May/June. 2013

Texas Journal of Chiropractic

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texas

JOURNAL OF CHIROPRACTIC

Helping Chiropractors Help People The Official Publication of the Texas Chiropractic Association

EXECUTIVE OFFICERS

TCA STAFF

President: Jorge Garcia, DC President-Elect: Jack Albracht, DC Secretary: James Welch, DC

CEO: John Darby Director of CE: Sterling Isdale Member Services: Abel Salazar Accounting Manager: Tracy Edwards Receptionist: Nicole Grimes

BOARD OF DIRECTORS

1122 Colorado St., Ste. 307 Austin, TX 78701 512.477.9292 phone 512.477.9296 fax www.chirotexas.org info@chirotexas.org

District 1: Paul Munoz, DC District 2: Jeff Williams, DC District 3: James Helton, DC District 4: Mike McGarrah, DC District 5: JP Quinlan, DC District 6: Cody Chandler, DC District 7: Lorin Wolf, DC District 8: Michael Henry, DC District 9: Mark Roberts, DC District 10: Chad Carpenter, DC District 11: Max Vige, DC District 12: Tom Hollingsworth, DC

Policies: Annual subscription to the Texas Journal of Chiropractic is included in TCA membership dues. Contact the TCA for subscription rates for nonmembers. The print Texas Journal of 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 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. All advertising material must be in graphics ready format and submitted as a .jpg, .jpeg, .gif, .swf, or .png file type.

The opinions expressed are those of the authors and do not represent the opinions of the TCA.

Texas Chiropractic Association Helping Chiropractors Help People 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.

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The Case for Animal Certified Chiropractic

by Mary Clark Animal chiropractic has gone mainstream during the last fifteen years. Similar to its human counterpart, animal chiropractic therapy focuses on proper spinal and joint function in order to relieve malfunction and improve pain.

Treatments are often incorporated into routine veterinary care and animal chiropractic adjustments are provided to everything from Clydesdales to dachshunds.

In order to become an American Veterinary Chiropractic Association animal chiropractor, a veterinarian or doctor of chiropractic must participate in a recognized animal chiropractic program, doctors must complete the required coursework and pass a written and practical examination administered by the American Veterinary Chiropractic Association (AVCA).

Only veterinarians and licensed doctors of chiropractic are allowed to become AVCA certified animal chiropractors. The rigorous training requires prospective animal chiropractors to learn not only about animals’ anatomy and musculoskeletal systems but also how to recognize other conditions unrelated to the musculoskeletal system for referral back to a veterinarian for treatment.

Additionally, animal chiropractors must undergo thirty hours of continuing education every three years in order to keep their AVCA certification in good standing. This continuing education requirement keeps animal chiropractors in the know on recent developments in animal healthcare as well as how to recognize symptoms of diseases in order to refer the animal back to their vet.

Becoming and remaining an AVCA certified

animal chiropractor is not an easy or simple process. Doctors of Chiropractic and veterinarians spend considerable time and money being trained in the science of animal chiropractic in order to provide optimum care for their animal patients. The rigor, expense and time commitment of being AVCA certified deters many D.C.s and veterinarians from obtaining the additional training above and beyond the requirements of their respective doctoral training.

In fact, Texas only has twenty-seven AVCA certified veterinarians and thirty-eight AVCA certified doctors of chiropractic. From a total number of almost eight thousand licensed veterinarians and over five thousand licensed chiropractors, only sixty-five have the training and ability to practice animal chiropractic with the AVCA certification.

Animal chiropractic is a very well respected and highly utilized treatment for horses and show animals. In the equestrian world, horses are adjusted to treat and prevent injuries, and show animals are judged on their stature and balance.

Proper spinal alignment plays an important role in achieving both. Adjustments are also used to treat dogs and cats. For example dachshunds are prone to back injuries and pinched nerves, which are improved through the application of animal chiropractic treatments.

Mindy Neal, DC is an AVCA certified animal chiropractor from Bovina, Texas. She has been treating animals for several years. She works on dogs, cats and horses. Doctor Neal’s geographic area spans across much of the panhandle region. This large territory often requires Doctor Neal and her clients to travel hundreds of miles in order to get treatments. Doctor Neal treats approximately two hundred human patients and about twelve animals per week. She runs a very busy human clinic yet still makes the time to drive out to barns hundreds of miles from her clinic in order to treat her equine patients.

Recently, Doctor Neal has come under scrutiny from the Texas Board of Chiropractic Examiners (TBCE) because of advertisements that incorporate both her Texas chiropractic licensure and her AVCA certification. According to the TBCE’s interpretation of the current law, Doctor Neal cannot identify herself as both TBCE licensed and AVCA certified, even though, as required by state law, Doctor Neal only treats animals that have been referred to her by veterinarian.

implications of being unable to advertise and promote herself as a licensed doctor of chiropractic and as a AVCA certified animal chiropractor. Doctor Neal’s inability to advertise her AVCA approved animal adjustment services is opening the door for untrained, unlicensed and unregulated laypersons to take advantage of the public’s ignorance and inability to obtain information about their local AVCA Doctor-of-Chiropractic-degreed-andlicensed animal chiropractors.

The advertisement issue arises because of the current wording in the Chiropractic Statute that governs chiropractors in Texas. Chiropractic, as defined by the statute, only covers the human body and requires that Doctor Neal to identify herself as a doctor of chiropractic-and ONLY human chiropractic. The TBCE has demanded that Doctor Neal remove references to animal treatment from her clinic website and to disassociate her Texas D.C. license from her AVCA certification.

Veterinarians and Chiropractors with AVCA certification invest a significant amount of time and money to go above and beyond for their animal patients. People without proper training are currently able to take advantage of the inability of animal certified D.C.s to advertise their greater training in animal chiropractic.

This harms the veterinarians and chiropractors and ultimately the pets and their owners in the State of Texas. The activities of under-trained lay people are putting the health and safety of animals at risk and deceiving animal owners.

Under-trained lay people do not offer the same

Doctor Neal is concerned about the potential

Annual Convention 2013

chiropractic services as animal certified doctors of chiropractic.

AVCA animal certified chiropractors deserve protection by the State of Texas. These veterinarians and chiropractors provide a vital service to the animals they treat. Chiropractic adjustments are sometimes the last therapy before a pet owner is forced to consider euthanizing their beloved animals.

A chiropractic adjustment can relieve pressure on nerves caused by spinal misalignment and correct problems that are causing conditions such as paralysis.

Pets provide significant value to their owners whether merely for companionship or for more utilitarian purposes like police horses and Seeing Eye dogs. Animals are important in every day life for millions of people in the State of Texas. Animal chiropractors such as Doctor Neal work hard to help these animals to live long, healthy and productive pain free, lives.

TMA Offers, in Writing, Reasons to Sue the Chiropractic Profession

by Chris G. Dalrymple, DC, FICC The Texas Medical Association, in its brief to the Texas Supreme Court, reveals the reasons for its string of lawsuits. The following are quotes from the TMA's brief.

"TMA's physician members, have standing to sue in their own right so long as there is ... proof that the rule 'interferes with or impairs, or threatens to interfere with or impair a legal right or privilege of the physician. … There is no doubt that the diagnosis of disease is the practice of medicine. At the very least, the rule [allegedly permitting whole body diagnosis] threatens to interfere with TMA's physician members' exclusive license to practice medicine."

Thus the TMA and TMB are concerned that the 5000 state licensed and regulated doctors of chiropractic are a "threat" and an "interference" to the 75,000 physician licensees, 5800 physician assistant licensees, 1000 acupuncturists, 310 surgical assistant licensees and the "other types of licensees, permits, and registrations" that are regulated by the TMB. The TMB licensees outnumber TBCE licensees some seventeen-to-one and yet the chiropractic profession is a threat in their collective minds that necessitates that the TMA and TMB must sue a minority profession to squash their different perspective on health care.

Says the TMA: "The legislature has declared the practice of medicine to be a 'privilege:' 'The practice of medicine is a privilege and not a natural right of individuals ... it is necessary to protect the public interest ... to regulate the granting of that privilege and its subsequent use and control' this privilege, held by individual licensed physicians, is so important in Texas that the Texas Constitution places restrictions on the type of medical schools that will qualify a person to be a practitioner of medicine."

The business of health care is considered by the State of Texas and the Texas Medical Association to be a privilege and NOT a natural right.

Take note Texans: it is not a natural right to diagnose…to heal. It is a government controlled activity and a financial privilege bestowed upon those deemed to have attended not just any school or philosophy of medicine, but a "special type of medical school." The TMA asserts that their livelihoods are more "special" than anyone else's.

When TMA states that the Texas Constitution "places restrictions on the type of medical schools that will qualify a person to be a practitioner of medicine", presumably the TMA is referring to Section 31 of Article 16 which states: "PRACTITIONERS OF MEDICINE. The Legislature may pass laws prescribing the qualifications of practitioners of medicine in this State, and to punish persons for mal-practice, but no preference shall ever be given by law to any schools of medicine."

Yet preference is frequently offered to "schools of medicine" to the exclusion of other philosophies of health care. The TMA itself notes this when it states "the privilege … is so important in Texas that the Texas Constitution places restrictions on the type of medical schools that will qualify a person to be a practitioner of medicine."

