducting filmed interviews for the future use of the TCA. Before I realized it, I was on my way to the House floor with Doctors Aubert, Albracht, Blackwell, Garcia, and Welch. The TCA was to be officially recognized on the house floor. We went to Representative José Menéndez’s office, the sponsor of the resolution recognizing the TCA and chiropractic. One of his staff members took us to the entry of the floor of the Texas House of Representatives.
As part of TCA Day at the Capitol chair massages were offered to Capitol staff. The chair massages where a huge hit and left many stressed representatives and their staffers relaxed and ready to go back to work. The Texas Chiropractic Auxiliary provided and distributed 187 lumbar chair cushions emblazoned with the TCA logo to various offices in the Texas Capitol. The lumbar supports are always much appreciated. Throughout the day a large number of people passed through the conference room, and staffers from a number of offices throughout the Capitol ate and visited with doctors and TCA staff about chiropractors and their services. Overall, TCA Day was a huge success for promoting the importance of chiropractors and patient choice. Everyone seemed to have a great time and enjoyed catching up with fellow chiropractors and meeting with their state leaders.
Doctors Albracht, Garcia, Blackwell, Welch and Aubert on the way to the House Floor While waiting, we had time to look around the foyer outside the floor on the lower level. There were several flags from various periods of Texas history. It was a thrill to see a part of the Capitol usually reserved for members and their staff. When we were allowed onto the floor, Johnny Manziel, Texas A&M’s Heisman Trophy Winner, was being honored. The House gallery was full and most of the representatives were present on the floor, as Doctors Aubert, Albracht, Blackwell, Garcia, and Welch were led out on to the floor. Representative Menéndez gave a speech in support of chiropractors and the resolution was passed declaring February 6, 2013 as TCA Day.
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It was an honor to be able to follow the TCA leadership onto the floor of the Texas House of Representatives, to visit and interact with the doctors and representatives present for the event, and to be able to share with you my observations. I enjoyed getting to meet a few of the doctors that make up the TCA’s Board of Directors. I learned of leads for future stories for your consideration. I am excited as I continue my journalism internship with the TCA these next several months! If you have ideas for future articles won’t you share them with me at mary@chirotexas.org. 31
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“(3) represents to the public that the person is a chiropractor; or (4) uses the term ‘chiropractor’, ‘chiropractic’, ‘doctor of chiropractic’, D.C.’, or any derivative of those terms or initials in connection with the person’s name.”
To Be, or Not To Be; and the Use of “D.C.” By: Chris G. Dalrymple D.C., F.I.C.C. For years now the chiropractic profession has wrestled with a number of dilemmas. One is what to do when one has earned a Doctor of Chiropractic degree, is in possession of a degree from the appropriate college or university that names one as D.C., BUT one is not yet licensed by the Texas Board of Chiropractic Examiners. Can one identify themselves with their title and the degree?
So an individual using any of the following has then identified themselves as being “in the practice of chiropractic” which is directly overseen by the TBCE: Dr. TheirName D.C.; TheirName D.C.; TheirName, Doctor of Chiropractic; TheirName, XYZ Chiropractor, (where XYZ describes some descriptor of a type of chiropractic or chiropractor such as “animal”) TheirName, XYZ Chiropractic; or any similar derivative of those terms or initials with the person’s name.
The answer is no, not in Texas. The way that our law is written you may not use “Dr. D.C.,” “chiropractor,” or similar words to identify yourself because these designations are reserved to the licensees of the TBCE. While reality would seem to indicate one thing, the laws of Texas require a different reality.
But there is also a law within the Occupations Code relating to “Healing Arts Practitioners” Section 104.003 REQUIRED IDENTIFICATION. This law requires that licensees of the Texas Board of Chiropractic Examiners use “chiropractor,” “Doctor, D.C.,” doctor of chiropractic,” or “D.C.”
Similarly, if one IS licensed by the TBCE, but desires to conduct a business for which they have been specially trained, but such business is, or may be considered to be outside the scope of chiropractic practice–animal chiropractic for example–can one identify themselves by either their degreed or their licensed designation using D.C. after their name? Again, the answer in Texas is no. “D.C.” in Texas is restricted to licensees of the TBCE and licensees of the TBCE may only practice within the scope of chiropractic in Texas.
