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Governor Cuomo Announces COVID-19 Vaccination Mandate for Healthcare Workers

At this time, it appears the vaccine mandate will apply to all healthcare workers in hospitals, long term care facilities and nursing homes and will require these facilities to develop and implement a policy mandating employee vaccinations, with limited exceptions for those with religious or medical reasons.

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NY Chiropractic Offices Must Continue to Follow COVID Protocols

NY lifts most COVID restrictions effective 6/15/21; Healthcare settings, including chiropractic offices, must continue to follow previous, in place COVID protocols

As you are already aware, the CDC federal mask mandate remains in effect for pre-K-12 schools, public transit, and healthcare settings in NYS. 

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NY lifts most COVID restrictions effective 6/15/21

Healthcare settings, including chiropractic offices,  must continue to use face masks

Governor Cuomo has announced today that New York has hit a 70% adult vaccination rate. This means that effective immediately the social and commercial restrictions are lifted on all industries, including sports & recreation, construction, manufacturing, trade, child care, camps, food services, offices, real estate, buildings, agriculture, fishing, forestry, amusement & family entertainment, personal care services, gyms, retail, malls and movie theaters.

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Updated Guidance from CDC Regarding Use of Masks

The Centers for Disease Control and Prevention (CDC) announced today that fully vaccinated people no longer have to wear mask in most settings indoor and outdoor.

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Urgent Appeal From COCSA

Dear NYSCA Members, An urgent appeal from COCSA is requesting the support of all state associations. The Congress of Chiropractic State Associations embraces two ACA initiatives. The first is a data collection project where each doctor sends the ACA 5 example charts showing managed care abuse that has hindered patient care; the second initiative is an effort to encourage all DC’s to appeal every restriction of care. This “en masse” effort is intended to push back insurers’ efforts to withhold benefits that patients are entitled to. The NYSCA is wholly behind these ACA initiatives. COCSA has set goals for the state associations in procuring un-sanitized case files of inappropriate denial of care. Details of their plan are found on their homepage You help is needed now! The ACA General Counsel states the window is now open for the real possibility of legal action against the shameless practices of Managed Care groups. The cornerstone of any legal action will be patient files that can be used as direct evidence. These files must bear the scrutiny of the court, therefore we urge you to review the instructions below and join the effort for your future as well as that of patients in your state. Data Collection initiative at (also below) DOI Appeals initiative at (toolkit for offices) To do your part and assist ACA, we ask that you take the following steps. 1. Read and sign the HIPAA Business Associate Agreement (found here) so that patient information may be provided directly to the ACA Insurance Relations Department. Note that all patient records will be kept in a locked room in locked cabinets pursuant to HIPAA requirements. 2. Identify patients whose care or benefits have been compromised by coverage decisions made by managed care networks and speak with them to ascertain if they are interested in allowing their medical file to be shared with the ACA and regulatory authorities. A patient information sheet is provided here for your convenience. No information regarding patients or their doctors will be shared with managed care companies. Specifically, we need copies of the following items from your patients’ files: a) Completed patient intake forms b) Completed diagnostic testing reports c) Chart notes d) All forms that show a complete chronology of the interaction with the managed care organization 3. Obtain HIPAA Authorization: Explain HIPAA rights to the patient – (a brochure can be found here just in case you are unsure if your office documentation is up to date.) Once you are sure the patient clearly understands the reason for this initiative, and they indicate they would like to participate, have them sign the HIPAA Authorization, found here which has been pre-completed for your convenience. 4. Mail the following to the ACA: copies of your five complete un-sanitized patient files with the associated HIPAA Authorization and your signed Business Associate Agreement to the following address: Documents Needed to Assist Business Associate Agreement Cover Letter to Doctors Four Steps to Help Patient Information Sheet HIPAA Authorization Questions? Contact @ ACA Daniel Lyons at [email protected] or call - 703-812-0225.

