Editor's note: The following three letters were written in response to Dynamic Chiropractic's recent series of articles on American Specialty Health Plans.
"When will our colleges stop pandering to insurance companies?"
Dear Editor:
When will we learn? Today I sat down and read your front-page story, "ASHP Drops Reimbursement to $30 Global Fee." When will our colleges stop pandering to insurance companies?
All chiropractors should drop their participation with every single HMO right now. We are slowly being bled to death economically by the HMOs, and we still sign up out of fear that our patients will go to the "other" chiropractor who will sign up to be paid less than half of what he or she is truly worth.
I say we should let those patients go. The chiropractor "down the street" will "wise up" when he or she gets tired of 60-hour weeks of endless paperwork, and patients whose loyalty is nonexistent!
Chiropractors who graduate in the next few years don't have a chance if we don't face this threat to our survival right now.
As I see it, we have only one option: drop out of all HMO participation and take control of chiropractic by seeing that 100% of every dollar spent on chiropractic reaches chiropractors!
What would your patients do if you and every other chiropractor in your community suddenly stopped accepting their HMO?
James Watson,DC
Canandaigua, New York
"It's a shame health care is run this way" Dear Editor:
I have just finished reading Dynamic Chiropractic's article interview with ASHP's finest. In the past, I haven't worried much about ASHP, what they had to offer and their impact on healthcare. I am a preferred provider on the network and am allowed to treat "scraps" of PPO patients. I have been on the plan several years, and I can honestly say that I have probably gotten 10 patients referred to me from ASHP - not much of an impact.
I was never worried about being an HMO provider because my practice was doing well (and still is), but I am now seeing more patients in under the HMO, whom I have to send to my partner who, is on the Select HMO plan. I also recently logged onto ASHP's website and curiously typed my name into their "provider-seeking" area. My name appeared as a non-provider. I was shocked! I called ASHP, and they said, "We don't acknowledge preferred doctors on the web page." When I asked why not, they had no answer.
I am at the point where I would like to get on the Select plan so I don't lose the patients I have. I'd hate to come to work one day to find that I was losing old patients as fast as I could get new ones. "Sallie Mae" won't be happy. I asked to apply for the Select plan, but I knew what the answer would be: "We already have the maximum amount of providers in your area, and if a spot comes available, you might be selected, but we have plenty of spots open in Truckee."
I believe this topic of closed networks has gone way too far. I believe that if a doctor is qualified and is willing to pay processing fees, he should be allowed to be on a plan.
No matter what the plan is, I will give a patient the time and treatment they need, not just what the plan pays for. Down the road is a guy who adjusts them and shoves them out the door as quick as possible. He's on the Select network and is having a great life. Why? Because he gives better treatment or because he's more qualified? I don't think so! It's a shame health care is run this way.
Why wasn't this topic discussed in your interview? I believe it should be one of the first questions asked every time you run into these people. I'm sure the majority of the chiropractic population would like a straight answer, other than "That's what our contract says and that's what the insurance companies request." What's the real reason?
At the same time, each chiropractic college student should be notified that when they graduate, they will be responsible for a $1000-per-month school payment, but that ASHP's network is closed.
David A. Sommer, DC,CSCS, RSMT,CSMT
Simi Valley, California
Did ASHP Get Their "Global Fee" Schedule from Landmark? Dear Editor:
I read your article in the August 6 issue of Dynamic Chiropractic and was dismayed to hear about ASHP and their $30 reimbursement. When I called, I was told that this was only for "certain" plans in California and that my participation in New Jersey was unaffected. It's a good thing because their rates are already too low. If they were any lower, I would have left prior to seeing my first patient.
I would, however, like to bring to your attention another organization that has been known to publish insightful studies regarding alternative health care. Landmark came into our area under PHS Health Plans a couple of years ago. They showed promise with an "OK" fee schedule. During the first year, they lowered our fees slightly, but This year, they now pay us a global fee of $33 including the initial visit. This doesn't even cover the initial new patient processing costs, and at $33, I barely break even. Sure, I can leave, and if they go any lower, I intend to.
Has anyone ever looked into this behemoth? I believe you should. Perhaps this is where ASHP got their idea. If they could do it, so could we. I would have already left, except we do a fair amount of visits with them. Incidentally, if a patient is under 50, the plan will probably make you "eat" those x-rays because they say it's medically necessary 20% of the time. (This is documented because they sent me a printout on our office with these stats.)
