We Get Letters

Thou Shalt Not Criticize

Dear Editor:

I recently wrote a highly critical letter to the Chiropractic Journal published by Terry Rondberg, D.C. To my surprise I have not received a copy of the Chiropractic Journal since that date, over eight weeks ago. I discovered this fact in reading a recent letter from a Dr. DiPietro of Tuscon, who had made a similar discovery. I find it disturbing that a publication that claims to be open to all viewpoints, would so radically trim their mailing list. The publishing policy of the Chiropractic Journal does not seem to live up to its own philosophy.

I am curious to find out if there are others who have written critical letters to the Chiropractic Journal that have also been thus eliminated. I am sure the advertisers in that shoddy journal would be interested in that fact also.

I have also written critical letters to Dynamic Chiropractic, and I am pleased to say that my subscription with your fine publication is still intact.

Donald R. Seidel, D.C.
Rochester, New York

Dear Editor:

I find myself in a dilemma.

I have been in private practice since 1949, have taught in our chiropractic colleges, written articles for our journals, and in general have made substantial contributions to the advancement and development of chiropractic.

During these "autumn of my life" years, I've devoted about 20 percent of my practice to conducting IMEs for various insurance companies, as well as attorneys. As such, it has become clear to me that many chiropractors are fraudulent overutilizers, billing the insurance companies out of thousands of unearned dollars.

Based upon your recent editorial, is it my responsibility to "blow the whistle" on those chiropractors who are blatently abusing the third-party payer system?

With deep appreciation for your efforts on behalf of chiropractic.

Author's name withheld by request.

Dear Editor:

I would like to thank all of my colleagues for their complacency which allowed the bestowal of this honor -- President of the International Chiropractic Association (ICA) for a Day.

Approximately four weeks ago I attended a seminar for the ACPPA (Arizona Chiropractic Preferred Providers Association) with about 200 other DCs. Available to all the doctors were 10 preprinted letters to President Bush, senators, representatives, Chairman of the Ways and Means Committee, U.S. Department of Health and Human Services, etc. These preprinted letters were regarding the injustices of the Medicare system and chiropractic's role in Medicare. The letters urged these people to contact the ICA or other chiropractic groups to discuss these issues. Well, like any good DC, I put them on my stationary and sent them out. I really figured they probably wouldn't read them, because they receive so many.

Yesterday I received a phone call from the assistant to the Secretary of the U.S. Department of Health and Human Services in Washington, D.C. regarding my letter! She was under the impression that I wrote this letter as the president and representative of the ICA. You see it was the only letter they received.

This is not an isolated incident. Two weeks prior, I had read in a local journal about a slanderous assault on chiropractic by a well-recognized, media medical physician in Arizona. The publication urged DCs to write to him and the station regarding this matter and even provided the address. So, I did, and sent a copy to the publication. Three weeks later this publication printed my letter. Why? Was I the only one who wrote one?

How can we make changes when we don't take the necessary action? It's not going to drop from the sky. I know we are not pleased with the way things are now, and I also know I'm not the only DC who cares. What happened to power in numbers? When I become president of some organization it will be because I've worked for it, not because I stand alone.

Remember! The squeaky wheel gets the grease. Let's all make some noise.

Linda Simon, D.C.
Scottsdale, Arizona

Dear Editor:

I write this letter to end an alarming trend in our profession. Due to new circumstances that allow DCs and MDs to work together in a practice setting, a degrading and humiliating situation has arisen. It is being done to us, but we are perpetrating the problem. This is the dilemma:

Registered physical therapists (RPTs) cost an MD a lot of money in a workers' compensation/personal injury practice. Instead of hiring a RPT for the job at the rate of $30-$40/hr, MDs and their office administrators have discovered that chiropractic doctors will work for less, while supplying a greater amount of services to the practice.

Chiropractic physicians in that type of setting can diagnose, adjust, do physical therapy, take x-rays, interpret x-rays, order and interpret all laboratory work, do physicals, write reports, bill under their own license, and more. RPTs can do physical therapy -- that's it. Yet we will work in an MD's office for $15/hr, after going to school seven to nine years, earning less than many laborers.