The meaning of "school" as a "place of instruction" originally comes from ancient word roots meaning "to hold, hold in one's power, to have." The original notion of a "school" was leisurely discussion, which then evolved in the 1300s into meaning the place for such leisurely discussions. By the 1610s the meaning of "school" came to be that of "people united by a general similarity of principles and methods" and by 1864 it developed into the concept of "school of thought." The current Texas Constitution took effect on February 15, 1876, about ten years after the concept of "school of thought" developed. The Texas Constitution is not stating "no preference shall be given to any 'place of leisurely discussion of

medicine'", it is stating that, like religion, the state should not enforce a particular set of principles and methods upon its populace. There is not a singular "school of medicine" any more than there is a singular "school of religion" or "school of philosophy." There are various "schools of thought" and the state, by its own constitution, should never give preference by law "to any schools of medicine."

The self-centered TMA even states, as if all TMB licensees were the sole participants of this "school of medicine" and that ALL were TMA members: "there can be no doubt that a medical license issued by the Texas Medical Board confers a unique and important privilege on the individual members of the TMA because no one can practice medicine without such a license."

The TMA asserts that: "TBCE's scope of practice rule ... allows unlicensed individuals to practice medicine, infringes on the practice of medicine, infringes on the practice of medicine by those who are licensed properly, and in so doing is harmful not only to the public, but also to the medical profession as a whole, and its individual licensed physicians."

Thus to TMA the ability to "diagnose disease" is exclusive to the "the practice of medicine," or is it? The TMA notes: "it is true that some allied health care professionals are authorized to diagnose diseases. ... These authorizations, however, are explicitly restricted to specific parts of the human body ... because these are the only parts of the body with which these professionals are involved."

Thus, to the TMA if you are responsible for a PART of the human body you may diagnose that part of the body, but you may NOT diagnose any other part for which you are not authorized to be responsible, nor may you diagnose the body as a whole entity. The "school of medicine" that TMA subscribes to is that licensees of the TMB are the "priests" and "high priests" of their own particular philosophy of medicine to which the state government grants preference over all others, even though it is demonstrated to be the deadliest in the world.

To continue their assertions, the TMA notes "allowing chiropractors to practice medicine undermines the value and integrity of medical licenses, and diminishes the licensed privilege of practicing medicine.”

Thus, to the TMA, allowing doctors of chiropractic to practice utilizing their training "diminishes" the medical profession. Their reasons for such "concern"? Is it as loftily as safe public practices? Is it as charitable as insuring quality providers? Is it in the best interests of regulation to make sure that there are enough "diagnosticians"? No. The sole reason promoted by the medical association is purely intended to give preference to a particular philosophy, a particular school, of medicine.

That ONLY licensees of the TMB and the preferred philosophy of health care espoused by the government are qualified to trade their services and receive money for it as an occupation.

Says the TMA: "One of the duties of the TMA and its members is to protect the integrity of medical licenses because licensure is the primary method by which they can be assured that only those who are properly educated and trained in medicine are allowed to engage in the practice of medicine."

To the TMA, only those who are of the "proper school of medicine" should be permitted to practice the occupation of "whole body health care."

Everyone else should be relegated to bits and pieces of the human body or to non-human animals.

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by Chris G. Dalrymple, DC, FICC

"The core of the profession (“middle-scope”), about 75-80% of chiropractors, provides patients a portal of entry to care as spine and musculoskeletal health providers, though the practices of these chiropractors take many forms."

In March of 2013 the Institute for Alternative Futures (IAF) published its third in a series of chiropractic futures reports. The report develops and presents four potential scenarios for the chiropractic profession and discusses each scenario in detail and offers recommendations to the profession.

"DCs in all three communities share an appreciation for the innate ability of the body to heal, a commitment to conservative and less-invasive care, and the use of manual modalities (including spinal adjustments)."

The Futures of Chiropractic

The report begins with the question "Where will the chiropractic profession in the United States be 12 years from now?" In answer to that question the IAF offers four different scenarios that provide four possible realities. To begin their journey the IAF first looks at the current state of affairs in the chiropractic profession: "Viewed from 2013, the future of chiropractic remains fascinating and uncertain. Chiropractic as a uniquely American invention has persisted and grown worldwide despite organized suppression. In fact, chiropractic has become a global force. More and more countries, including Denmark and Switzerland, are granting legal recognition for the practice of chiropractic, and accept the profession as a member of governmentsponsored health care delivery programs. There are now more schools of chiropractic located outside the United States than within it.

Chiropractic has also become a recognized and accepted health profession at the World Health Organization. International educational standards are being adopted across various accreditation agencies.

Regulatory bodies are working to remove the impediments to practitioner mobility between jurisdictions. Chiropractic research is advancing as well in the U.S. and in countries around the world."

The profession's weaknesses are noted as well: "The entrepreneurial spirit of chiropractors, fractures within the chiropractic community, and isolation from and oppression by organized medicine have all left chiropractors largely independent and separated from health care provider systems.

As chiropractors were included in health insurance coverage in the 1980s, chiropractors enjoyed a brief period of relatively unrestricted, well-paid patient visits and many earned high incomes. However, a tightening of both reimbursement levels and allowable visits followed. With the rise of managed care in the 1990s—and later managed access to chiropractic services—chiropractors have seen their incomes, on average, fall further. Now, with the implementation of the Patient Protection and Affordable Care Act of 2010, “value” is being redefined and measured in new ways; primary care is shifting from largely solo and small group physician practices to multidisciplinary teams; and provider organizations are shifting from fee-for-service to bundled payments, risk sharing, or capitation. These are among the major changes in health care that chiropractic is facing."

In short, it not only feels like a "whole new world" out there, it is rapidly becoming one.

One for All, or All for One? In previous reports the IAF promoted the concept of a "unified professional vision." In this report the IAF now recognizes that there are three distinct communities with the chiropractic profession. "There is great diversity of practice styles and philosophies within the chiropractic profession," the IAF notes. Taking these styles and philosophies into consideration, they recognizes three communities within the chiropractic profession. The IAF terms these focused-scope, middle-scope, and sbroad-scope practitioners. Notes the IAF: "About 10% of chiropractors (“broad-scope”) focus on primary care or specialties dealing with a range of conditions beyond the spine. Many in this latter group want to broaden their practice rights further to include prescribing rights. They have been trying for years to do so and in 2013, it appears they may win this battle in a few states."

"At the other end of the spectrum, 10-15% of chiropractors (“focused-scope”) correct subluxations in the spine to free the body’s self-healing capacity. Some argue that they do not “treat conditions” but only fix problems with the spine and nervous system. They are more fundamentalist in their philosophical positions than members of the middle scope or broad-scope communities. Focused-scope chiropractors actively oppose broad-scope chiropractors’ efforts to expand their practice rights as violating chiropractic identity and principles."

The IAF takes note of these three communities because: "Rather than recommending a unified vision as we have in the past, we now recommend that each of the three major communities within the profession (focused-scope, middle-scope, and broad-scope) grow and develop authentically. The differences of opinion across these three communities on some issues are pronounced. Because of these differences, efforts to develop and pursue a unified vision have failed and are likely to fail in the foreseeable future. In addition, unity efforts may prevent each of these communities from making its unique contributions to the entire field.

Acknowledging and accepting these differences would allow the field to spend less time and resources on self competition and internal attacks, and more on activities and strategies that are likely to benefit chiropractors across all three communities."

Thus, to paraphrase the infamous Musketeer motto, the IAF no longer advocates a "one profession for all practitioners" approach, but rather recommends that we pursue a mindset of "all practitioners for one profession."

What Path to the Future?

The IAF built upon their previous studies refining and improving upon their work--the first report in 1998, a second report forecasting the 2005 to 2015 time frame, and this current report. They also made use of other reports from the fields of health care and primary care. They developed preliminary forecasts and reviewed them with a wide variety and number of leaders within the entirety of the chiropractic profession. They then developed these forecasts into four scenarios that fall into three zones: A "zone of conventional expectation" representing an expectable future; a "zone of growing desperation" which represents a set of plausible challenges that may emerge resulting in a challenging future; and a "zone of high aspiration" where "a critical mass of stakeholders pursues visionary strategies and achieves surprising success."

Using these, and other tools, the IAF has developed one expectable scenario (Scenario 1), one challenging future scenario (Scenario 2), and two surprising successful futures (Scenarios 3 and 4). Let's term these futures the "Good, the Bad, and the Ugly".

The Good (Scenarios 3 and 4) Scenario 3--Integration and Spine Health Leadership In Scenario 3 the IAF paints a scene where patients play an assertive role in getting the care that they want and one in which the United States "achieves near universal health care coverage." In this scenario many chiropractors partner with "the mainstream" to help get patients what they want. "Many chiropractors join integrated teams," the IAF envisions in this scenario, "and become critical partners in addressing back pain and spinal health." This scenario also envisions "DCs and DPTs no longer compete with one another for patients. The two professions partner on integrated health care teams in screening and triaging neuromusculoskeletal complaints, and educating the public about prevention of chronic pain."

The IAF summarizes it this way: "The U.S. achieves near universal health care coverage. Patients play an assertive role in getting the care they want, stimulating and using digital health coaches and alternative or conventional approaches according to their individual needs and wants. Providers use predictive models and simulations to help their patients achieve the best health possible.

Chiropractic enters mainstream medicine as the spinal health expert in the health care system. Many join PCMH and other integrated care teams and become critical partners in addressing back pain and spinal health.

'Big data 's patient care provides additional compelling evidence from chiropractic outcomes. Other chiropractors find that growing public acceptance means that they can sustain their independent or group practice and in many cases thrive. Ten states pass legislation broadening practice rights for chiropractors."