Sec. 104.003. REQUIRED IDENTIFICATION. (a) A person subject to this section who uses the person’s name on a written or printed professional identification, including a sign, pamphlet, stationery, or letterhead, or who uses the person’s signature as a professional identification shall designate as required by this section the healing art the person is licensed to practice … (e) A person who is licensed by the Texas Board of Chiropractic Examiners shall use: (1) chiropractor; (2) doctor, D.C.; (3) doctor of chiropractic; or (4) D.C.
Another is if one forsakes use their credentials in any manner, yet uses a descriptor such “chiropractic” in association with one’s name– such as “John Smith, animal chiropractor” one was likewise in violation of the Chiropractic Act. Such conundrums have long left many within our profession with confusion. Let’s look specifically at the various laws involved in this matter.
This law also makes provision for “others who use the title doctor.” Says Section 104.004: Sec. 104.004. OTHER PERSONS USING TITLE “DOCTOR”. In using the title “doctor” as a trade or professional asset or on any manner of professional identification, including a sign,
The Chiropractic Act in Texas says that a person “practices chiropractic” IF the person: Texas Journal of Chiropractic
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pamphlet, stationery, or letterhead, or as a part of a signature, a person other than a person described by Section 104.003 shall designate the authority under which the title is used or the college or honorary degree that gives rise to the use of the title. Thus it is then that when one has a doctorate but is not acting under the auspices of one of the licensed healing arts professions they should be able to make use of their title “doctor” as long as they designate the authority under which the title is issued. Thus one can be “Dr. TheirName, graduate of Texas Chiropractic College” or “Dr. TheirName, degreed by Texas Chiropractic College”; or “Dr. TheirName, graduate of Parker University School of Chiropractic.” In this manner one may comply with Section 100.004 of the Occupations Code by identifying by what authority “Dr.” is used and at the same time not designating that they are necessarily acting as a licensee of the TBCE as long as they are not actively involved in practicing chiropractic in any other manner.
If the business you are conducting IS chiropractic then you must use “D.C.,” “chiropractor,” “chiropractic,” or any other derivative as part of your name as if it were a title.
•
If you are conducting business under the purview of another healing art, such as providing your services to animals, make sure that you are complying with ALL of the rules and regulations of that licensing entity– for you are following their rules within their business. To avoid confusion as to whether you are acting under the Chiropractic Act or another healing arts act, do NOT use “D.C.,” “chiropractor,” “chiropractic,” or any other derivative as part of your name as if it were a title, but you may cite the credentialing authority which issued any title you do use, e.g. “Dr. X, graduate of Y chiropractic college.”
If you are conducting business that is not, or may not, be considered to be within the scope of chiropractic AND it is not regulated by the state by any other agency then do NOT use “D.C.,” “chiropractor,” “chiropractic,” or any other derivative as part of your name as if it were a title, but you may cite the credentialing
If one is conducting a business that does not fall within the realm of another healing art or profession licensed by the state; or if it is permitted that the conduct of such a business falls under the auspices of another healing art or profession and one is a degreed professional, One merely must cite the authority that credentials them. Thus: •
•
If the business you are conducting is NOT chiropractic OR if you are NOT licensed by the TBCE then do NOT use “D.C.,” “chiropractor,” “chiropractic,” or any other derivative as part of your name as if it were a title.
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authority which issued any title you do use, e.g. “Dr. X, graduate of Y chiropractic college.”
Another key role for DCs in the national health care transformation is that of primary care provider. While there is intraprofessional debate about the definition and scope of duties of a PCP, what is not up for debate is that when patients enter our offices, they must be properly examined and diagnosed prior to treatment. In fact, many recent studies reveal that when a treatment plan is developed and initiated by a DC, costs, diagnostic testing, medication and surgical utilization goes down. We must never give up the ability to have direct access to patients and to perform and order appropriate and necessary diagnostic studies. A study from the Journal of General Internal Medicine nicely highlights how important it is to retain our physician-level training and services.