When I filed a formal complaint with the Department of Insurance against Landmark, they sounded reasonable in their rebuttal, using some references that they pulled from "somewhere" to support their point of view in their radiological criteria. There are also standards of practice in lawsuit cases, and in most of these judgment cases, not "taking the film" will cause you to lose a malpractice judgment. I really do not want to guess when it comes to a person's spinal condition. Therefore, if I need them, I take film when necessary. Perhaps you should investigate this.
In my view, these companies are "category" killers, not unlike Costco. We as providers are punished with ridiculous paperwork and denials. How many people do we really need in offices, anyway?
William D. Charschan DC, CCSP
North Brunswick, NJ
"Let us build on what we have instead of adding to the divisions" Dear Editor:
The responses presented by Drs. Pruit, Erickson and Harrison to Dr. Winterstein's suggestion of separating the "chiropractor" from the "chiropractic physician" (DC, July 10, 2000) range from the ludicrous to the intelligent (though possibly misguided). I am not saying that I agree with either point of view, however, the point of contention has been missed once again. Most arguments revolve around what the scope of practice of a licensed chiropractic doctor is, was, or will become. However, some of the participants in this argument attempt to equate the scope of practice of chiropractic doctors with the term chiropractic. These two are not equivalent, never have been, and never will be.
Do we attempt to define what "chiropractic" is or is not by what the founder said it was, or by what he did? D.D. Palmer used many different types of treatment, including diet and naturopathic methods. I have never read, in any of his three books, any instance in which he stated that these were "chiropractic," and I don't believe he regarded them as such. That he used them can only mean one thing: D.D. Palmer thought that these methods had something to offer and that they were within his rights to use on patients. The fact is, D.D. Palmer used chiropractic and other methods in his chiropractic practice.
A pitfall very rarely missed by the opponents in this continuing argument is the a priori assumption that everything a chiropractic doctor does falls under the definition of what "chiropractic" is, rather than being rightly placed in the category of the allowed scope of practice of chiropractic doctors.
If a person makes the assumption that what a chiropractic doctor does is equivalent to chiropractic, they must also assume that what a medical doctor does is medicine and what an osteopath does is osteopathy. As some medical doctors take their patients' temperatures, applying the aforementioned logic, this must be medicine. But if an osteopath does this same procedure, are they practicing medicine, or is it osteopathy? What of the chiropractic doctor who does this as well? Can taking a patient's temperature be all three? Of course not: taking a patient's temperature is not medicine, not osteopathy and not chiropractic. It is a diagnostic procedure used by health care professionals on occasion to arrive at a diagnosis. Likewise, telling a patient to drink enough water is not medicine, nor osteopathy, nor chiropractic; it is educating your patient on the importance of water intake.
Both of these examples clearly illustrate the crux of the problem. Both are within the scope of practice of all three types of doctors, and yet, neither are limited to one. They are within the scope of practice of the three, but they are not those three.
To some, this may seem like a trivial distinction, but if one looks at the medical professions, it is easy to see the differences and demarcations within it. In chiropractic, we have those distinctions as well, and we already have a system in place. It may be wiser to expand upon the established system rather than add a nebulous term such as "chiropractic physician" which, incidentally, is already used by many, irrespective of treatment approach or postgraduate education.
I would suggest the following steps:
- Revive the American College of Chiropractic Specialties (ACCS) as a distinct organization, separate from our political organizations, and as the accrediting agency. The ACCS would oversee all educational programs and testing procedures for their member boards.
- Establish the necessary specialty boards under the ACCS either by assimilation of existing ones or the formation of new ones.
- Promote the specialists within and without the profession.
This approach would be much more feasible than adding yet another modifier to "chiropractic" which would only serve to confuse the public more. We already have chiropractic radiologists, chiropractic orthopedists, chiropractic pediatricians, chiropractic internists, chiropractic neurologists,
ad nauseum. Let us build on what we have instead of adding to the divisions.
Brian A. Smith,DC
West Hollywood, CA
"Florida and the rest of the country do not need another chiropractic college" Dear Editor:
Once again, I am amazed that there are people within the chiropractic profession who really think we need another chiropractic college.
The Florida Board of Regents reasoned that because 700 Floridians leave the sunshine state each year to pursue a chiropractic education, it is evidence that an in-state chiropractic college is needed. Debbie Brown, CEO of the Florida Chiropractic Association, said, "Each FCA member can take special pride in seeing this project come to fruition."
Let me remind those people of the state of chiropractic today. There is now a chiropractor on almost every street corner in America. Anyone in this country is able to see a chiropractor the same day they need one. Income for chiropractors has been dropping each year. Many chiropractors are dropping out of our profession because of an inability to make a living. Many recent graduates are unable to repay their student loans. Insurance coverage for chiropractic is declining each year.