In this scenario the IAF would expect the number of practicing chiropractic doctors to rise from 55,000 in 2012 to 68,000 in 2025. The United States would be wildly responsive to integrated care and 85% of the population would be making use of integrated care systems. This would be up from the 20% using it in 2012. As such, the percentage of the population using Complimentary and Alternative Medicine (CAM) rises from 38% in 2007 to 55% by 2025. The population percentage utilizing chiropractic care also rises from just under 8% in 2004 to 9% of the US population in 2025. Spinal manipulation, however, is increasingly performed by providers other than chiropractic doctors. Where 6% of non-chiropractic providers were providing spinal manipulation in 1991, in this scenario by 2025 40% of spinal manipulation is expected to be provided by non-chiropractic providers.

The face of the chiropractic profession would also change under this scenario. Whereas nearly 70% of the chiropractors in 2012 were in solo private practice, under this scenario by 2025 only about 25% of the profession would still be in solo private practice as most move into integrated health care. The percentage of chiropractors in group practices (including interdisciplinary group practices) would rise from just about 22% in 2012 to 35% in 2025; those working as associate doctors are expected to rise from nearly 8% to 10% of chiropractic doctors.

In this scenario 31% or some 21,000 doctors of chiropractic are practicing in integrated health systems, hospitals, and other interdisciplinary groups.

Some 350 DCs are expected to practice in the VHA and 300 more in the DoD. While 20% of all DCs ran successful "cash only" practices in 2012 by 2025 this number would decrease to 15% as the need for "cash only" practices decreases.

In Scenario 3 states become increasingly interested in utilizing chiropractic doctors for more primary care access and it is expected that 10 states will broaden chiropractic scope to include prescription rights with some 3,100 DCs prescribing medications.

Chiropractic Colleges will also change in the Scenario 3 future. While their were 18 chiropractic colleges in 2012, 17 of those are expected to still be in operation in 2025, and the number of students increases from 10,000 in 2010 to 12,000 in 2025. In 2010 2,600 graduates were produced per year and 2,700 graduates per year are expected in 2025 under this scenario. Some 1,723 DCs will retire each year by 2025 resulting in a net INCREASE of some 977 DCs per year in the chiropractic profession in 2025.

Scenario 4 envisions that "health care reform continues and the market bifurcates essentially around payment. Forty percent of the population obtains full health insurance and receives care primarily through ACOs using risk sharing and capitation. Another 40% of the population enrolls in high-deductible catastrophic care health plans, and relies primarily on out-of-pocket expenses and self-care approaches with the help of sophisticated digital health coaches and local market transparence.

Chiropractors succeed among both groups of patients."

In this scenario the IAF would expect the number of practicing chiropractic doctors to rise from 55,000 in 2012 to 66,000 in 2025. The United States would be responsive to Integrated health care and 40% of the population will make use of integrated care systems and 40% consumer-directed care. This would be up from the 20% using it in 2012.

The percentage of the population using CAM rises from 38% in 2007 to 55% by 2025. The population percentage utilizing chiropractic care remains the same as 2004 figures at about around 8%. Spinal manipulation is increasingly performed by providers other than chiropractic doctors. Where 6% of non-chiropractic providers were providing spinal manipulation in 1991, 25% of spinal manipulation is expected to be provided by non-chiropractic providers in Scenario 4.

The face of the chiropractic profession would also change under this scenario. Whereas nearly 70% of the chiropractors in 2012 were in solo private practice, under this scenario by 2025 only about 40% of the profession would still be in solo private practice. The percentage of chiropractors in group practices (including interdisciplinary group practices) would rise from just about 22% in 2012 to 30% in 2025; those working as associate doctors would be expected to rise from nearly 8% to 10% of chiropractic doctors.

In this scenario 21% or some 14,000 doctors of chiropractic are practicing in integrated health systems, hospitals, and other interdisciplinary groups.

Some 300 DCs are expected to practice in the VHA and 250 more in the DoD. While 20% of all DCs ran successful "cash only" practices in 2012 by 2025 this number would increase to 25% of practices.

The number of states broadening the chiropractic practice, and the complexion of the chiropractic colleges are identical to the numbers reported for Scenario 3 above.

The Bad (Scenario 2--Hard Times and Civil War) If that's the "good" news, what is the bad news?

Scenario 4--Vitalism and Value This scenario also presents chiropractic in a favorable light but from a slightly different perspective. In this scenario chiropractic grows ever more popular as "contemporary vitalism" gains popularity and chiropractors take a leading position in this movement. "Many chiropractors and others," says the IAF, "engage in research supporting chiropractic and integrative health care, including the exploration and development of contemporary vitalism."

Says the IAF of Scenario 4: "Vitalism has made a major comeback ‌ paralleling the rise in scientific research on prayer, intention, and consciousness in healing, as well as the investigation of energy medicine, chi, vital force, vis medicatrix naturarae, and other traditionally vitalist concepts. Chiropractors are among the leaders in this research and no longer struggle with hostility among the DC communities or from most other health professions because of chiropractic's philosophical but unsupported positions."

"Research supporting chiropractic and integrative health care grows, including the exploration and development of contemporary vitalism.

Popular awareness of self-healing and interest in modalities that support it grow as well. Many chiropractors succeed as the leading providers for spine health in integrated systems. Many other chiropractors do well among patients enrolled in high-deductible catastrophic care health plans, who rely primarily on out-of-pocket expenses and self-care approaches with the help of sophisticated digital health coaches and local market transparency. Chiropractors also join efforts to shape community conditions that promote health and wellbeing. However, outcomes research, the movement to capitated care, and transparency in prices that chiropractors and others charge, keep the chiropractic profession from growing faster."

"Chiropractors join other providers and systems in supporting population health, going beyond clinical care to shape community conditions that promote health and wellbeing."

Let's look at the numbers first before we examine their potential cause.

In this scenario the IAF would expect the number of practicing chiropractic doctors to decrease from 55,000 in 2012 to 45,000 in 2025.

The United States does not readily participate in integrated care as anticipated and only 30% of the population would be making use of integrated care systems, up from the 20% using it in 2012. As such, the percentage of the population using CAM stays nearly stagnant at 40% by 2025 up from 38% in 2007.

The population percentage utilizing chiropractic care decreases from just under 8% in 2004 to only 4% of the US population in 2025, and spinal manipulation is increasingly performed by providers other than chiropractic doctors. Where 6% of non-chiropractic providers were providing spinal manipulation in 1991, 30% of spinal manipulation is expected to be provided by non-chiropractic providers by 2025.

The face of the chiropractic profession would also change under this scenario. Whereas nearly 70% of the chiropractors in 2012 were in solo private practice, under this scenario by 2025 only about 40% of the profession would still be in solo private practice. The percentage of chiropractors in group practices (including interdisciplinary group practices) would rise from just about 22% in 2012 to 35% in 2025; and those working as associate doctors would stay at the nearly 8% number of 2012.

In this scenario 13% or some 5,700 doctors of chiropractic are practicing in integrated health systems, hospitals, and other interdisciplinary groups.

Some 180 DCs are expected to practice in the VHA and 150 more in the DoD. Twenty percent of all DCs ran successful "cash only" practices in 2012, this percentage does not change by 2025.

In Scenario 2 states become less interested in utilizing chiropractic doctors for more primary care access and only 3 states will broaden chiropractic scope to include prescription rights with only some 750 DCs prescribing medications.

Chiropractic Colleges would dramatically change in the Scenario 2 future.

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While there were 18 chiropractic colleges in 2012, only 8 of those are expected to still be in operation in 2025. The number of chiropractic students would be expected to decrease from 10,000 in 2010 to only 5,000 in 2025. In 2010 2,600 graduates were produced per year but only 1,125 graduates per year are expected in 2025. More chiropractic doctors are anticipated to retire each year with some 2,120 DCs leaving practice each year by 2025, resulting in a net DECREASE in the chiropractic profession of some 995 DCs per year in 2025.

Bad news indeed, but why might this scenario come to pass? In forecasting this future the IAF notes "the period from 2013 to 2025 becomes difficult for most of American health care. Millions of people enroll in high-deductible catastrophic care plans, and everybody is trying to pay as little as necessary. Only clear and compelling value can sustain chiropractic practices, but the scarce evidence base for chiropractic hurts DCs." In this scenario the profession continues to promote the differences within itself rather than the common things that ALL chiropractic doctors provide and strive for. "For the public, the most visible part of the chiropractic field is the civil war waged by focused-scope chiropractors against the broad-scope chiropractors' efforts to expand practice rights." Ultimately this division created by the civil war between 20% of the profession will have negative consequences for the remaining 80% of the profession.

Because of the variability in the quality and the outcomes provided among the solo and small practice practiitoners DCs become overlooked by the new integrated health care entities and "once these Accountable Care Organizations are set and standardized, it becomes too difficult to create change." As a result the IAF predicts that "a low-quality/low-cost chiropractic industry grows and provides care that sometimes harms people in highly publicized cases." Such a bleak outlook for the profession and the unpromising return on investment lead prospective chiropractic students to opt for other career pathways, and many chiropractors are driven from the profession.