I understand that the bills are coming due and that student loans are knocking on the door, but please don't prostitute yourselves or the profession.

MDs earn $35-$70/hr. Are we, as doctors in the workers' compensation/personal injury arena, second rate? I would say no. A majority of our education is geared toward physical medicine. An MD's education is geared very little, if any, to physical medicine. I would hope that with all our education and knowledge that we would not accept less than a truly acceptable wage. Hold out -- I am.

Christopher Sabatino, D.C.
Hollywood, California

Dear Editor:

I, like others, have been a practicing chiropractor for more than 30 years and have had to endure much, but in my opinion, no issue in the past can compare to the magnitude of the ongoing damage that is occurring in our profession through paper reviewers and Medicare.

When a doctor receives a request from an insurance company for copies of his records, he can kiss the doctor/patient relationship goodbye, as well as his legitimate fee for services rendered to that date, in 99 percent of the cases. Why is this true? Simply because these reviewers are essentially hired guns, typically used by insurance companies in a covert attempt to pit us against each other; to do the work that they would like to do themselves but cannot, without jeopardizing the insurance contract relationship. In order for these review services to survive, they must perform for the benefit of the insurance industry. It is unfortunate that chiropractic diplomates of orthopedics, or the general chiropractor, will placate and prostitute our doctor/patient relationship, by doing the dirty work that the insurance company will not do so as not to destroy their policyholder's contractual relationship. It is peculiar how the insurance company will insulate itself from harming the contractual relationship, isn't it? Yet, when a paper reviewer does his work against another chiropractor, he will destroy that chiropractor's patient/doctor relationship and hurt the entire profession as well.

In my opinion, there is no ethical or legitimate way or excuse to insist upon or continue with the performing of paper reviews by way of outside firms that solicit this business. However, there are avenues available to the insurance industry who legitimately perceive a problem with an individual doctor. Those avenues are the state peer review committees, and the ordering of an independent chiropractic examination.

I also note with interest that the NCMIC has currently refused to provide malpractice coverage for these individual paper reviewers, as should well be, because the process as practiced today is fraudulent. I personally have caught insurance companies selectively sending, for paper review only, copies of my office notes, which would leave much to be desired in a fair adjudication or review.

In addition, I have heard of cases in which the paper reviewer was a neurologist, a nurse, or even a nurse's aide, which, if true, is an abdomination. Let's review some of the important things that comprise the doctor/patient relationship aside from a case history, examination findings, and daily notes: There are many interpersonal skills that go into making up this relationship, which are so important to the outcome of the treatment protocol, such as the doctor's observation of the patient's attitude, manner, gait, poise, and posture, as well as personal inspections of the ailing personality. Aside from the injured body part(s), all of these observations help the doctor mentally arrive at a treatment protocol. In addition, the treatment is based solely on the doctor's determination of the cause and extent of the problem, the chiropractic treatment skills in which the doctor is proficient, and those he selects to utilize in the best interest of the patient. Try preparing adequate office notes that reflect all this effort, and you will suddenly have a paper-work bureaucracy of federal magnitude right in your office.

I suggest that both the International Chiropractors Association (ICA) and the American Chiropractic Association (ACA), as well as state associations and examining boards, declare it to be an unethical procedure to perform 'paper reviews' for companies that solicit this business with attendant penalties. The only legitimate reviews should be conducted by state peer review committees, or by an independent chiropractic examination performed within the area of the ailing patient.

Raymond P. Spillane, D.C.
Columbus, Georgia

Dear Editor:

Please inform Dr. Paul Kell that I appreciate the article he contributed.

Thank you for supplying this caliber of refreshing, dedicated, reminders that help me feel good about my profession.

It was a deep breath of fresh air and a soft smile that I felt, when I read his article.

Please thank your staff for helping me realize with every issue that your paper has a team of professionals working together to inform and enrich my profession.

Let them know there are many readers who know they are your strength and foundation, and we know that when you speak, they speak to us, through you.

We know that the ink is forged with their dedication and commitment.