Representative Dennis Jones,DC of Florida said that when he realized many students were leaving Florida to pursue a chiropractic career, he would not stop until the need for an in-state chiropractic college was met.
Let me tell Representative Jones that both Florida and the rest of the country do not need another chiropractic college. Just who is Rep. Jones representing? Not practicing chiropractors; not his constituents. His ego, maybe?
Florida State University will soon be graduating an additional 500 chiropractors a year. I can assure you, the other chiropractic colleges around the country will not allow a decrease in their enrollment. Where do you think these new graduates are going to set up offices? That's right, down the block.
Jerry Marshall,DC
South Norwalk,Connecticut
Read the Law Before Adjusting an Animal Dear Editor:
Your July 10 issue has an interesting article on Dr. Kyle Goltz and a veterinarian adjusting a bear. I trust your article will not give "Charlie Chiropractor" the idea that he can adjust animals belonging to his patients and/or that it would be OK with the law.
This subject was taken up with the California Board of Chiropractic Examiners (CBCE). They responded: "A few years ago, the California Board of Veterinary Medicine was going to enact a regulation that would have permitted the referral of animal patients to licensed chiropractors.
However, this was stopped. This would have caused the chiropractors to violate the law since Title 16, Division 4, Section 302 (Chiropractic Regulations by CBCE) states that a chiropractor may manipulate and adjust the spinal column and other joints of the human body." They even sent out a memorandum from the CBCE to licentiates concerning this matter.
I hope that any interested chiropractor reads his or her state law first. If the term "human body" is contained therein, it would be a violation thereof. If the CBCE would take under consideration a curriculum for DCs to study and qualify before they could adjust animal patients, it might be a different story if it were adopted by their state board. The vets are as proud of their profession as MDs are of theirs, and DCs must be careful if they choose to violate these other acts.
Robert B. Jackson,DC
Jones, Oklahoma
"Medicare Has Not Kept up with Modern Advances in Treatment Options for Patients" Dear Editor:
Regarding the statement on your website involving Medicare's overpayment of prescription drugs: On the surface, this "overpayment" seems like a waste of taxpayers' money. The issue is much more complex. Medicare only pays for prescription drugs that are administered in outpatient treatment centers and at home as part of the medical equipment benefit.
As you know, Medicare has not kept up with modern advances in treatment options for patients. In response to managed care and control of medical costs, outpatient centers and home infusion have developed technologies to deliver pharmaceutical products that used to require hospitalization. These services are literally hospital care without walls. These drug "overpayments", as Congress is defining them, have been the only source of payment that covers all of the overhead involved in maintaining these services. Medicare does not contain a billing mechanism to cover these services, but they have been offered to Medicare patients because the "overpayments" cover the costs.
If Congress reduces the payments without adding a fee to cover the costs, all Medicare patients will have to be hospitalized again to receive treatment. Congress is unaware of the treatment trends that have developed, and it looks good in an election year to look like you are uncovering waste, but the money has been spent on patient services. Believe me, Medicare patients are still a loss compared to insurance patients. Nobody has run off with this money.
Katherine Werner,RN "A cancer nurse who knows the truth"
Feevale Was Not the First Chiropractic Program in Latin America Dear Editor:
I just read your article on the WFC's electing new executives (editor's note: see the July 24 issue of DC). Thank you for your coverage. Please note, however, your error on referring to the Feevale program as being the "first in Latin America."
Mexico had a Palmer School of Chiropractic during the early part of last century. While practicing in Mexico, I had the privilege of meeting and working with that school's graduates. The Feevale program was the first in South America, and the first in Brazil, but not the first in Latin America.
An article on this early pioneering school might be an interesting subject for a future article. I suspect it was the first school outside of the USA. It no longer exists, but it was important in establishing chiropractic in Mexico and pioneering it in Latin America.
Ronald Lee Firestone MS,DC
Santa Cruz, Mexico
Not the Kind of "Help" He Wanted Dear Editor:
This letter is written in regards to Paul Hooper's article, "I'm Here From the Government & I'm Here to Help You" in the July 24 issue.
As I remodeled my office in 1996, the government, through OSHA and ADA, "helped" me to the tune of $20,000 of extra expenses and changes that I have yet to utilize in any way. Four years later, the extra $4,000 for the handicapped ramp that I was forced to install goes unused. The way I see it, if any ADA advocate or OSHA fan wants to write me a few checks, only then will I agree that "government" is any help.
Just like Elian Gonzalez, government will "help" you through force; try to get a business license or occupancy permit if you don't make the OSHA/ADA improvements.
I would like to "help" government in the same way government has "helped" me, but that's illegal.
Bill Butson,DC
Lenoir, North Carolina