The IAF summarizes this "bad news" scenario: "Another recession hits in 2015. The economy improves in subsequent years, but the market for chiropractors does not rebound. Millions of patients enroll in high-deductible catastrophic care plans, and stressed families struggle to support their health. Only clear and compelling value can sustain chiropractic practices. Yet the scarce base of comparative effectiveness research for chiropractic hurts DCs. The variability in quality and outcomes among solo and small practice practitioners also causes DCs to be overlooked

by ACOs and PCMHs. Instead, chiropractors are on a “hamster wheel” of many, ever-shorter visits and lowering their expenses enough to make a living. Most visible to the public is the noisy civil war between the broad-scope chiropractors seeking expanded practice rights and the vehement opposition of focused-scope chiropractors in every state where expanded rights are sought. Ten chiropractic colleges close and many chiropractors are driven from the field."

The Ugly (Scenario 1--Marginal Gains, Marginalized Field) The word "ugly" is derived from an old Norse word meaning "fear, apprehension, or dread". Perhaps the future most apprehended is that which is likely not to be as good as desired nor as bad as feared. The ugly truth is that things are likely to land between the "good" and the "bad." What is the IAF's most "likely" scenario? That would be: "As health care reorganizes, the historical isolation of chiropractors hinders most DCs in joining integrated care provider organizations. The majority remains in solo and small group practices and face major challenges in building or maintaining an adequate patient base. Research to develop and demonstrate evidence-informed practice grows. This gets DCs more favorable attention, yet networks often use the data to limit fees and the number of visits. Five states assign broader practice rights to DCs. Focused-scope oriented colleges join leading academic medical centers in exploring quantum biology to explain healing and subluxation. However, four chiropractic colleges close. Low starting income for chiropractors in many settings, and limited career prospects for most DCs coupled with high student debt, hamper the growth of the profession over the decade leading to 2025."

In this scenario, the IAF envisions, the multiple individual identities found

within the chiropractic field in 2013 persist to 2025. "While health care reform leads to major changes, no community inside the chiropractic field significantly changes its position." Most are expected to remain in solo and small group practices in the face of low-cost wholesale providers of chiropractic care and the constraints imposed by insurance networks through the systematic reorganization of health care delivery.

The numbers indicate modest improvements and moderate losses. In this scenario the IAF would expect the number of practicing chiropractic doctors to rise from 55,000 in 2012 to 63,000 in 2025. The United States would be responsive to integrated care and 40% of the population would be making use of integrated care systems, up from the 20% using it in 2012. As such, the percentage of the population using CAM changes from 38% in 2007 to 40% by 2025. The population percentage utilizing chiropractic care stagnates at 7% of the US population in 2025, down from 8% in 2004. Spinal manipulation being performed by providers other than chiropractic doctors also stays the same as the 1991 figure of at 6%.

While nearly 70% of the chiropractors in 2012 were in solo private practice, under this scenario by 2025 only about 44% of the profession would still be in solo private practice. The percentage of chiropractors in group practices (including interdisciplinary group practices) would rise from just about 22% in 2012 to just 25% in 2025; while those working as associate doctors would be expected to rise from nearly 8% to 15% of chiropractic doctors.

In this scenario 16% or some 10,000 doctors of chiropractic are practicing in integrated health systems, hospitals, and other interdisciplinary groups.

Some 230 DCs are expected to practice in the VHA and 200 more in the DoD. "Cash only" practices will remain the same as 2012 figures with 20% of the chiropractic practices being "cash only."

States take an interest in utilizing chiropractic doctors for more primary care access and it is expected that 5 states will broaden chiropractic scope to include prescription rights with some 1,500 DCs prescribing medications.

Chiropractic Colleges are expected to "take a hit" in our profession's future over the next 12 years. While there were 18 chiropractic colleges in 2012, only 14 of those are expected to still be in operation in 2025, and the number of chiropractic students will decrease from 10,000 in 2010 to 8,000 in 2025. In 2010 2,600 graduates were produced per year yet only 1,800 graduates per year are expected in 2025. About 1,723 DCs will retire each year by 2025, resulting in a net increase in the chiropractic profession of only some 219 DCs per year in 2025.

The Present Mahatma Gandhi is quoted as saying "the future depends on what you do today." The IAF has observed changes in the chiropractic profession for almost 20 years now. Offering more than merely a “crystal ball” for chiropractic, the IAF also provides specific recommendations for the entire profession. The IAF has provided evidence on a couple of good paths that our profession might take, a really bad path that our profession could travel and the ugly reality that while things might get a bit better, not much will change within the chiropractic profession.

This should be an unacceptable outcome for anyone who calls themselves a "professional" (one engaged in one of the learned professions). Ours is a profession that requires an advanced degree and as a "doctor" (any of several academic degrees of the highest rank). We should all SEEK to make our learned profession MORE accessible to the public, MORE widespread and invite a sufficient number of students to learn our profession to insure that the profession maintains its viability.

History is littered with a number of professions that would not, or could not take the steps necessary to insure that their learned profession stayed viable.

Gandhi points out that "the future depends on what you do today." I once had a mentor that told me that I have two choices and ONLY two choices.

I can "keep it the same and complain" or I could work to "change it RIGHT now." The same choices apply to our profession. These ARE the only options open to us--we can "keep it the same and complain" in which case we are very likely to end up with the "bad" or the "ugly" futures, OR we can "change it RIGHT now"--not "later", not "next month" or "next year". Take steps RIGHT NOW to begin to change our future. If YOU as an individual of this profession will do that then the likelihood of the profession participating in a "good" future will increase. The future indeed depends upon what you do today!

THE RECOMMENDATIONS The IAF, recognizing that that there are three distinct communities within the chiropractic profession, offers specific recommendations for all three communities. For the approximate 10% of those who are in the "focusedscope" community the IAF offers the following recommendations: "Shift communication about chiropractic’s healing qualities from philosophical to a more scientific, evidence-based terms that will appeal to patients, other chiropractors and providers, and policymakers."

Communication is the effective exchange of ideas between individuals and new research is continually providing evidence to support the healing qualities of chiropractic. Use terms that communicate effectively with those in the scientific and evidenced-based worlds to avoid miscommunication.

"Pursue research in the science of self-healing as it relates to chiropractic principles. Conduct this research in conjunction with other healing traditions that have deep vitalism roots, particularly naturopathy and oriental medicine. Whenever possible, link this research to related developments in quantum biology research, epigenetics, and other fields of biological and scientific inquiry."

"Use research on the science of (self-) healing as a platform for shared language and interests with middle- and broad-scope chiropractors. Frame this body of work, concepts, and terms in ways that take into account the interests, concerns, and priorities of other chiropractors and providers, thus promoting interest and collaboration across chiropractic and other health professions."

The presentation of one's idea without the opportunity for an exchange on those ideas is not communication, it is "dogma" (an official system of principles or tenets concerning faith, morals, or behavior). Science is about the exchange of observations not dogma.

"Develop and maintain research on all focused-scope practices, both to further define the relationship of chiropractic care and self-healing, and to develop outcome measures for focused-scope providers."

For the approximate 10% of the profession in the "broad-scope" community, the IAF offers the following recommendations: "Pursue expanded practice rights, but develop a conservative pharmacology practice that supports self-healing." Share this concept with others so that they might understand the advantages as well as the drawbacks to such a practice.

"Develop and maintain outcomes research on all practices. If the broad-scope community is to succeed in gaining and obtaining prescribing rights, it must frequently research and evaluate its own patient outcomes and cost-effectiveness.

These data can then be compared to the results achieved by other providers with prescribing rights, as well as to outcomes from non-prescribing chiropractors."

For the ENTIRE chiropractic profession the IAF recommends: 1. "Integrate chiropractic into health care systems, particularly into Accountable Care Organizations and Patient-Centered Medical Homes."

"Health care is poised to change its payment streams, shifting from feefor-service options to integrated and captivated streams, particularly through Accountable Care Organizations (ACOs)."

"Patient-Centered Medical Homes (PCMHs) are shifting primary care from solo-practice physicians to teams of providers. IAF’s scenarios envision integrated care (capitated or risk-sharing and integrated across delivery sites and providers) comprising between 30 and 85% of health care in 2025, depending on the scenario. To date, chiropractic has remained largely isolated from delivery systems. However, chiropractic can and should make its way onto primary care teams and ACOs. Failing to do so will maintain the status quo of keeping the profession isolated."

"The role DCs could have as the spine health leaders on primary care teams is an important opportunity to pursue for this integration. This will

require local, personal efforts by chiropractors to establish relationships with medical directors and others who will determine which providers will be on the primary care teams and in the hospitals."

"In this integration, DCs will inevitably have to work—or contend—with physical therapists (PTs). PTs (and increasingly doctors of physical therapy or DPTs) can and do compete with chiropractors. They outnumber chiropractors 4 to 1 today, and the U.S. Bureau of Labor Statistics forecasts that the number of physical therapists will grow faster than chiropractors for the rest of this decade. PTs are also already better integrated into health systems. While scope of practice fights with PTs will persist, the competition should be on outcomes, given that both DCs and DPTs will be seeking similar patients and/or the spine health leader role within primary care teams."

Specific strategies for chiropractors to further ensure and solidify their integration include: "Take full advantage of integration in the Veterans Health Administration (VHA) and Department of Defense (DoD).

Chiropractors have years of experience getting integrated into two major systems, namely the VHA and the DoD. The number of sites with chiropractors needs to be expanded, and chiropractors can actively advocate for this expansion while continuing to prove their worth through good outcomes. Research on DCs’ outcomes in the VHA and DoD also needs to be actively communicated" "Increase the prevalence of clinical training in chiropractic education. Additional clinical experience for students before beginning their practice is essential. Chiropractic colleges should accelerate their efforts to provide students with clinical experience in hospitals, rehab, primary care, and other treatment settings. Community health centers are beginning to offer such opportunities, and these options should be increased and expanded further."