This reader truly appreciates what you have done together for each one of us.

Henry Press, D.C.
Westlake Village, California

Dear Editor:

Here are several thoughts I'd like to share with the profession -- that is why I've sent a copy of this letter to Dynamic Chiropractic and The Chiropractic Journal.

We are doing a wonderful job of distracting ourselves from our objectives by all of this infighting, while our real opposition (the medical, insurance, and pharmaceutical industries) lick their chops and watch as we slowly destroy our own profession.

Their slander couldn't do us in. Now they're going to try to legislate us to death. Keep an eye on the "bare bones" health insurance bills that, if not already in front of state legislatures, soon will be. In the meantime, we jealously protect our own small portion of the profession's "ten percent turf."

Instead of cutting each other's throats, to attract more patients, we should work together, ethically, to start carving out chunks (huge chunks) of the "90 percent turf," and start kicking some butts!

A good place to start would be for Dr. Rondberg and Mr. Petersen to kiss and make up. There will always be differences of opinion, philosophy, and goals. Why let that deter us from our mission of getting the best form of health care in this world to as many people as possible?

One way to accomplish the goal of getting these two gentlemen together would be to lock them up in a tiny room to hash out their differences. Any other suggestions are welcome.

I will make one observation that I think many people will agree with. I am not in total agreement with Dr. Rondberg's opinions and philosophy, but I think Mr. Petersen would better serve the chiropractic community by not worrying so much about VSRI and getting on with more important considerations; such as, the advertising of NOOPR, the advertising of a money back guarantee on services performed (yes this is happening, at least here in Cincinnati, if nowhere else!) and working against the aforementioned "medical triad."

We are the best alternative available to bring down skyrocketing health care costs (other alternatives do exist, most are not worthy of consideration) but we can't do it if we are divided. Differences will exist; however, we must coexist with each other if we are to ever achieve our mission. One good place to start is with our dirty laundry, inside a closed room.

David C. Black, D.C.
Cincinnati, Ohio

Dear Editor,

The survey of the profession which Dr. Robert Jansen and the Pacific consortium proposed is a fine idea. However, the "freeloaders" in the profession, i.e. those uncommitted chiropractors at large, (University of California at Los Angeles) should not be included.

Peter Patsakos, D.C.
Grand Rapids, Michigan

Dear Editor:

Please don't place your foot in your mouth! After reading the recent editorial on "The Enemy No One Fights," I nearly had to gag. It suggested a challenge to seniors in medical school regarding the basic sciences. Has the disparity of academic pre-requisites to admittance to chiropractic school versus medical school been forgotten?

Medical students only get to medical school if they are exceptional academic achievers from the genesis of their academic education. This is not true of chiropractic students. When I entered chiropractic school in 1973, I had just finished college with a degree in psychobiology. I was aghast at the quality of students in my school. Fortunately, many did not pass, but others did!

I hope you are right. I know when I graduated from chiropractic school that I would challenge any medical student's knowledge of the basic sciences.

However, in our profession we should spend our time and money on scientific research. We should allow only the best academic students into our colleges and graduate only the best of the best.

I don't agree with you. We should not spend our time "attacking the medical goon squads," as you so cogently stated. Leave such attacks to the academic underachievers.

C.M. Wilkerson, D.C.
Carson, California

Dear Editor:

I love the no-nonsense attitude of your editorials and your columnists. You cut through the double talk that seems to pervade the minds of those in our profession who are more interested in promoting themselves than in promoting chiropractic and serving patients.

Dear Editor:

I certainly agree with your ideas and strategy for the 'grass roots" approach to public relations for the chiropractic profession. I personally feel that the grass roots approach, of using the strength of our patients to help influence society, is still our strongest suit.

One disagreement regarding your November 7, 1990 editorial. You mentioned the chiropractic assassin Stephen Barrett, M.D. he said, "The American Medical Association is not the one responsible for the poor image that chiropractors have with medical doctors. What the MDs hear from their patients, who are also patients of chiropractors, create the poor image." I feel that quotation is true less than half of the time. Chiropractors have many times had a patient or someone else tell their DC how they were reluctant, or even afraid to tell their MD about receiving chiropractic care. Many felt that the MD would get "mad" at them and possibly even dismiss them as a patient if they knew that the patient was seeking chiropractic treatment.