ACA President Reports the “State of Chiropractic” As we close in on ACA’s 50th anniversary gala celebration during the National Chiropractic Legislative Conference (NCLC) and Educational Symposium next month in Washington, D.C., I can’t help but think about the amazing opportunities standing before our profession. For example, recent estimates show that there will be a shortage of more than 90,000 primary care medical physicians in the U.S. over the coming years, and society is finally looking at the need to increase wellness and preventive services.
On the other hand, if you think our role as PCPs is so obvious we need not spend our valuable resources talking about it, please know that the Florida Medical Association (FMA) recently passed a resolution (unanimously) that would seek to stop DCs in the Florida from calling themselves doctors. According to the Florida Chiropractic Physician Association:
A study by the World Health Organization found that spinal conditions rank among the most prevalent health issues impacting the entire world’s population, and additional studies show that these same spinal conditions represent a major reason patients visit their primary care providers (PCP). Therefore, our challenge in Washington, D.C., is to make certain our legislators recognize the important role chiropractic physicians can play in this new health care paradigm.
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 Governor’s may wish to direct FMA staff to consult and coordinate with specialty societies on possible legislative remedies.
Research Is On Our Side. A number of recent articles illustrate the current health care landscape. I’ll start with an interview with Alan Post, DC in Rhode Island. Nationally, Medicaid will be expanded to help cover the 40 million newly insured by the health reform law. Dr. Post developed a pilot program in Rhode Island which found that if a patient utilizes the services of a DC, the cost for chronic pain care may be greatly reduced while maintaining exceedingly high outcomes and satisfaction. Dr. Post’s pilot will become a benchmark program as it becomes more patient and provider friendly. I want to emphasize that I believe each state should try to harvest this type of true data in its own system to help create opportunities to save significant Medicaid dollars. Texas Journal of Chiropractic
So I ask you, is the FMA–and its national organization, the American Medical Association, which recently passed a similar resolution to eliminate section 2706, the provider nondiscrimination clause, from the health reform law–primarily interested in patient welfare, or is there something a bit more self-serving going on? 34
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Take a look at a recent study in Spine. It showed that care initiated by a DC was associated with a nearly 50% lower likelihood of MRI within the first six weeks of low-back pain (LBP) symptoms. Chiropractic providers are actually more likely to use radiographs which are substantially cheaper than MRIs, and clinical outcomes do not differ by imaging modality. The research suggests that care initiated by a DC results in significantly lower costs and greater patient satisfaction.
more coordinated have been too slow in creation. Within HHS, programs are too separated, according to the authors of the 98-page report, who describe programs at the Centers for Disease Control and Prevention as “often siloed and based on diseases and conditions,” instead of offering integrated and focused prevention strategies. We are the doctors of the future. Our patients and society deserve the option of conservative care as a first step. For our patients’ sake, we cannot and should not give up the battle even for a moment, and we couldn’t even think of doing it without YOU.
Even Harvard Medical School Says It’s Time to Work Together. The Harvard Medical School special health report, “Low Back Pain – Healing Your Aching Back,” outlines factors leading or contributing to LBP and suggests therapeutic options for patients who live with it. Chiropractic is listed as a viable therapeutic option for patients suffering from acute LBP, noting that chiropractic relieves pain and reduces the necessity of medication for some of these patients.
Too Many Pills in Pregnancy Pregnancy-related hazards are linked to many medicinal substances: prescription and overthe-counter drugs and herbal remedies, as well as abused drugs and even some vitamins.
The report quotes “a 2010 review of 12 different studies involving 2,887 people with low back pain,” which concluded that “chiropractic care improved short- and medium-term pain more than other treatments, including exercise, physical therapy, and medication …People who saw chiropractors also reported being less disabled over the short term (one month) compared with people who received other treatments such as standard medical therapy.”
Now, however, the latest findings about drug use during pregnancy have ignited new concerns among experts who monitor the effects of medications on the developing fetus and pregnancy itself. During the last 30 years, use of prescription drugs during the first trimester of pregnancy, when fetal organs are forming, has grown by more than 60 percent.