"Seek to practice with other types of health care providers in as many settings as possible. This includes working in community health centers and providing pro bono care in free health care clinics and other settings."

2. "Accelerate research."

"The significance of a solid research funding organization cannot be overstated. Chiropractic organizations, colleges, and individual chiropractic researchers and practitioners will all need to keep generating (or begin generating) research on the following: a) The therapeutic efficacy of chiropractic and how it compares to other types of treatments (including drugs), b) The cost-effectiveness and value of chiropractic treatment, and c) The outcomes of specific chiropractic practitioners and clinics (practitioner-generated outcomes data will parallel the outcomes information that delivery systems, consumers, insurers, and managed care networks will be gathering)."

"Promote and facilitate data collection in chiropractic practices, and publish that data in peer reviewed journals. Chiropractic practices and chiropractic colleges are creating registries from which outcomes data can be generated. Managed care networks are analyzing data from the health care systems with which they are associated … . Those developing the registries and the managed care networks must work to publish their results as rapidly as possible."

"Anticipate changes and additions to electronic health records (EHRs) for chiropractors. In the years ahead local transparency of costs and results of health professionals and their treatments will require that DCs collect and publish outcomes data from their practices. The chiropractic community therefore needs to promote effective implementation, interoperability, and use of EHRs. This will allow chiropractors to be better prepared for future uses of electronic records, which will be designed to include patients’ vital signs, biomonitoring data, and ultimately their genetic codes. EHRs will also include information on the constellation of social determinants of health affecting the individual patient. Chiropractors’ EHR systems will need to be developed in a way that both contributes to and uses this enhanced data collection."

"Develop the science of self-healing and vitalism. Chiropractors must increase the research on why chiropractic adjustments yield cost-effective outcomes for their intended condition, why they often have beneficial

non-musculoskeletal effects, and how adjustments affect gene expression and self-healing. Chiropractors would do well to integrate this research with the vitalism theories and research of other complementary and alternative medicine (CAM) approaches including naturopathy, oriental medicine, other healing traditions with vitalist roots, and prayer, as well as quantum biology, epigenetics, and gene expression. Scientists who study Eastern healing, prayer, and traditional forms of shamanism that are observed in many cultures may help open areas of study that offer evidence for the vitalism described in chiropractic health and healing. Chiropractic research should include such areas as quantum biology, where a new scientific understanding may enter the mainstream and provide chiropractors with evidence that supports vitalism."

3. "Continue to strive for high standards of practice."

"The chiropractic profession should define and ensure high standards of practice that will keep existing patients satisfied with their care while attracting new patients to chiropractic. Higher standards will better position chiropractic as a profession, and will produce individual chiropractors that are more likely to be successful, whether they seek to integrate or to maintain independent practices."

"Support local reporting of outcomes. The development of local and national reporting systems that indicate the results of health care providers in their patient care will be important in the years leading to 2025. For patients, these systems will ultimately comprise comparative reports on individual providers. The chiropractic profession and its various associations and organizations should support the development of such reporting on chiropractors and other health care professionals. Ultimately, this reporting will take into account patients’ disease and risk sensitivities, along with other measures such as patient satisfaction, in rating the outcomes of health care providers. Angie’s List, PatientsLikeMe, and other local or national groups will make these outcomes and costs transparent for patients, often in relation to patients’ specific conditions.

This reporting will allow patients, ACOs, PCMH teams, and chiropractors to better identify the best providers in the community, as well as those chiropractors who oversell services and technology."

"Provide more effective policing of false and misleading advertising. The professional chiropractic organizations and state licensing boards should have strict standards against false and misleading advertising, communications, and marketing. Chiropractic state licensing boards and organizations should publicize those standards and enact effective consequences for chiropractors who violate them."

"Promote the use of best practices and agreed-upon guidelines. The profession needs to have guidelines that define best practices, including treatment courses. ... Rather than rely on non-chiropractors to entirely define the guidelines, the chiropractic field should develop or co-develop guidelines that can be agreed upon and used by ACOs, PCMHs, and managed care networks. These should rapidly incorporate research showing additional indications where chiropractic care is effective."

"Better police the profession: …the profession, particularly licensing boards and possibly state associations, must play a more active role in policing the profession."

4. "Anticipate and engage consumer-directed care plans and tools."

"Engage with the development of self-care tools, particularly their decision-making rules. Consumer-directed health plans are growing, as are the tools that will allow patients to more wisely spend their out-ofpocket health care dollars. It is likely that people will become better informed and more scrutinizing in their choices. Chiropractors have always been good at directly engaging consumers or patients, but will need to recognize that consumers and patients will be using these selfcare tools that tell them when to go to a chiropractor, what the best course of therapy is, what the costs are in their communities, and who the best DCs are. Chiropractors should take part in developing the criteria that will be used to define “best” in this context."

"Avoid misleading arguments. Much of the business-planning advice for chiropractors ignores outcomes. The public communication campaigns for the field, as well as marketing by chiropractors to consumers, must instead include a focus on the established therapeutic efficacy of chiropractic treatments. This will position chiropractors better in the marketplace of consumer-directed health plans."

5. "Create greater tolerance and mutual support within the profession."

"Support chiropractic colleagues in a good faith pursuit of their visions. In 1998 and 2005, IAF called for unity in the profession. Given the value of diversity within the profession and the improbability of unity in the profession (indeed, few professions can claim to be fully “unified”), IAF now recommends the development of a mature tolerance among chiropractors, and the authentic pursuit of the distinct visions of the focused-scope, middle-scope, and broad-scope wings of the profession."

6. "Promote individual chiropractors’ contributions to public health and to improving population health."

"Identify roles in public health and population health for individual chiropractors and chiropractic organizations to assume.

Chiropractors, like all health care providers, must influence the health condition of their patients and their communities. Since 1998 IAF has recommended that chiropractors promote health equity. Improving population health is part of that objective. Since our 2005 report, increasing the population’s health has gained more recognition. The Triple Aim has become the leading standard for judging quality in health care systems (the aims are improved patient experience, lower per capita costs, and increased population health). All health care professionals and health care systems are considering how to increase population health.

Chiropractors must reimagine and reinvent their roles. The fact that hundreds of chiropractors have joined the Chiropractic Section of the American Public Health Association serves as an indicator of the growth of this topic. We recommend that each chiropractor understand what contribution he or she can make to public and community health, and how to become involved in these fields. We recognize that many are already doing this, but most chiropractors are not. We also recommend that relevant organizations in the field develop options or roles for chiropractors in population health, as the Foundation for Chiropractic Progress has done regarding chiropractors’ roles in the Patient-Centered Medical Home."

7. "Develop geriatric chiropractic."

"Develop outcomes for chiropractic care of elders and press Medicare to expand the coverage of chiropractic care. One of the largest growth areas in health care will be care for elders or geriatric care.

The health care needs of the elderly population are more pronounced than younger age groups, and will grow disproportionately as the Baby Boomers age. Aging Baby Boomers will look for alternative methods of care that can help them reduce pain, treat their conditions, and remain as active and as healthy as possible. Chiropractic has much to offer for elders."

"We recognize that chiropractic care for elders is complicated by Medicare’s 'subluxation only' coverage for chiropractic care.

Medicare’s coverage should be expanded to include diagnosis and evaluation by chiropractors as well as those chiropractic treatments for conditions covered by other insurers and state statute. There is also the challenge that Medicare payment levels for services are low and will be under pressure to remain low or even be reduced."

"Chiropractors must generate better evidence for geriatric chiropractic. In addition, as they show their cost effectiveness, DCs will need to press Medicare to expand coverage and maintain adequate payment levels."

The IAF has presented our profession with four possible futures. They have generated for us specific objectives that each individual practitioner, each individual practice, each association, each regulatory board and anyone else associated with the profession can take steps toward implementing. Gandhi said "the future depends upon what YOU do today." Will you "keep it the same and complain about it" or will you take action to change it, RIGHT NOW? The future is yours. * Institute for Alternative Futures, Chiropractic 2025: Divergent Futures.

Alexandria, VA. March 2013. Available from http://www.altfutures.org/ pubs/chiropracticfutures/IAF-Chiropractic2025.pdf.

Inducements...

by Dr. R. A. Foxworth, FICC, MCS-P Sometimes, being in practice and dealing with regulatory agencies can feel like being about four years old: we get told “No!” or “You can’t do that!”—but aren’t given enough clear information to understand why.

Case in point: you can’t offer inducements— even the most innocent-seeming discount – to federally insured patients to “help” them receive care from your practice. In case you missed this ruling, it was set forth by the Office of the Inspector General (OIG) back in 2002.

Here’s what they said: “Under section 1128A(a)(5) of the Social Security Act (the Act), enacted as part of Health Insurance Portability and Accountability Act of 1996 (HIPAA), a person who offers or transfers to a Medicare or Medicaid beneficiary any remuneration that the person knows or should know is likely to influence the beneficiary’s selection of a particular provider, practitioner, or supplier of Medicare or Medicaid payable items or services may be liable for civil money penalties (CMPs) of up to $10,000 for each wrongful act. For purposes of section 1128A(a)(5) of the Act, the statute defines “remuneration” to include, without limitation, waivers of copayments and deductible amounts (or any part thereof) and transfers of items or services for free or for other than fair market value. (See section 1128A(i)(6) of the Act.) The statute and implementing regulations contain a limited

number of exceptions.”