Office of Inspector General Seeks Chiropractic Records

(Arlington, Va.) -- The Department of Health and Human Services Office of the Inspector General (OIG), the agency responsible for identifying and reporting inefficiency in Medicare, Medicaid and other related HHS programs, announced in its 2008 Work Plan that it would again seek records from doctors of chiropractic as a follow-up to its 2005 report on chiropractic documentation. "ACA strongly urges all doctors of chiropractic who receive an OIG record request to contact the association for assistance on how to fully comply with the request,” said ACA President Glenn Manceaux, DC. “Timely response to an OIG record request is mandatory, and ACA representatives are available to help you navigate the OIG request process.” ** Official OIG record requests will be sent on letterhead that clearly states “Office of the Inspector General.” Upon receipt of an OIG request, it is critical that doctors of chiropractic include all necessary information and complete the request by the date specified by the OIG, noted John Falardeau, ACA’s vice president of government relations. In addition to those doctors who recently received an OIG record request, ACA would also like to hear from providers who have already submitted their information to the agency. The 2005 OIG Report, which was based on a random sampling of claims data from 2001, concluded that 67 percent of the claims examined as part of the study contained documentation errors or omissions that led to what the OIG considered to be inappropriate reimbursement under Medicare. The report also extrapolated that U.S. taxpayers could save more than $280 million per year if improperly documented claims filed by chiropractors were not paid by Medicare. To contact ACA regarding an OIG record request, send an e-mail to [email protected] or [email protected] . **ACA’s assistance is designed to provide authoritative information to help doctors of chiropractic fully and accurately comply with the OIG request. This assistance is provided with the understanding that ACA is not engaged in rendering legal or other professional services. If legal advice or other expert professional assistance is required, the services of a competent professional person should be sought.


Vitamin D Deficiency and Risk of Cardiovascular Disease

ABSTRACT Background—Vitamin D receptors have a broad tissue distribution that includes vascular smooth muscle, endothelium, and cardiomyocytes. A growing body of evidence suggests that vitamin D deficiency may adversely affect the cardiovascular system, but data from longitudinal studies are lacking. Methods and Results—We studied 1739 Framingham Offspring Study participants (mean age 59 years; 55% women; all white) without prior cardiovascular disease. Vitamin D status was assessed by measuring 25-dihydroxyvitamin D (25-OH D) levels. Prespecified thresholds were used to characterize varying degrees of 25-OH D deficiency (Conclusions—Vitamin D deficiency is associated with incident cardiovascular disease. Further clinical and experimental studies may be warranted to determine whether correction of vitamin D deficiency could contribute to the prevention of cardiovascular disease. From the Framingham Heart Study, Framingham, Mass (T.J.W., M.J.P., E.I., K.L., E.J.B., R.B.D., R.S.V.); Cardiology Division (T.J.W.) and Renal Division (M.W.), Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass; Statistics and Consulting Unit, Department of Mathematics (M.J.P., R.B.D.), Boston University, Boston, Mass; Jean Mayer US Department of Agriculture Human Nutrition Research Center on Aging (S.L.B., P.F.J.), Tufts University, Boston, Mass; and Sections of Cardiology and Preventive Medicine (E.J.B., R.S.V.), Boston Medical Center, Boston University School of Medicine, Boston, Mass. Circulation. 2008 10.1161/CIRCULATIONAHA.107.706127 FOR FULL TEXT PDF click on the link below:


FCER Receives a $20,000 Unrestricted Donation from State Association Council

Citing the “great work” for the chiropractic profession by the Foundation for Chiropractic Education and Research (FCER), a state association council that wishes to remain anonymous has given FCER a $20,000 donation. The unrestricted donation may be used for FCER’s major new initiatives such as the continuing development of the DCConsultSM Evidence-Based Resource Center (EB-RC) and the State of Research program, both announced in 2007. “FCER is very grateful for this impressive donation, especially since it came from a state association council with a relatively small membership,” Charles R. Herring, DC, FCER President, said. “For a state association council to make this large of a donation to FCER highlights the perceived trust that chiropractic organizations have in the value of FCER’s programs and importance of these initiatives to the future of the profession,” he added. FCER’s EB-RC includes an online resource center that the day-to-day practitioner can access for patient care information, discussion on the latest research and how it translates into practice, a pathway to more detailed research articles and commentaries and active links to other databases that have a related theme such as in the areas of nutrition, herbs, exercise and fitness and so on. The site will be available during the first quarter 2008. The State of Research initiative involves FCER working with state association research committees to identify needed state-specific research, especially for reimbursement, and assisting practitioners in utilizing research in daily patient care. To date, 22 states have appointed research committees as part of this program. FCER is the chiropractic profession’s oldest not-for-profit foundation, serving the profession since 1944. Based in Norwalk, Iowa, FCER has as its mission to “Translate Research into Practice” by granting funds for research and in producing practitioner and patient education materials including teleconferences, CDs, books and pamphlets. FCER is developing the DCConsult web site as part of its Evidence-Based Resource Center, an online source for customized clinical and patient education information.


Medicare Finalizes Quality Measures Reporting List; Doctors of Chiropractic Eligible to Participate in 2008

(Arlington, Va.) -- Through the leadership of the American Chiropractic Association (ACA), doctors of chiropractic will soon be eligible to participate in Medicare’s quality reporting program, known as the Physician Quality Reporting Initiative (PQRI). In 2008, the program will include 119 quality measures, including two applicable to chiropractic. The Centers for Medicare and Medicaid Services (CMS) finalized the 2008 measures in mid-November. Beginning Jan. 1, doctors of chiropractic can report on measures related to “pain assessment prior to initiation of patient treatment,” and “adoption/use of health information technology.” “The inclusion of quality measures applicable to chiropractic care in the 2008 PQRI affords our profession an opportunity to strengthen its involvement in the promotion of quality patient care,” said ACA President Glenn Manceaux, DC. “The ACA urges doctors of chiropractic to participate in PQRI. To assist doctors in this endeavor, the association will soon release chiropractic-specific information and practical tips to help educate clinic staff on the reporting process and to ensure proper documentation.” The PQRI program has established a financial incentive for doctors of chiropractic and other health care providers to participate. Chiropractors who successfully report on a designated set of quality measures on claims for dates of service from Jan. 1 to Dec. 31, 2008, may earn a bonus payment estimated to be between 1.5 and 2.0 percent of submitted claims. For the past two years, CMS sponsored a voluntary program for physicians to report codes to the government regarding “quality” protocols and services performed in their practices. Under the 2008 program, eligible providers who choose to participate will help capture data about the quality of care provided to Medicare beneficiaries. Participating providers will also help government officials identify the most effective ways to use quality measures in daily practice. “Proper documentation will be the lynchpin for full chiropractic parity in Medicare. With the profession eagerly awaiting analysis of the Medicare chiropractic demonstration project, I urge chiropractic offices to become fully acclimated in reporting quality measures,” Dr. Manceaux added. While physicians are not required to register prior to participation in PQRI, they must be enrolled in Medicare and have a National Provider Identifier (NPI). In early 2007, recognizing the importance of improving quality patient care in the chiropractic setting, ACA established an internal Performance Measurement Workgroup to address quality measures development, endorsement, and implementation issues specific to the care provided by doctors of chiropractic. Under the guidance of an ACA hired consultant, the Workgroup has been successful in providing chiropractors an opportunity to report on quality measures specific to the Chiropractic Manipulative Treatment (CMT) codes recognized by Medicare. The detailed specifications for all final PQRI measures, along with other information about the PQRI program, can be found at Information regarding practical tips for doctors of chiropractic who plan to participate in the 2008 PQRI will soon be posted on ACA’s Web site at:


ACA Champions FCER’s State of Research Initiative at Recent COCSA Meeting

The American Chiropractic Association (ACA) has pledged its support for the State of Research initiative launched by the Foundation for Chiropractic Education and Research (FCER), during the recent meeting of the Congress of Chiropractic State Associations (COCSA) in Nashville, Tennessee. The State of Research initiative was announced earlier this year as a project where FCER works with state chiropractic associations to identify practitioners’ research-related needs, assists in getting the research conducted, and helps the practitioner to use the research in evidence-based practices. To date, 22 state associations have appointed state research committee chairpersons to work with FCER’s State of Research Committee on this initiative. “The American Chiropractic Association supports FCER’s State of Research project as an aggressive way to help identify the research needs of our clinicians, especially in the area of reimbursement,” Glenn D. Manceaux, DC, ACA President, said. “We encourage the state associations to get firmly behind this project, which will offer additional research- and education-related opportunities for the profession,” he added. Charles R. Herring, DC, FCER President, said, “We greatly appreciate ACA’s support in this initiative, which is an important component of FCER’s new mission. This project, along with the development of FCER’s Evidence-Based Resource Center, adds to the profession’s body of knowledge, which in the long run will make us better practitioners for our patients,” he added. Associations in the following states have appointed committee chairpersons: Alabama, Arizona, Colorado, Georgia, Idaho, Iowa, Louisiana, Michigan, Missouri, Nebraska, Nevada, New Hampshire, New Mexico, New York, North Dakota, Rhode Island, South Carolina, South Dakota, Vermont, Virginia, Washington and Wisconsin. FCER’s State of Research Committee members are Reeve Askew, DC, chair; Charles Herring, DC; Jeffrey Fedorko, DC; Mark Kruse, DC, and Robert Hayden, DC. The ACA, based in Arlington, Virginia, is the largest professional association in the world representing doctors of chiropractic. The ACA provides lobbying, public relations, professional and educational opportunities for doctors of chiropractic, funds research regarding chiropractic and health issues, and offers leadership for the advancement of the profession. FCER is the chiropractic profession’s oldest not-for-profit foundation, serving the profession since 1944. Based in Norwalk, Iowa, FCER has as its mission to “Translate Research into Practice” by granting funds for research and producing practitioner and patient educational materials including teleconferences, CDs, books and pamphlets. FCER is developing the DCConsultSM web site as part of its Evidence-Based Resource Center, an online source for clinical and patient education information.