Of course many DCs offer much more than spine care and believe we are one of the few doctoral-level professions that really understand prevention. A report from the not-for-profit Trust for America’s Health is calling for a revamp of public health management at the federal, state and local levels, in a report that urges a greater focus on preventive care. “A Healthier America 2013: Strategies to Move From Sick Care to Health Care in the Next Four Years,” argues that the different agencies in the U.S. Department of Health and Human Services (HHS) involved with preventive healthcare should work more closely together to coordinate efforts, and that existing attempts to become www.chirotexas.org
About 90 percent of pregnant women take at least one medication, and 70 percent take at least one prescription drug, according to the Centers for Disease Control and Prevention. Since the late 1970s, the proportion of pregnant women taking four or more medications has more than doubled. Nearly one woman in 10 takes an herbal remedy during the first trimester. A growing number of pregnant women, naïvely assuming safety, self-medicate with over-the35
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counter drugs that were once sold only by prescription.
The traditional Mediterranean diet, the researchers noted, is characterized by lots of olive oil, fruit, nuts, vegetables, legumes, and cereals, some fish and poultry, and limited amounts of dairy products, red meat, processed meats, and sweets. As well, the diet includes moderate amounts of wine with meals.
The Food and Drug Administration estimates that 10 percent or more of birth defects result from medications taken during pregnancy. “We seem to have forgotten as a society that drugs pose risks,” Dr. Allen A. Mitchell, professor of epidemiology and pediatrics at Boston University Schools of Public Health and Medicine, said in an interview. “Many over-thecounter drugs were grandfathered in with no studies of their possible effects during pregnancy.”
Watchful Waiting Best for Ear Infections Stricter diagnostic criteria and broader use of observation to further rein in antibiotic prescribing for acute otitis media emerged in a revision of American Academy of Pediatrics (AAP) guidelines. The update, in the March issue of Pediatrics, also added a recommendation against antibiotic prophylaxis for kids with recurrent ear infections.
“Among medications approved for use in the U.S.A. from 2000 to 2010, over 79% had no published human data on which to assess teratogenic risk (potential to cause birth defects), and 98% had insufficient published data to characterize such risk,” the authors wrote.
The 2013 guidelines are specifically for uncomplicated acute otitis media at ages 6 months to 12 years in otherwise healthy children without tympanostomy tubes, anatomic abnormalities such as cleft palate or Down syndrome, immune deficiencies, or cochlear implants. The pediatrics organization also cited overdiagnosis, “often without adequate visualization of the tympanic membrane,” as a problem.
“Many medications that are not recommended during pregnancy can be replaced with low-risk alternatives.” A reliable online resource for both women and their doctors, Dr. Mitchell said, are fact sheets prepared by OTIS, the Organization of Teratology Information Specialists, which are continually updated as new facts become available: http://www.otispregnancy.org.
The 2004 guidelines used a three-part definition for acute otitis media:
Mediterranean Diet Curtails Heart Troubles
• • •
Eating a Mediterranean diet rich in olive oil and nuts lowered the rate of major cardiovascular events, at least among people at increased risk for heart disease, researchers reported.
The 2013 update also requires middle ear effusion for diagnosis, but it now has to be based on tympanometry or pneumatic otoscopy. Although early acute otitis media can occur without effusion, the guidelines committee acknowledged, “the risk of overdiagnosis supersedes that concern.” They suggested that clinicians should be aware as they use these criteria that recent onset of ear pain and intense
In a randomized trial in Spain in high-risk people, those who ate the Mediterranean diet supplemented with extra-virgin olive oil or mixed nuts saw a reduction in the rate of major cardiovascular events by nearly 30% compared with a control group eating a low-fat diet. The results support the use of the Mediterranean diet for “primary prevention” of heart disease. Texas Journal of Chiropractic
Acute onset of symptoms Acute middle ear inflammation Middle ear effusion
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erythema of the ear drum can be the only otoscopic finding.
16.2% for 15- to 17-year-olds and 1.9% for 26to 44-year-olds.
Other diagnostic criteria are:
Alcohol is still the most widely studied prenatal drug of abuse, and the evidence is strongest for fetal growth problems, congenital anomalies, and abnormal infant neurobehavior.
