ICA Speaks Out on Unethical Patient Recruitment

Chiropractic is a profession under extreme pressure these days. Driven by the need to contain health care costs, private insurers and public programs are working overtime to trim payments and limit access to chiropractic care. Other providers, including medical doctors, are engaged in an intense marketplace competition for the patient dollar, often going head-to-head with chiropractic competitors for the same patient base. As if this weren't enough, the campaign to discredit chiropractic continues with a new intensity in the pages of newspapers, health journals and magazines, and on the public airwaves.

Chiropractic is not only under pressure from external forces but is, perhaps, in the great danger from within its own ranks. Anyone who has seen the recent edition of Medical Economics and read the article by Dr. Mark Sanders: "Take It from a DC: A Lot of Chiropractic Is a Sham," will have a strong sense of what I mean. This is no case of a "hidden enemy." Dr. Sanders' activities, while irritating and grossly distorted, are out in plain sight. His writings provide responsible voices within the profession, and an important opportunity to educate otherwise poorly informed people, including other providers, by responding forcefully, accurately, and thoroughly via every possible forum, including Medical Economics itself. If you have not written to the editors of this publication to express your feelings on the Sanders' article, I urge you to do so immediately.

Danger to the profession presents itself in many forms, few as overt and understandable as Mark Sanders' angry blast. Far greater danger from within lurks in the activities of those who would step across ethical and legal lines to make a quick buck.

Chiropractic is not unique among health professions in that the development of a successful practice requires public education, advertising, and in many cases, activities that could be considered patient recruitment. The doctors of chiropractic have a far more difficult and challenging job in this area than do other licensed primary providers is an established fact. This does not mean, however, that the doctor of chiropractic is absolved from responsibility for maintaining the highest ethical standards just because the market places an extra burden on the chiropractic profession.

Patient recruitment and practice building have historically been ethical weak spots for the chiropractic profession. The activities of a few unethical promoters and their followers did great damage in years when the vast majority of DCs were struggling to build credibility with the public, the insurance industry, health care institutions, and other providers. Because of the dedicated efforts of the majority, and despite the actions of a few, chiropractic has achieved a status and an acceptance that are of great value in both social and economic terms, and which are worthy of being vigorously defended and protected.

Regrettably, there is little defense a profession can mount against an unethical practitioner determined to go outside the law to claim payment that is not deserved or has not been rightfully earned. International Chiropractic Association has long held that: " ... any doctor of chiropractic who administers or prescribes any care not warranted by the needs of the patient, solely to augment the income of their practice, is engaging in unethical conduct and should be subject to strict discipline upon a legal finding of such a fact" (ICA policy statement on insurance consultants). Insurance fraud and abuse are crimes. Legal structures exist to deal with those who engage in these activities. Licensing and disciplinary boards are empowered to deal with the professional consequences of this kind of activity. There are, however, growing areas of grey that are not so clearly covered by either laws and public authority or by professional canons or codes of ethics. One such concern is programs that seek to recruit patients under the guise of chiropractic research. These schemes are growing in number and pose a threat to the public perception of chiropractic an as ethical and credible alternative of health care.

These schemes work in a variety of ways: Usually, lists of potential "research subjects" are obtained and contact is made by letter, telephone, or in person. These target individuals are told that spinal research is being conducted at a given location by a specific doctor of chiropractic and they are invited to be examined at no cost to themselves. During the course of this "research" the clinic will make an effort to determine which "research subjects" have insurance. Most, if not all "subjects" are told they have a need for chiropractic care. The objective is to maximize participation in post-research care by those who have insurance or who have the means to pay out-of-pocket.

The elements of deception and misrepresentation that underlie this approach to patient recruitment are both ethically repugnant and potentially dangerous and destructive for the chiropractic profession as a whole. Not only do these activities jeopardize the market acceptability of all chiropractors, they threaten to undermine the perceived validity and objectivity of legitimate chiropractic research. The last thing the chiropractic profession needs is a scandal that offers the profession's opponents a basis to reject or ignore the outcomes of legitimate research.

As a professional society dedicated to establishing and maintaining the highest technical, professional, and ethical standards for the chiropractic profession, ICA felt compelled to take this lead in speaking out against these and other destructive, unethical, and very possible illegal business practices. To that end, the board of directors at the International Chiropractors Association meeting on October 4-6, 1990, adopted the following statement as official policy:

ICA Policy Statement
Unethical Patient Recruitment

The International Chiropractors Association recognizes that in the highly competitive modern health care economy, the doctor of chiropractic often must engage in public education, various methods of practice promotion, and perhaps advertising to establish and maintain a viable practice. The ICA further recognizes that this process is a difficult and challenging one. The difficulty of the marketing task, however, does not absolve the doctor of chiropractic from maintaining the highest ethical and professional standards in the marketing process.

The International Chiropractors Association holds that the enticement of potential patients into any chiropractic clinic or office on the basis of the assertion or the representation to the potential patient that research will or is being conducted, at no charge to that subject patient, is inherently suspect. The ICA further holds that attempts to convert such "research subjects" into paying patients, either via self-payment or through third-party payers, represents unethical behavior contrary to the interests of the consumer, the chiropractic profession and the insurance system.

ICA recognizes the danger such schemes hold for the chiropractic profession at large, and the damage these unethical and repugnant activities can and will do to public perception of the integrity and reliability of the chiropractic profession as a whole.

The ICA encourages appropriate authorities to carefully examine patient recruitment schemes that contain the elements of deception and misrepresentation embodied in such research-practice promotion schemes, and take such action as is appropriate to protect the public.

The ICA believes that the adoption of a strict position on this important ethical issue will serve the interests of both chiropractic and the public. It will strengthen our position and it will put us on a secure footing as we work to educate insurance companies and public third-party payers on the strength and potential -- not only the science of chiropractic, but of the doctors we are asking them to trust to provide these valuable and unique services.