What does that mean in plain English?

Basically, you can’t give away or discount your services, and you can’t waive deductibles or copays. Doctors who do this (and, sadly, there are many kind hearts who do just this sort of thing with the very best of intentions) are putting their practices—and their licenses—at risk.

What happens if you do? The Feds aren’t kidding on this one. When they audit a practice and uncover any kind of inducement, they can slam you with up to $10,000 in fines for each wrongful act or line item. Consider how many line items there can be on just one CMS 1500 form!

We are not talking pocket change!

So what do you do with a Medicare patient who is on a fixed income? Easy: become a provider with ChiroHealthUSA. With ChiroHealthUSA, you can transition Medicare patients to our fee schedule for all non-covered services. (Exams, x-rays, therapies and extremity adjustments) Using your ChiroHealthUSA provider fee schedule streamlines your practice and makes it more affordable for your patients. Most importantly, it keeps you legal—and with audits on the rise, running afoul of the OIG is a risk no one should run.

Why? Yes, the answer is the same as it was when you were four: because they said so.

If this sounds like a perfect way to keep you safe while you care for your Medicare patients, it is. Learn more about how ChiroHealthUSA can help your practice with less risk and more satisfaction. Join us on a free webinar that will give you all the details about how you can become a provider. Go to www.chirohealthusa.com to register today.

Dr. Foxworth is a certified Medical Compliance Specialist and President of Chi¬roHealthUSA. 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 pastpresident of the Mississippi Chiropractic Association. He was voted by his peers as 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 Chairman. You can contact Dr. Foxworth at 1-888-719-9990, info@chirohealthusa.com or visiting the ChiroHealthUSA website at www.chirohealthusa.com.

TCA Annual Convention June 6-9 Austin, TX

June 6

June 7

June 8

June 9

12pm

8am

8am

9am

Registration Opens

Opening Keynote Session

CE Courses

Post-Convention BOD Meeting

1pm Pre-Convention BOD Meeting

Schedule at a Glance

4pm Pre-Convention Workshop

7pm Opening & Exhibitor Reception

Diagnosis: Domination or Definition?

by Chris G. Dalrymple, DC, FICC Diagnosis. It's a simple word, or is it? The Texas Medical Association (TMA) would have you believe that it is not just a simple a matter of reading the dictionary definitions in their entirety. Various dictionaries give us definitions of the word. Some of these include "the process of determining by examination the nature and circumstances of a diseased condition"; "a scientific determination"; "a determining or analysis of the cause or nature of a problem or situation"; or "an answer or solution to a problematic situation."

Because ONE of these definitions contains the word "diseased" the TMA would have us believe that, in Texas, no one but licensees of the Texas Medical Board (TMB) may USE the word diagnosis, because ONLY licensees of the TMB have been granted the privilege of diagnosing and treating diseases. This is not an individual interpretation or opinion folks, this is what they openly state to the Texas Supreme Court!

Before we look into their reasoning let's be clear about what "disease" is. The dictionaries tell us that it is "a disordered or incorrectly functioning organ, part, structure, or system of the body resulting from the effect of genetic or developmental errors, infection, poisons, nutritional deficiency or imbalance, toxicity, or unfavorable environmental factors." It is also "illness; sickness; ailment." Disease is "any harmful, depraved, or morbid condition", and "any impairment of normal physiological function affecting all or part of an organism, especially a specific pathological change caused by infection, stress, etc, producing characteristic symptoms; or illness or sickness in general." [1]

9am

12pm

CE Courses

Luncheon hosted by Dr. Charles Webb

12:30pm

1pm

Auxiliary Luncheon

CE Courses

1:30pm

6pm

CE Courses

Cocktail Reception

7pm

7pm

TCA Stars Gala Auction

Presidential Banquet & Awards Ceremony

In their attempt to "own a word in common usage" (and this is not the first instance where "organized medicine" has attempted this, they have also attempted to "own" the word "doctor" [2]) they would in this instance take upon themselves the nature of "caretaker of all things harmful, depraved, or morbid" and permit no one else to do so.

DC lends helping hand to victims of Texas explosion

Lest you think that this is merely an opinion, let's look at the TMA's own words from their reply brief to the Texas Supreme Court. I'll emphasize in bold.

"TMA is a professional trade organization whose members include approximately 41,000 physicians and medical students. Any person who practices medicine in Texas must be licensed and must comply with the Texas Medical Practice Act. Licensed chiropractors are exempt from complying with the Texas Medical Practice Act so long as they do not engage in the practice of medicine. TBCE's scope of practice rule authorizes chiropractors to ... diagnose medical conditions. By authorizing these activities, the scope of practice rule expands the practice of chiropractic into the practice of medicine." [3] And just why is the TMA so concerned about Doctors of Chiropractic being able to diagnose anything?

"Allowing chiropractors to practice medicine undermines the value and integrity of medical licenses, and diminishes the licensed privilege of practicing medicine. ... One of the duties of TMA and its members is to protect the integrity of medical licenses because licensure is the primary method by which they can be assured that only those who are properly educated and trained in medicine are allowed to engage in the practice of medicine." [3]

April 29, 2013 — In wake of the tragedy in West, Texas last week, the American Chiropractic Association (ACA) was pleased to learn that Christopher Cochran, DC, was offering free chiropractic services to victims affected by the massive plant explosion that killed 15 and injured at least 200.

Last weekend, Cochran volunteered several hours at the VFW post by offering chiropractic services to several other volunteers, police officers, fire fighters, and those directly affected by the blast. When asked about why he drove out to the city to provide his services, Cochran responded, "I just want to help others."

Source: American Chiropractic Association

The TMA is concerned about maintaining the "privileged status" of its members and the TMB of its licensees. Such base motives are couched in grandiose language such as being carried out in the name of "public safety", "public health", and to "cure disease", but the motivation is plainly stated by the TMA--"One of the duties of TMA and its members is to protect the integrity of medical licenses" and allowing chiropractors to diagnose "undermines the value and integrity of medical licenses." How "noble."

Let's see in TMA's own words just what it is they believe: "Before addressing these arguments, it is important to recall that chiropractors are exempt from the licensure requirements of the Medical Practice Act ONLY if they are engaged 'strictly' in the practice of chiropractic as defined by law. And ... a chiropractor can do no more than 'analyze, examine or evaluate the biomechanical condition of the spine and musculoskeletal system.' ... A fair reading of both briefs leads to the conclusion that both TBCE and TCA contend that chiropractors are authorized by the Chiropractic Act to diagnose diseases of the spine and musculoskeletal system." [3] It seems that the 41,000-plus membership of the TMA is AFRAID. They are afraid that the 5000 doctors of chiropractic might suddenly, and for no apparent reason, wish to shift their focus FROM "restoring normal function" and "to diagnosing disease" thereby suddenly rendering "medical" diagnoses willy-nilly.

Doesn't this say something about the integrity of our "organized medicine" cousins? Isn't it interesting that while "organized medicine" complains that there will not be enough primary care providers to meet the needs imposed by the soon to be implemented national healthcare reform, at the same time they FEAR that 5000 properly trained graduates from federally overseen institutions, duly licensed as DCs in Texas, might actually step up to assist in filling that niche. And they take it upon themselves to prevent the state from "allowing chiropractors to diagnose" because it "undermines the value" the medical licenses and "one of the duties of TMA … is to protect the integrity of medical licenses."

The Texas Chiropractic Association in their brief to the Texas Supreme Court discusses the use of the word diagnosis. Says the TCA: "TCA will briefly address the merits of TMA’s assertion that provisions of the scope-of-practice rule are invalid because they use the word 'diagnosis.' ... The Chiropractic Act speaks in broad terms. It permits chiropractors to “analyze, examine, or evaluate” certain biomechanical conditions.

Although the word “diagnosis” does not appear, the plain meaning of the phrase “analyze, examine, or evaluate” encompasses diagnosis."

"To “diagnose” means “to analyze the cause or nature of” something … or to “identif[y] ... a disease or condition by scientific evaluation of physical signs, symptoms, history, laboratory test results, and procedures.”… The trial court correctly reasoned that the “ordinary meaning [of diagnosis] is the identification of the nature or cause of a condition, which is not different substantively from ‘evaluation’ or ‘analysis.’” In short, the Chiropractic Act gives chiropractors wide latitude to analyze and evaluate the biomechanical condition of the body, and diagnosis is simply a particular kind of analysis and evaluation—the kind that occurs when a health care provider uses analytical and evaluative skills to identify the nature or cause of a patient’s troubles." [4] This, however, is not suitable to the TMA. Their reasoning, in their own words, goes like this: "TBCE and TCA contend that the legislature's use of the word 'diagnosis' in the Chiropractic Act is proof that the legislature intended to authorized chiropractors to diagnose. ... TMA

argued ... that the absence of the word 'diagnosis' from the part of the Chiropractic Act that defines chiropractic proves that the legislature did not intend for chiropractors to diagnose diseases. [3] "The word 'diagnosis' or a variation of it, is used four times in the Chiropractic Act. TBCE and TCA claim that because the word is used repeatedly, this must mean that the diagnosis of diseases of the spine and musculoskeletal system is within the scope of practice of a chiropractor.