•
•
•
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Moderate to severe bulging of the tympanic membrane or new onset of discharge not due to an infected ear canal
For nicotine, studies have consistently shown an effect on fetal growth, but longitudinal studies haven’t found a consistent effect on long-term growth problems.
Mild bulging of the ear drum and onset of ear pain within 48 hours, which could be indicated by holding, tugging, rubbing of the ear for nonverbal children, or intense redness of the tympanic membrane For less severe cases, watchful waiting could be offered instead of antibiotics in joint decision-making with parents or caregivers.
Marijuana appears to have no significant effects on fetal growth or congenital anomalies, but long-term studies have shown effects on behavior, cognition, and achievement. Opiates, on the other hand, have welldocumented effects on neonatal withdrawal syndrome, the most significant problem tied to these drugs.
Prophylactic antibiotics shouldn’t be prescribed to reduce recurrences, according to the AAP.
Studies on prenatal methamphetamine exposure are still in their infancy, but early work has shown an effect on fetal growth and infant
AAP Outlines Fetal Damage with Drug Abuse The effects of drugs on the developing fetus are wide-ranging and vary by substance and time of exposure, according to an American Academy of Pediatrics (AAP) report. Early in gestation, commonly used substances such as nicotine, alcohol, marijuana, opiates, cocaine, and methamphetamines can have teratogenic effects, but later in pregnancy, they’re more closely associated with brain development issues. Maternal alcohol use has been associated with fetal growth challenges and intellectual disabilities, while opiate use has been most significantly associated with neonatal withdrawal issues, they found. The overall prevalence of illegal drug use among pregnant women was 4.4%, and was highest among younger women, ranging from
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neurobehavior, although there doesn’t appear to be an effect on congenital anomalies.
figure out whether they need medications for conditions such as high cholesterol, under a proposal now before the FDA to make some prescription medications over the counter.
Walmart to Offer Health Screening Stations
Rival firms are marketing similar technologies. Dublin, Ohio-based HealthSpot has enclosed cubicles that allow patients to pay $59 to $79 for a video “visit” with a doctor. NowClinic online, a subsidiary of UnitedHealth Group, provides 10-minute video chats with physicians for $45.
A burgeoning consumer health industry is betting that as Americans gain coverage under the federal health law, putting increased demand on primary care doctors and spurring interest in cheaper, more convenient care, unmanned kiosks may be part of what their manufacturer bills as a “self-service healthcare revolution.
Technology “has become a new arm of the healthcare delivery system,” says Jay Sanders, an adjunct professor at Johns Hopkins University and CEO of The Global Telemedicine Group, a consulting firm in McLean, Va. “You need to bring the exam room to where the patient is, not where the doctor is.”SoloHealth’s founder and CEO Bart Foster saw larger possibilities for automated screening after he began providing Walmart with self-service vision tests as a way to get shoppers from the product aisles to Walmart’s optical shops.
“SoloHealth’s stations, slated to be in 2,500 Walmarts and Sam’s Clubs next month, to video consultations with doctors, to smartphone apps that track blood pressure and heart rate, consumer health technology is attracting bigname backers such as retailer Walmart, health insurers Wellpoint and UnitedHealthcare, and companies that make or distribute medical products, such as Johnson & Johnson and Cardinal Health.
In 2010, the firm got a $1.2 million grant from the National Institutes of Health to develop new approaches to screening for people in underserved communities. It has also received more than $43 million in investments from computer maker Dell, health insurer WellPoint, and Coinstar, maker of the Red Box DVD rental boxes, he says.
Walmart’s interest is especially significant, given the giant retailer’s reach, the growth of its pharmacies and retail medical clinics, outlining plans for a push into primary care. Some doctors’ groups and consumer advocates urge caution, raising concerns about how companies might use personal health data, the quality of their medical information, and whether advertisers and other sponsors might shape their advice and referrals for commercial reasons. “There is a trend in general by retailers and health insurers to provide ‘fluff’ to consumers in the guise of real medical information as an advertising delivery device,
Today SoloHealth’s kiosks, which are not connected to a live physician, allow consumers not just to test their eyesight and learn if they are obese, but to get information on diet, vitamins and pain management. A “find a doctor” function can direct users to nearby doctors, although the one in Sterling listed only “optical doctors” — and those appeared mainly to be Walmart-affiliated.
