What began as an idea by a few individuals who wanted to increase their new patients has become big business. These types of programs are now being utilized by chiropractors across the United States and possibly in Canada as well. Chiropractors are being sold these programs by a number of "for profit" companies. At least one of these companies has made over a million dollars selling its program to chiropractors.
How do these programs work?
How do these programs differ from research conducted without a profit motive?
Why are chiropractors using these programs?
Will the use of research to recruit patients ultimately be a boon to the chiropractic profession or a disaster?
HOW DO RESEARCH/RECRUITMENT PROGRAMS WORK?
The program is very simple. An individual creates a company to conduct "chiropractic research." This research is usually in the form of survey research.
The program is well packaged and sold to chiropractors for a fee of as much as $2,500. The promoters of these programs explain that this initial fee will be recovered after the program generates the first few new patients.
Once the chiropractor pays the fee, they usually receive all of the information needed to begin. Survey forms for their "research volunteers" to fill out and which are to be sent back to the company, instructions on how to advertise or hire "telephone service representatives" to solicit volunteers, even the verbiage to use when working with the volunteers that the chiropractor ultimately hopes to convert into patients.
The ads are placed in the local newspaper or the "telephone service representatives" make random calls in an effort to bring these "volunteers" into the chiropractor's office. In Arizona, one of these "research programs" (the Vertebral Subluxation Research Institute/Outreach 2000 (VSRI) is even going to the extent of obtaining the records of accident victims from the local police department. The accident victims are then sent a letter offering them $50 to come into a local chiropractor's office.
Once there, the volunteer is given the survey form to fill out. These forms ask a multitude of questions that try to establish a correlation between vertebral subluxations and various health disorders.
The volunteer is then examined by the chiropractor to establish the presence of subluxations. This examination usually includes x-rays or other diagnosis, but doesn't have to.
At this point, the research side of the office visit is essentially over. The survey form is complete and all information is gleaned. But in order for the program to be beneficial to the participating chiropractor, the volunteer is asked to return in a few days for the report of findings.
When the volunteer returns, they are presented with the findings of the examination. At this point, the volunteer is treated just like a new patient. The routine is the same, but the volunteer doesn't pay for the initial visit. This is the chiropractor's opportunity to recoup his $2,500 or earn a return on the investment.
HOW ARE THESE PROGRAMS DIFFERENT FROM RESEARCH THAT IS NOT PROFIT MOTIVATED?
The first way that the patient-recruitment research programs differ from non-recruitment research is that there is no profit motive for the person conducting the non-recruitment research. In fact, the person conducting traditional research may not be compensated at all. This is typical of most non-recruitment clinical research performed by private physicians.
In the case of research conducted on a grant basis, the primary investigator is normally paid for their time and necessary expenses. The amount paid, on an hourly basis, is usually very small compared to the amount of work, education, and expertise involved.
In the case of patient recruitment research, the chiropractor is motivated to earn money by converting subjects into patients. Many chiropractors who are participating in these recruitment programs have suggested that they look at the money they paid as an investment to be returned by the converted volunteers or their insurance companies.
Many critics of these patient recruitment/research programs have pointed out that this conflict of interest is probably significant enough to not only entice chiropractors to recommend unnecessary treatment, but also to invalidate the findings of the survey.
The second major difference between traditional research and these recruitment/research programs is the financial burden placed on the research volunteers. Normally, a volunteer is compensated, even if only nominally, for his time and participation. The exception to this standard would be in the case of research conducted on deadly diseases such as AIDS. In these cases, often the subjects simply receive expensive treatment at no charge.
In the case of research/recruitment programs, the volunteers/patients pay almost all costs. The participating chiropractor uses the program to recover the money paid to the promoter and the cost of the initial visits (x-rays, other diagnostics, staff time, etc.).
Some have suggested that the only reason these types of programs are utilized is that they take full advantage of the insurance companies without any of the tell-tale signs. Rather than bill one insurance company for one patient with 150 visits, the research recruitment programs can bill 10 insurance companies for 10 patients, with 15 visits each. Some critics have compared these programs with No Out Of Pocket Expense (N.O.O.P.E.) schemes.
An interesting study would be to correlate the number of volunteers who were accepted as patients with those who also have insurance that will cover most, if not all, of the costs of care.
There are many other more subtle differences, but the money motivation is probably the greatest differentiation.
WHY DO CHIROPRACTORS PARTICIPATE IN PROGRAMS THAT USE RESEARCH TO RECRUIT PATIENTS?