[TMA believes] the legislature's use of 'diagnosis' in certain sections of the act and its omission of the term from the section which defines the practice of chiropractic mean that the legislature did not intend for 'diagnosis' to be included within the scope of practice. … Given the common meaning of the words used, the legislature's exclusion of diagnosis from the phrase authorizing a chiropractor to 'analyze, examine or evaluate' is perfectly consistent with the legislature's limitation of the practice of chiropractic to the 'biomechanical condition of the spine and musculoskeletal system.

"These are the types of activities--analyze, examine, evaluate--one normally associates with the investigation of mechanics; 'analyze' means to separate (a thing, idea, etc.) into its parts so as to find out their nature, proportion, function interrelationship, etc.; 'examine' means to look at or into critically or methodically in order to find out the facts, condition, etc. of; investigate, inspect, scrutinize, inquire into; and 'evaluate' means 'to find the value or amount of ... to find the numerical value of.' The common, ordinary meaning of these words is not associated with 'the identification of disease,' which, of course, is the primary meaning of 'diagnose.' The contention that the plain meaning of 'analyze, examine, or evaluate' encompasses 'diagnosis' is plainly wrong." [3] Wait a minute. The TMA asserts that analyze means to separate a thing, idea, etc. into its parts so as to find out their nature, proportion, function, interrelationship etc. TMA acknowledges that examine means to look at or into critically or methodically in order to find out the facts, condition; and TMA states evaluate means to find the value or amount of (ignoring that it is also defined as to judge or determine the significance, worth or quality of a thing--to assess it) and yet they completely ignore that the definition of diagnosis includes "the process of determining by examination the nature and circumstances of a diseased condition"; a"scientific determination"; or analysis of the cause or nature of a problem or situation"; “an answer or solution to a problematic situation."

So let's remove, for a moment, the meanings of the words analyze, examine, and evaluate underlined in the above definition of diagnosis. One is then left with--diagnosis: the process of determining ______ a diseased condition; a scientific ______; ______ problem or situation; an answer or solution to a problematic situation. The reality here is that the TMA desires that the Texas Supreme Court REWRITE THE DICTIONARY so that "diagnosis" ONLY means the process of determining a diseased condition, a scientific problem or situation, or an answer or solution to a problematic situation.

What, apparently, really frightens the mega medical-monopoly is the thought that chiropractic will not be pigeon-holed into something less than it actually is. Says the TMA: "TBCE and TCA consistently have taken the position that chiropractors are practitioners over the whole body. … '[unlike podiatrists, optometrists and dentists, the body systems chiropractors treat are not confined to discrete areas of the body. For example, the musculoskeletal system runs literally from a patient's head to toes.' Neither the plain language of the chiropractic Act nor the Act's legislative history provide any support for the idea that the legislature

intended chiropractors to have such broad, essentially unlimited, diagnostic authority."

TMA also speculates fearfully that the addition of one word to the TBCE rule, results in the ability for chiropractic to diagnose any "medical condition" that is associated with the muscles, bones and biomechanics of the body. Says the TMA: "The statute authorizes a chiropractor to analyze examine and evaluate 'the biomechanical condition of the spine and musculoskeletal system,' whereas the rule adds the word 'regarding' before the word 'the:' 'An analysis, diagnosis or other opinion regarding the biomechanical condition of the spine and musculoskeletal condition.'"

Never mind that since before the 1900s the founder of Chiropractic, D.D. Palmer, stated: "I founded Chiropractic on Osteology, Neurology, and Functions--bones, nerves and the manifestations of impulses. …

Functions performed in a normal manner and amount result in health." [5] Never mind that since before the 1900s the chiropractic profession has had "holistic" as its hallmark. Never mind that since its earliest days chiropractic has defined disease as "function out of time with need" and "not as the result of what something does TO the body, but rather as what the body does about it." [6] Never mind the demonstrated HISTORY of the profession in Texas for the past century, the TMA wants to reserve unto itself the WHOLE human being and delegate to others only PARTS of the body and to limit them to the diagnosis of such parts.

In chiropractic the focus is on the function of the WHOLE rather than on the dysfunction of its parts. The profession that concerns itself with being the "caretaker of all things harmful, depraved, or morbid" cannot comprehend a profession that concerns itself with being the "caretaker of the normal function of the body."

Ever since the early 1900s the Texas Chiropractic Association has strived to preserve this wholly functional perspective on health care. The TCA brief notes: "Although the Chiropractic Act does not use the precise word 'diagnosis,' the trial court correctly observed that '[a] use of a synonym for a statutory term is by definition consistent with it and a reasonable interpretation of it, unless the legislature has forbidden its use.' When the Legislature intends to forbid a health care profession from diagnosing, the Legislature has consistently denied diagnostic authority in explicit terms. (dental hygienists may not “diagnose a dental disease or ailment”); (professional nursing “does not include acts of medical diagnosis”); (physical therapists “may not engage in diagnosing diseases”); (occupational therapy “does not include diagnosis or psychological services of the type typically performed by a licensed psychologist”); (massage therapy does not include “the diagnosis or treatment of illness or disease”).

No such denial appears in the Chiropractic Act—powerful evidence that the Legislature did not intend to strip chiropractors of the authority to diagnose that is otherwise implied by the plain meaning of the Act." "Other provisions of the Chiropractic Act dispel any lingering doubt about a chiropractor’s authority. The Act makes confidential '[r]ecords of the identity, diagnosis, evaluation, or treatment of a patient by a chiropractor that are created or maintained by a chiropractor.' The phrase “by a chiropractor” modifies “diagnosis,” demonstrating that the Legislature understood chiropractors would make diagnoses."

"In another provision, the Act creates an exception to the confidentiality of these records for “another chiropractor or

personnel under the direction of the chiropractor who participate in the diagnosis, evaluation, or treatment of the patient.” Again, the notion that chiropractors or personnel under their direction will 'participate in the diagnosis' clearly indicates the Legislature’s intention that chiropractors would diagnose."

"For all these reasons, the Chiropractic Act authorizes chiropractors to diagnose, and the scope-of-practice rule can use the word 'diagnosis.' At the very least, TBCE’s use of the word “diagnosis” reflects a reasonable interpretation of the Chiropractic Act that deserves deference from the courts."

The word "diagnose" literally derives from words meaning "to know thoroughly" and is from the Greek words dia meaning "apart" and gignoskein meaning "to learn." When we diagnose the motives of the Texas Medical Association the desires of the mega medical-monopoly become readily apparent--to be the caretaker of all things harmful, depraved, or morbid for the whole of human-kind; to reserve unto themselves the ability to "know thoroughly" "all things harmful, depraved, or morbid"; and to divide the human body into parts. While other professions may focus upon parts of the body only the mega medicalmonopoly may focus upon the body as a whole. THIS is the objective of the Texas Medical Association.

It is time to realize that when the Texas Constitution states that the legislature shall "give no preference to any schools of medicine" it is referring not to physical places to learn an occupation but to a philosophy or school of thought.

There are two profound schools of thought when it comes to "organized medicine" and "holistic healthcare"--one concerns itself with all things harmful, depraved, or morbid; and the other concerns itself with the restoration and improvement of normal function. The TMA/TMB vs TBCE/ TCA readily illustrates that this is indeed a conflict between two "schools of thought."

[1] http://dictionary.reference.com/browse/disease [2] http://journal.chirotexas.org/2013/01/24/florida-medical-associationwe-doctor/ [3] TMA v TBCE No. 12-0667; Petitioner's Reply to Respondents' Briefs on the Merits [4] TMA v TBCE No. 12-0667; Respondent Texas Chiropractic Association's Brief on the Merits [5] Text-Book of the Science, Art and Philosophy of Chiropractic, For students and Practitioners, by D. D. Palmer; 1910, Portland Printing House Company, Portland, Oregon.

[6] Anything Can Cause Anything, a Correlation of Dr. Daniel David Palmer's Principles of Chiropractic, by William David Harper; Third Edition, 1974; Published Privately by the Author, Seabrook, Texas.

When Good Chiropractors Make Bad Web Mistakes

by Drew Stevens PhD One of the most important aspects for any chiropractic practice is building. Many chiropractors must be very active creating a host of circumstances that bring new patients into the practice. For many, this is a process known as integrated marketing. Chiropractors must provide a slew of activities that create awareness and help build community for their brand. In today's contemporary society the traditional approaches of advertising or utilizing the Yellow Pages is not efficient in bringing patients to the practice so chiropractors must present a host of activities that help to manifest a brand.

To that one of the most efficient methods is the use of the Internet and building a purposeful website. the reason for building a good website is that rather than use the Yellow Pages, most patients today are using the power of their fingertips to discover information about subspecialty doctors such as chiropractors. With over 1 billion searches conducted daily, patients have more information at their fingertips today than they have had in the last 30 years. 10 to 15 years ago I would've told many clients to ignore the speculation of the Internet. However, its practicality and its reach are too important to ignore. And, it is one of the most costefficient methods of manifesting your brand. Unlike your practice, a useful website is available 24 hours per day, seven days per week, 365 days per year.

Yet, while the website is one of the most efficient methods used, there are often many mistakes that chiropractors make. Some of the simplest reasons include: -Many chiropractors believe that they can create it themselves avoiding some of the simplest design floors.

-Many chiropractors don’t know some of the most important things to use to ensure that patients can find the doctor on the Internet.

-If design is one thing, then text is another. Many chiropractors tend to make the sites too wordy thinking this will attract their patients.