SoloHealth’s a Duluth, Ga.-based company, aims to expand its kiosk offerings to teach people how to quit smoking, test whether they are at risk for diabetes, and even enroll them in health coverage. Self-serve computer stations are also eyed as a way to help consumers Texas Journal of Chiropractic
SoloHealth has received lists of doctors from sponsors, including Walmart, and also allows doctors to buy a listing. SoloHealth does not do any independent review of doctors’ credentials. About 20 to 30 doctors are typically 38
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offered.”We’re treading a fine line,” Foster says. “We don’t want to practice medicine, just educate people.”But such programs raise a red flag for some consumer advocates who worry the “advice” might be an advertisement.ads, which can be targeted to particular consumers based on their answers, are SoloHealth’s revenue model. “Reach customers when they are aisles, not miles, away,” the firm’s message to advertisers on its website says.Users who enter their email addresses — and about 18% do — will receive test results, along with information that might include “ask your doctor about this drug” or “pick up some Advil on aisle four,” But the new technology carries potential risks. “You have a situation where a patient is voluntarily disclosing information, which means there is no privacy protection, generally.” “They may not know if the information is being kept and might be used weeks or years after.” SoloHealth’s Kendig says the firm is not considered a covered entity under the Health Insurance Portability and Accountability Act of
1996, meaning it is not law’s privacy standards. health information with providers, then it would standards.
required to meet the If it shares personal insurers or medical need to meet those
All information, except the email addresses, is aggregated and shared with SoloHealth sponsors without personal identifiers. Those who leave their email address can track their test results over time and may be sent more information, including newsletters targeted to specific health conditions.
Texas Legislative Bills Pertaining Directly to “Chiropractic” This list of bills, with a link directly to the text of the bill, all contain the word “Chiropractic” in them. Our legislative team is tracking many more bills that directly or indirectly affect our profession, but these mention the chiropractic profession by name. 83(R) HB 3335 - Introduced version - Bill Text Excerpt: BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: SECTION 1. Section 201.002(b), Occupations Code, is amended to read as follows: (b) A person practices chiropractic under this chapter if the person: (1) uses objective or subjective means to analyze, examine, [or] evaluate, or diagnose the biomechanical condition of the spine and musculoskeletal system of the human body; (2) performs nonsurgical, nonincisive procedures, including adjustment and manipulation, to improve the subluxation 83(R) HB 3187 - Introduced version - Bill Text Excerpt: BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: SECTION 1. Section 201.002(b), Occupations Code, is amended to read as follows: (b) A person practices chiropractic under this chapter if the person: (1) uses objective or subjective means to analyze, examine, [or] evaluate, or diagnose the biomechanical condition of the spine and musculoskeletal system of the human body; (2) performs nonsurgical, nonincisive procedures, including adjustment and manipulation, to improve the subluxation 83(R) HB 1169 - Introduced version - Bill Text Excerpt: BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: SECTION 1. Section 201.002(b), Occupations Code, is amended to read as follows: (b) A person practices chiropractic under this chapter if the person: (1) uses objective or subjective means to analyze, examine, or evaluate the biomechanical condition of the spine and musculoskeletal system of the human body or the condition of another system of the human body that is affected by the musculoskeletal system; (2) performs nonsurgical 83(R) HB 2925 - Introduced version - Bill Text Excerpt: PAYMENT DISPUTES RELATING TO CHIROPRACTIC CARE. (a) An insurer may not bring an action related to a payment required under Section 1952.156 made for chiropractic care unless not later than one year after the date of service the chiropractor and the insurer have submitted the dispute to an alternative dispute resolution process and failed to resolve the dispute. 83(R) HB 3730 - Introduced version - Bill Text Excerpt: SECTION 2. If before implementing any provision of this Act a state agency determines that a waiver or authorization from a federal agency is necessary for