Many times I have complimented, shook hands with or even hugged a patient in gratitude when they had the courage to tell their family doctor or medical specialist that they had chiropractic care and were indeed helped. There are tens of thousands of chiropractic patients who were prior medical failure cases. They're afraid to tell the MD that their condition had improved through chiropractic care. If more patients had that courage and also, as you mentioned in your editorial, the education and knowledge of chiropractic, it would be more easily accomplished.

I look forward to a follow-up in Dynamic Chiropractic about this subject.

John P. Grumish, D.C.
Bourbonnais, Illinois

Dear Editor:

I just finished reading Dr. C.C. Wilcher's article on "The Bio-Dynamic Quantum Physic Model of Chiropractic in the November 21, 1990 issue of Dynamic Chiropractic. Wow! All those big words are really impressive. What exactly does it all mean? Our profession is only now beginning to embrace true biomechanical models in our chiropractic approach. Only a small portion of our profession has progressed past line drawings on x-rays and knocking down high spots. Now in addition to finding joint fixations, precise biomechanically sound adjustments, and an integrated wholistic treatment approach, we have to understand parallel universes and Einstein's bio-dynamic quantum physics.

What about Newton's concept of gravity and the chiropractor's understanding of its effect on the human body? I take offense in my manipulative skills being considered a primitive beginning from which the new advanced science is emerging.

I agree with Dr. Wilcher's belief that all disease is not directly related to spinal dysfunction. Often organic disease is the primary cause of spinal dysfunction. I do not feel that innate has anything to do with bio-dynamic.

While we are advancing our science with BDQPM of Chiropractic, we should also drop this outdated philosophical term. The points raised in the article concerning microcurrent acupuncture, and homeopathy are valid, and we don't have to hide them behind big words. These treatment approaches are valid and in most instances well-researched. They should or could be part of every chiropractor's treatment regime, but they will never replace a chiropractic adjustment (or series of) that is directed into the direction or directions of fixation.

Terry M. Elder, D.C.
Winfield, Kansas

Dear Editor:

With regards to the article titled, "Nine Rules and Procedures to Prevent Insurance Fraud," in the October 24, 1990 issue of Dynamic Chiropractic, the information presented was very good, concise, and informative. However, in the authors' rule #1, the example given compares an auto accident patient being charged $85 for six x-rays and a comprehensive examination, to a patient who hit his head in a pool being charged $25 for two x-rays and a brief examination.

The fee for a flexion/extension injury is not necessarily the $85 as purported in the article. The $85 fee is representative of the doctor's charges for a comprehensive examination and presumably x-rays. This would then be the "customary charge" for this service. The "customary charge" is the fees for services, not for a diagnosis. The authors are mistakenly attempting to connect a charge to a diagnosis. The charge of a chiropractic physician should be made for the time involved with the patient, the skill, effort, responsibility and medical knowledge required of the physician to form the diagnosis for that patient. The charge is, therefore, made for the steps necessary to acquire and interpret the information necessary to form the diagnosis, not for the diagnosis itself.

I am not in the position that the doctor in the example would be, free from risk. I fully support the creation of patient protocol based on diagnosis or extent of injury. However, I do not support fees based on the diagnosis or extent of injury. Two-tiered billing is not created with a charge of $85 for a comprehensive examination and a $25 charge for a brief examination.

When a third-party payer becomes liable for a patient's bill, the facts of practice are that more extensive documentation is going to be required by that third-party payer. The fact that a comprehensive examination was performed on a patient with insurance coverage does not necessarily constitute two-tiered billing.

According to standard billing and coding procedures, as defined in the CPT-4, the physician should base his fees, as previously mentioned on time, skill, effort, and knowledge required. The more extensive the documentation needs to be for any particular case, the higher the fee.