Rather than try to suggest possible reasons, it seems more appropriate to let the participating chiropractors speak for themselves:
"I feel the Outreach Program has helped accelerate my growth in practice by the volume of new patients that have come in and I would really recommend this program highly to someone who is starting out in practice and really wants to get a jump start on a lot of new patients. -- Lorraine Urbina, D.C., Long Beach, California
"I've been in practice on my own for approximately ten months. I started using the Outreach Program in July of this past year. So it's been about seven months. I would say that the program paid for itself within approximately two weeks." -- Steven D. Billings, D.C., Springfield, Oregon
"I've been in practice 13 and 1/2 years. I started using the program one year ago and in approximately six to eight weeks, the program completely paid for itself. The program has been a significant improvement to my practice in increasing the number of patients we've seen." -- Larry A. Bartell, D.C., Dearborn, Michigan
"After having taught advertising and promotion for many years in a chiropractic college, it's hard to find anything in a dollar sense that makes more sense than the Outreach Program. For a small investment, in fact, the investment is so small, I'd have to say probably within about a month it had paid itself back in our office. But you're spending so little, once you have it -- you have it, on an on-going basis." -- Richard Plummer, D.C., Inman, South Carolina
"Since we've been using the program, we don't really use our Yellow Pages anymore. We don't do any other type of advertising. We don't do spinal screens which we used to do a lot of. We used to get involved in a lot of ways to get chiropractic out to the people, and I frankly don't feel the need to do it anymore. The Outreach Program brings in more than enough people to the office. The program in itself basically and literally paid for itself just in the first week or two of using it." -- Michael Shaikewitz, D.C., Phoenix, Arizona
"I must say in my experience with different kinds of marketing types of products and practice building procedures, VSRI is honestly the only thing that I've ever done that has much more than paid for itself. One of the exciting things about the program is that it not only helps to turn people on to chiropractic who otherwise wouldn't have had the chance, but it pays for itself many, many times over." -- Steven Shochat, D.C., Tuscon, Arizona
"I can tell you that Outreach 2000 is the single most important marketing program we did in our office that took our main office in Vineland, New Jersey from 200 office visits a week to over 600 office visits a week in just 18 months. I don't think I have to say anything else about Outreach 2000, something you need to be doing as part of your overall marketing strategy in your clinic." -- Michael J. Harvey Jr. D.C., Vineland, New Jersey
All of the above statements were taken directly from a promotional videotape which has been produced and distributed by one of the larger promoters (VSRI/Outreach 2000) of a research/recruitment program.
HOW WILL THE USE OF RESEARCH TO RECRUIT PATIENTS ULTIMATELY AFFECT THE CHIROPRACTIC PROFESSION?
To answer this question, "DC" conducted a survey of some of the most respected individuals in the chiropractic profession. These chiropractic leaders were asked two questions:
- Should chiropractors be involved in research programs that utilize research to recruit patients? Why?
- How will the participation of chiropractors in these types of programs affect the reputation of chiropractic and chiropractic research?
This is how they responded: (in alphabetical order)
Alan H. Adams, D.C.
Vice President of Chiropractic Education
Los Angeles College of Chiropractic
No. This approach raises serious ethical issues. All clinician-researchers should honor the ethics of clinical research by abiding by the requirements of informed consent of subjects and a review of research protocols by competent bodies such as institutional review boards. Proper informed consent includes the element of disclosure. Prospective subjects must be told the purposes of the research program. I don't think any competent institutional review board would approve such a research protocol.
Yes. Such programs have the potential to undermine the credibility of properly conducted research activities.
Gary A. Auerbach, D.C.
Tuscon, ArizonaThe World Federation of Chiropractic, of which I serve as president, has no official position on either of these issues. So the following comments are expressed as my individual opinion.
I feel it is ethical for bona fide research projects to try to recruit subjects for their projects. This is based on the premise that the research is a bona fide project and consumers are being recruited primarily for research purposes. If, however, consumers are being procured primarily for the purposes of recruiting patients, I believe it is unethical.
It would be helpful if appropriate local and/or state governing boards (i.e., examining boards) would establish appropriate avenues whereby research projects could be registered, so the consumer could be better aware of valid research projects versus invalid research projects. If the research projects are valid, under the stipulations listed above, such research projects could reflect positively on the chiropractic profession. As most valid research is done within a university or college structure, research not done under the auspices of such institutions should be carefully scrutinized.
Fred Barge, D.C., President
International Chiropractors AssociationI am of the conviction that, whenever possible, research in the field of chiropractic should be in cooperation with our chiropractic colleges. Individualistic research projects can be reported in papers delivered by chiropractors at our many scientific symposiums, and this is a perfectly legitimate way of presenting field research.
Chiropractic public relations programs that solicit patients under the guise and promise of research sponsored by entrepreneurial organizations are inherently suspect. When they are actually utilized as patient procurement gimmicks they are not only repugnant but unethical. Such shenanigans are remnants of the turn-of-the-century medical era and have no place in health care programs today.
Chiropractic has been able to achieve a high degree of public esteem, acceptance, and respect even while under the constant duress of medicine. The participation by chiropractors in scurrilous research programs would serve to denigrate our position of integrity as a profession and furthermore provide legitimate fuel for increased medical attacks against our profession. A profession unable to police its own actions deserves the ill consequences of its inaction. It is time for our entire profession to take a stand on this issue.
David H. Boschowitz, D.C., F.I.C.C.
Immediate Past President
Florida Chiropractic AssociationObviously this is deplorable. One looks at research as the cornerstone of science and should be only used to that effect. Certainly what is gleaned from the research should be put into practice for everyone to utilize and benefit mankind. To specifically create a research program which would, in turn,