-Chiropractors, at least some, don’t believe in the power of the Internet and they simply ignore it!

While these are some of the most identifiable flaws, it is important to realize that chiropractors have only seven seconds to make an impression on a patient. Therefore, it is imperative that chiropractors ignore the four largest pitfalls in developing their site. What follows is the identification of those flaws and how to simply avoid them.

What’s In a Name?

Perhaps the biggest issue when developing the website is choosing a name. It is ironic how chiropractors will choose many names such as Holistic Health, Comprehensive Chiropractic, Healing Arts, Beyond The Back, et cetera. While all of these names sound interesting, the chiropractor forgets what the patient is looking for: the doctor! I often find that one of the biggest flaws in developing the site is choosing his or her name. All URLs must be in the name of the doctor. Patients today are not looking for the name of the organization but rather a) the doctor of chiropractic and b) the methodologies that they employ to heal the patient. Why on earth what a chiropractor choose a sexy title only to be lost amongst the web. According to Royal Pingdom there are 634 million web pages and over 246 million domain name registrations in 2012. With that traffic you have as much luck screaming for help in the middle of the Pacific or Atlantic Ocean during a hurricane. There is too much noise, too much competition and not enough self-definition.

Being on the Internet is about brand building and information availability.

Chiropractors must make it easy for patients to find them. To that end, the site must be based on the chiropractors first and last name such as Doctor Drew, or John Smith DC. This is what patient search for.

It’s all in the Bait I enjoy fishing and similar to hooking the best fish, you must have the proper bait in order to do so. Present websites use a myriad of schemes to capture attention, yet one of the easiest is using keywords that patients

use when search. Typically, this implies that patients are looking for back pain, stress management, knee stiffness, neck pain.

In a recent review of over 150 websites, many chiropractors failed to mention their patient issues. The sites speak of subluxation, the years of practice, laser and decompression machines. Who cares? The patient doesn’t. If the site does not offer wording sought by the patient the site will be passed.

To help you with the proper search terminology, chiropractors must use the proper tools to help. These include keyword tool finders such as those offered by Google. These free web resources help the doctor to understand regional and global search terminology so that there is polarity in what patients want and what the doctor provides. Additionally, these words must be placed organically (in the descriptive site text) and technologically (hidden in the source code) so that the site rises to the top of the search (food) chain. Build it right and they will come.

Words of Wealth Create Magnetism Using proper words create emotion and patients become interested based upon emotion. The use of the proper words creates patient magnetism. Patients never make practical decisions they make emotional ones! Therefore, the proper wording must be used on your site in order to to attract your perfect patient. To that end, chiropractors need to stop being so prescriptive and start thinking like their patients. Patients are seeking outcomes, they see results, and they seek value. Chiropractors must convert the science of chiropractic into the results of chiropractic.

One of the things I typically look for when researching the website is how a chiropractor positions him or herself. By this I mean, how many times the word subluxation or adjustment or decompression is listed. Patients are unfamiliar with these scientific terms unless they've been to chiropractors prior. What they really seek out is identification of their issues and how the doctor reverses it. Therefore, the wording on the sites not only has to match the key terms that patients search for but also their issues and how the chiropractor helps overcome them. Chiropractors must convert website wording into outcomes and results.

Additionally, the use of testimonials is also a flaw. We can get anyone to say some terrific things about us. What is really required is the use of case study to illustrate an issue, illustrate the remedies used and finally the solution and results the patient received. When you provide case study it makes you more believable while also illustrating your value and differentiation.

White Space Is the Place Last but not least is the amount of text chiropractors should use. We have all heard the terminology of the kiss method but many fail to use it. In our contemporary society less is more. Don't believe me? Think of how many tweets are sent per day. And also think about the brevity used on social media sites such as Facebook and Pinterest. The constant flourish of emails and social media pounds us with over 7000 messages per day.

Patients just like you and I lack time and as such we need to keep it simple. The shorter the better!

We need to use the white space on the websites to our advantage. Text in paragraphs should be no longer than 250 to 300 words. And all of the important information must be above the fold. This is an old newspaper terminology that indicates that all-important text must be on the screen before a patient needs to scroll. The less scrolling a patient must do to find content the better.

One final note here, all of your pages must have a purpose. Each page on your website must have some mission that provides important content to the patient. And, it must link them to other areas of the site. In other words, you want to use each page as a roadmap to get deeper into your site. Finally, every single page must have a call to action. You must tell them what you want them to do and tell them how to do it. They will not do it unless they read it!

Oh Yes, the Money Magnet A final thought to make your website most purposeful is to have something known as a money magnet. This is nothing more than a free giveaway to help encourage patients to provide you with their email. This is a useful tool that has been around for years and has been available even in traditional advertising. A doctor of psychology at Arizona State University defined the term “Law Of Reciprocity” in his book “The Power

of Persuasion”. Dr. Robert Cialdini states that if you provide your prospective patient with something they are more than likely to reciprocate. Take the time to develop a web form that offers something for free such as a free posture analysis, or the free booklet so that the patient will provide you with their name and their email to help you remain in constant contact. This is a great method so that you can develop trust and relationship over the course of time. Most chiropractors miss you because they are absent of a money magnet.

Notice also that “If you do not respond within 20 days, your case will AUTOMATICALLY be set for a contested case hearing at SOAH.”

Taking the time to build a website will be helpful for your practice. The ability to advertise and attract prospective patients 24 hours a day will help lessen your labor and increase patient volume. This is not an overnight process, but the results can be quite rewarding. If you take the time to build it right they will come. If you avoid the flaws you will illustrate value and differentiation. When you take the time to develop a good foundation your prospective patients become aware of your value and help build your online and off-line community. This is when your brain manifests and you’ve done great things to build a great practice.

KEEP THE TBCE INFORMED OF YOUR CURRENT ADDRESS!

© 2013. Drew Stevens PhD. All rights reserved.

Drew Stevens Ph.D. is a world-renowned marketing mentor for chiropractors. Drew transforms struggling chiropractors into wealthy chiropractors. He is a frequent contributor to Chiropractic Economics and can be reached at www.stevensconsultinggroup.com

Keep Your Postal Address Current with TBCE!

by Chris Dalrymple DC, FICC Do you really want to pay several hundred dollars in fines?

Do you really want to have to hire an attorney?

Do you really want to take the time to go through an administrative law hearing?

KEEP THE TBCE INFORMED OF YOUR CURRENT ADDRESS! We have reported previously, the TBCE is serious about fining its licensees because their postal address is not current. 22 TAC Article 73.1 states: “Licensees shall maintain a current physical home and business address with the Board. A different mailing address may be provided in addition to the home and business address.

Licensees shall notify the Board, in writing, of any change in address within 30 days of the change. The notification shall be signed by the licensee and must include the license number.”

You do NOT want to receive a certified letter stating: “YOU ARE HEREBY NOTIFIED that the TBCE Enforcement Committee has determined that a violation of the Chiropractic Act, Board Rules, and/or order has occurred and recommends to the Board that an administrative penalty … be imposed against you. … Additionally, the Enforcement Committee recommends that this “finding be included in your professional records, as well as posted in the TBCE Newsletter.”

Do you really want to pay several hundred dollars in fines?Do you really want to have to hire an attorney?

Do you really want to take the time to go through an administrative law hearing?

TCA Communications–Getting the News Out!

by Chris Dalrymple DC, FICC The Texas Chiropractic Association has spent the past year working to improve it’s instantly accessable communications. We invite your participation in sharing news. If you see an article, news story, or know of an event that needs to be shared with others just send an e-mail to editor@chirotexas.org and let us know. We’ll work to get it published in the appropriate publication.

Our News site at journal.chirotexas.org is a veritable one-stop-shop of information to keep you up-to-date on news in the chiropractic world, health and healthcare in general, and reports pertaining to legislation and regulatory information. Go to journal.chirotexas.org (no “www” required).

You’ll see the “front page” of the TCA News. This will show you the most current news posted in chronological order going backwards in time as you scroll the pages. At the top of the page you’ll see links to the TCA Association site at www.chirotexas.org and a link to the article archives all 5000+ of them!

In the left menu you see “Sections.” Think of these as the sections of a newspaper, or of “mini-journals” pertaining to a particular topic. Click on one of the sections and you’ll find postings in chronological order relating to that topic. Some articles may be posted in more than one section.

In the right column you see the latest postings in chronological order, a link to join the TCA General e-mail list, a convenient calendar, and a way to follow TCA on social media.

Regularly check journal.chirotexas.org. Important news and announcements are reported here and general news is posted daily! We are working to bring you the information that you need to better help people.

District leaders and committee chairs: need to report to the world some important event that we ALL need to know about? Send an e-mail to editor@chirotexas.org and let the world know.

DOWNLOAD THE FREE TEXAS JOURNAL OF CHIROPRACTIC APP IN THE ITUNES STORE.

If you should receive such a notice you will have 20 days to pick one of the following: “Accept the determination and recommendation of the Enforcement Committee and sign the proposed agreed final order included with this notice; or Request an Informal Settlement conference to discuss resolution of this complaint iwht a member of the TBCE; or Request a hearing with the State Office of Administrative Hearings (SOAH). You will receive written notice of the hearing date, time, and place.”

NOW YOU CAN READ THE JOURNAL ON THE GO! BE ON THE LOOK OUT FOR THE NEXT JOURNAL! THE JULY/ AUGUST ISSUE WILL BE AVAILABLE AUGUST 1.

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