The fact that a patient will have his bill, or a portion thereof paid by a third party, has, in everyday practice, necessitated more extensive documentation. This necessity has grown from the common practice of third-party payers attempting to limit their liability. Included in these practices are such things as demanding completely objective findings for every aspect of both diagnosis and treatment. Also included, are such practices as ignoring subjective findings, on the basis that they are unreliable.

Let me summarize: Insurance companies and third-party payers have, through their own demands, caused the number of services necessary to substantiate a diagnosis to significantly increase; thus legitimately increasing the dollar amount needed to cover such "extra" services.

Stephen W. Vaitl, D.C., C.C.S.P.
Corpus Christi, Texas

Dear Editor:

I am sure you will get a flood of mail about your "research" articles. I particularly applaud your printing the responses from those chiropractors using Vertebral Subluxation Research Institute (VSRI). It's interesting to note that every DC using VSRI spoke favorably about it; however, not a single DC mentioned anything about research! Perhaps those using the VSRI program are, inadvertently, telling us the most about this controversial program.

David R. Hepler, D.C.
Lincoln, Illinois

Dear Editor:

Today is letter day. The first letter is one that I wrote to you in September. I am writing this one after reading The Chiropractic Journal article regarding Dr. Mark Sanders' article in Medical Economics. The difference in Dr. Sanders and me, is that my letter stayed in my computer. It was written for my satisfaction only. After you read it, I hope you throw it away, but realize that many of us in chiropractic are frustrated.

My letter to you today regards your editorial, "What If Your Patient Did Your PR?" In it you quote Dr. Stephen Barrett from the NCAHF: "The AMA is not the one responsible for the poor image that chiropractors have with medical doctors. What the MDs hear from their patients (who are also patients of chiropractors) creates this poor image." There's a real scientific mind for you. Just how many of your satisfied patients go to a medical doctor? How about zero." The only ones that see and hear anything at all about chiropractic are the ones who didn't get any help from your care. If they show up at the MD's office with a cold, and provided you haven't been treating the cold (you haven't have you?) they are not going to mention the care you have been giving them, because it is not relevant.

What percentage of your low back pain patients who have been to the medical doctor, are happy with his treatment of their low back pain? Oh sure. They went to him, took some pills, and now they feel great, but just thought they would drop by for a check-up. Doesn't happen like that in my neighborhood.

You then go on to challenge us by asking us to assume the future of our practice depends on our patient's ability to explain chiropractic to their MDs.

Now there's a really scary thought. You mean the patient I just explained the cervical spine to, who asked where the vagina was in the picture? Or how about the patient looking at the lumbar spine and asking where the forehead is?

We, as chiropractors, are so concerned with patient education that we have forgotten to practice chiropractic. I like what Dr. Gonstead said: find it, accept it, correct it, and leave it alone. I especially like the "leave it alone" part.

Besides, what if the future of medicine depended upon patients being able to describe their need of care to us chiropractors? Most patients you see are on some type of medication. If you don't think so, you aren't listening, or they are lying. "You know, doc, little pink pills." They don't even know what they are taking, let alone how it mixes with the six-pack they intend to consume later in the day, after they have finished the second pack of cigarettes that you don't know about.

One reason medicine has done so well is they don't educate patients; if they did, they would scare most of them off.

I think our problem is trying to explain anything to MDs. They don't want us. Read the NCAHF Newsletter. Think they had good things to say about the British study? Well, the study design was poor; chiropractors treat more than ten times; and the Owestry guestionnaire is flawed. Besides, some Bakersfield chiropractor paralyzed a lady in September and is being sued for five million dollars. See, chiropractors are quacks, but we have always encouraged chiropractic care for functional low back pain. Sure you have.

We are in competition with medical doctors for patients, especially for functional musculoskeletal complaints. The only way we will survive is to continue to produce the results that our patients want -- not treatments that they can explain to their MDs, but results they want.

So give up. Don't try to explain anything to Stephen Barrett, or to John Renner -- they already know what they want to know. Nothing you do or say is going to change their viewpoint. In your dreams, maybe, but not in your lifetime.

Michael Repp, D.C.
Shawnee, Kansas