implementation of that provision, the agency affected by the provision shall request the waiver or authorization and may delay implementing that provision until the waiver or authorization is granted. 83(R) HB 2628 - Introduced version - Bill Text Excerpt: BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: SECTION 1. Section 1451.109, Insurance Code, is amended by adding Subsection (e) to read as follows: (e) A health insurance policy issuer may not deny payment or reimbursement to, or reimburse at a lower rate, a chiropractor who, in accordance with Section 201.451, Occupations Code, delegates to an assistant a task or procedure relating to the provision of a service by the chiropractor that is within the scope of the chiropractor's ... 83(R) HB 1876 - Introduced version - Bill Text Excerpt: EMPLOYMENT OF DOCTOR OF MEDICINE OR OSTEOPATHY BY CERTAIN PROFESSIONAL ASSOCIATIONS. (a) A professional association formed and owned by persons licensed as chiropractors by the Texas Board of Chiropractic Examiners may employ a person licensed by the Texas Medical Board as a doctor of medicine or as a doctor of osteopathy to perform professional services that fall within the scope of practice of the practitioner. 83(R) HB 3270 - Introduced version - Bill Text Excerpt: (d) The insurer's request for a waiver must state whether any physician or health care provider is available within the service area for the covered service or services for which the insurer requests the waiver. EXCLUSIVE PROVIDER BENEFIT PLAN REQUIREMENTS. This subchapter applies only to exclusive provider benefit plans. 83(R) HB 406 - House Committee Report version - Bill Text Excerpt: (e) If a first application for a disabled parking placard under this section is made by or on behalf of a person with: (1) a mobility problem caused by a disorder of the foot, the notarized written statement or written prescription required by Subsection (c) may be issued by a person licensed to practice podiatry in this state or a state adjacent to this state; [or] (2) a disability caused by an impairment of vision as provided by Section 681.001(2), the notarized written statement or written... 83(R) HB 406 - Introduced version - Bill Text Excerpt: (e) If a first application for a disabled parking placard under this section is made by or on behalf of a person with: (1) a mobility problem caused by a disorder of the foot, the notarized written statement or written prescription required by Subsection (c) may be issued by a person licensed to practice podiatry in this state or a state adjacent to this state; [or] (2) a disability caused by an impairment of vision as provided by Section 681.001(2), the notarized written statement or written...
Classified Ads CLICK HERE Click on the ad’s title to see the entire ad. To place an ad call 512-477-9292 or email info@chirotexas.org VICTORIA,TX – Efficient practice in a great location Efficient practice in a great location perfect for DC wanting turnkey system offering chiropractic services a n d d e c o m p r e s s i o n t h e r a p y. Collected $353k in 2011 with $136k profit. Asking $299K. Contact Dr. Peseau at Epracticesales, 1-800-227-6603 or email to email: drpeseau@epracticesales.com THE WOODLANDS, TX- Clinic for Sale. North Houston, is the #1 fastest growing and upscale area in Texas, and the #4 most desirable locations to live in the US! This clinic is a solid, consistent performer. First class in location, appearance, layout and operation. Organization and… Cleveland Texas Chiropractic Practice for Sale Cleveland Texas Chiropractic Practice for Sale $25,000.00 Low overhead, been in this space for 23 years! Easy transition E-mail: info@4rehab.net for details.
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Irving—Lease Space Looking for a Chiropractor to lease space in existing, busy, multi-doctor practice. No worries for doctor, all staff and facilities (including x-ray, therapy) covered. Please contact Dr. Rice – richardmricedc@msn.com LUBBOCK ASSOCIATE WANTED: OPPORTUNITIES ARE TEMPORARY, SO WHEN A GREAT ONE COMES KNOCKING–BE SURE Y O U A N S W E R ! ! Excellent Opportunity for an Energetic, Caring, Reliable Chiropractor. Busy Office with Great, Knowledgeable, Support Staff has Immediate Opening for the Right Chiropractor-Is That YOU? Above-Average Salary PLUS… Licensed Chiropractor Wanted We are looking for a motivated and energetic Chiropractor licensed to practice in Texas. We offer great base salary and benefits plus a monthly bonus. We have six locations in the Houston area. Please fax your C.V. to 281-496-5311 or… Practice For Sale: Joshua, TX TX Joshua: Practice for sale Southwest of the Dallas-Fort Worth Metroplex (Joshua, TX) Thriving and growing family practice collecting $230K. 450 monthly visits, averaging
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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