Five Insurers in Three Weeks Adopt Model Created Together with National Medical and Consumer Groups NEW YORK, NY (November 20, 2007) – Attorney General Andrew M. Cuomo today announced an agreement on doctor ranking programs with Group Health Incorporated (GHI) and Health Insurance Plan of Greater New York (HIP). With this agreement, a total of five insurers have adopted the Attorney General’s doctor ranking model. The others are CIGNA Healthcare, Aetna, Empire Blue Cross Blue Shield, and UnitedHealthcare. CIGNA, Aetna, and Empire’s parent, WellPoint, will also apply the principles of the Attorney General’s doctor ranking model nationwide. GHI and HIP provide health benefits to over four million people in the tri-state area. This model was created in consultation with the American Medical Association and the Medical Society of the State of New York, along with a host of consumer advocacy groups including the Consumers Union and the National Partnership for Women & Families. The North Shore Physician Organization also provided key assistance to the Attorney General’s doctor rankings initiative. “Major insurers are lining up to embrace our national model for doctor rankings. This model is supported by both doctors and consumers and has become the industry standard,” said Cuomo. “I applaud GHI and HIP for being the first insurers to preemptively accept our model before having any plans to design a program. As their commitment shows, insurers considering a program for rating doctors can and should use the national model as their foundation.” “GHI and HIP believe that consumers must have access to accurate and useful information about their physicians,” said Dr. Dan Dragalin, Executive Vice President and Chief Medical Officer of HIP. “A standard of measurement that is transparent and accurate and open to review by physicians and accrediting organizations is a solid foundation for any programs in the future. For this reason, even though we do not have a physician ranking program, we signed this agreement.” said Dr. Aran Ron, President of GHI. “The American Medical Association applauds GHI and HIP for joining the growing number of insurers who are adopting this model,” said the American Medical Association's President-Elect, Dr. Nancy Nielsen. “Patients and physicians need to be sure that any system for ranking doctors is accurate and fair. We are very pleased that Attorney General Cuomo has made accountability to physicians and patients in doctor ranking programs a widely accepted standard within the insurance industry.” “Consumers and insurance members stand to benefit greatly from today’s agreement,” said Debra Ness, President of the National Partnership for Women & Families. “Consumers deserve to know what factors go into ranking their doctors, and should be able to easily choose the doctor that is best for them. The more insurers that adopt this model, the more consumers will be able to do just that.” "Thanks to the leadership of Attorney General Cuomo more and more insurers are adopting doctor ranking programs that provide patients with clear and comprehensive information, and that accurately reflect the quality of health care provided by doctors," said Dr. Robert Goldberg, President of the Medical Society of the State of New York. "This model provides transparency in the way ratings are created and ensures a level of independence by the inclusion of an oversight examiner reporting to the Attorney General. Doctors are well served by having major insurers in New York and nationwide adopting this model." The model reforms doctor ranking programs by compelling insurers to fully disclose to consumers and physicians all aspects of their ranking system. Additionally, under this model, the insurer must retain an oversight monitor, known as a Ratings Examiner (“Rx”), who will oversee compliance with all aspects of the agreement and report to the Attorney General every six months. Under the national model, insurers will: • Ensure that rankings for doctors are not based solely on cost and clearly identify the degree to which any ranking is based on cost; • Use established national standards to measure quality and cost efficiency, including measures endorsed by the National Quality Forum (NQF) and other generally accepted national standards; • Employ several measures to foster more accurate physician comparisons, including risk adjustment and valid sampling; • Disclose to consumers how the program is designed and how doctors are ranked, and provide a process for consumers to register complaints about the system; • Disclose to physicians how rankings are designed, and provide a process to appeal disputed ratings; • Nominate and pay for the Ratings Examiner, subject to the approval of the Attorney General, who will oversee compliance with all aspects of the new ranking model and report to the Attorney General’s office every six months; the Ratings Examiner must be a “national standard setting organization” and will be national in scope, independent, and an Internal Revenue Code § 501(c)(3) organization. Doctor ranking programs are a rapidly growing practice within the healthcare industry. Major insurers nationwide either operate or are in the process of developing these programs. Today’s agreement with GHI and HIP covers the following related companies: GHI, GHI HMO Select, Inc., Health Insurance Plan of Greater New York (HIP), HIP Insurance Company of New York, Inc., The PerfectHealth Insurance Company, ConnectiCare of New York, Inc., ConnectiCare Insurance Company, Inc., ConnectiCare of Massachusetts, Inc., and ConnectiCare, Inc. The Attorney General’s industry-wide investigation of doctor ranking programs is ongoing and is being handled by Linda Lacewell, the head of the Attorney General’s Healthcare Industry Taskforce. Attachment:

Lumbar Supports to Prevent Recurrent Low Back Pain among Home Care Workers

ABSTRACT A Randomized Trial Background: People use lumbar supports to prevent low back pain. Secondary analyses from primary preventive studies suggest benefit among workers with previous low back pain, but definitive studies on the effectiveness of supports for the secondary prevention of low back pain are lacking. Objective: To determine the effectiveness of lumbar supports in the secondary prevention of low back pain. Design: Randomized, controlled trial. Setting: Home care organization in the Netherlands. Patients: 360 home care workers with self-reported history of low back pain. Intervention: Short course on healthy working methods, with or without patient-directed use of 1 of 4 types of lumbar support. Measurements: Primary outcomes were the number of days of low back pain and sick leave over 12 months. Secondary outcomes were the average severity of low back pain and function (Quebec Back Pain Disability scale) in the previous week. Results: Over 12 months, participants in the lumbar support group reported an average of –52.7 days (CI, –59.6 to –45.1 days) fewer days with low back pain than participants who received only the short course. However, the total sick days in the lumbar support group did not decrease (–5 days [CI, –21.1 to 6.8 days]). Small but statistically significant differences in pain intensity and function favored lumbar support. Limitations: Study participants were unblinded, and a substantial amount of missing data required imputation. Objective data on sick days due to low back pain were not available. Conclusion: Adding patient-directed use of lumbar supports to a short course on healthy working methods may reduce the number of days when low back pain occurs, but not overall work absenteeism, among home care workers with previous low back pain. Further study of lumbar supports is warranted. 20 November 2007 | Volume 147 Issue 10 | Pages 685-692 For Full Text click on the link below:


Update on ACA’s Legal Activities

The ACA recognizes and takes quite seriously its traditional duty, on a national level, as protectors of the profession and the patients we serve. In that regard we have, as you know, been engaged in an "all fronts" effort to address the serious threat posed by the practices of certain chiropractic managed care networks and related insurance companies. We will detail, to the extent that we can, the administrative and regulatory actions now under way. We believe we have made significant progress and have initiated a series of state investigations that have resulted in collaboration among many states to make this a national issue. The matter is on the agenda of the National Association of Insurance Commissioners. All of this has the potential of becoming a nationally coordinated investigation by state and federal regulatory officials. We believe we have the facts, the law and the critical momentum on our side. However we now desperately need the follow through of the doctors in the field. Managed care and insurance abuse continues to plague our profession. In over 20 states, the ACA’s legal department and insurance department have visited or otherwise contacted both Attorney General Offices and Departments of Insurance. Many of these contacts have been made with and as a result of the excellent cooperation received from state associations. ACA has been successful in raising the consciousness of these regulatory officials on the problem of managed care and insurance abuses. As a result, the ACA has augmented states’ efforts by providing the national perspective regarding the egregious nature of these issues and that the problems are growing. The message back from these officials has been very clear - if you provide us with the hard evidence of these abuses, we will act and act decisively. ACA has an extensive and active program to collect this type of hard evidence directly from the doctor. Often, our issues mirror those other professions have communicated to them, so our message is connecting and there is now an effort among Departments of Insurance to make this a national effort. A recent effort of DOIs in 36 states against UnitedHealthcare shows the success of such collaboration among regulators resulted in a penalty of $20 million, with an agreement to implement a three-year “process improvement” plan. Failure to meet set benchmarks for appropriate claims payment could result in an additional $20 million fine. ACA has also launched a parallel effort to address managed care and insurance abuse. In addition to collecting information from the doctor in the field, this effort is designed to encourage doctors to file an appeal for every inappropriate denial or restriction of care. We want to exert maximum pressure on the problem by both directly engaging AG Offices and Departments of Insurance and at the same time encouraging a groundswell of appropriate appeals from doctors in order to underscore the depth of the problem. The ACA website has extensive information on how ACA can help doctors file these appeals. It is essential to realize that the solutions to many of our problems are already at hand, we just need the commitment and will to follow through. Both federal (i.e. ERISA) and state statutes are already in place to facilitate aggressive enforcement activities. Now that we have regulators’ attention, they seek more complaints to show how pervasive the problems are in each state and they would like this documentation to follow the channel of direct complaints from patients and providers. Because of our efforts, and those of state chiropractic organizations, regulators now increasingly understand the insidious nature of certain managed care policies and procedures and they are ready to act based on well-documented complaints outlining these abuses. In the case of Maryland’s DOI, officials took an example of one complaint provided by us and directly initiated the investigation process while we were still in their office. You are well aware of our recent data collection of un-sanitized records that began in May. This effort has further opened the door to clarifying that the inappropriate policies used to “manage” chiropractic are, without a doubt, restricting necessary care. As we have indicated, thanks to our combined efforts, regulators now increasingly "get it", and as we respond to their requests to facilitate direct complaints, we are moving to “Phase II” of what is now a three-year intensive effort. We need to mobilize every chiropractor to take the time to exhaust internal appeals for every denial or restriction from insurers/networks and, if not successful, to file DOI complaints so that a massive investigative process can be started that will cross state lines. To assist doctors, the ACA has designed a web pages; provides tools to file successful appeals, and guides the submission of patient files to ACA, and ultimately to regulators. In the coming months we will be identifying key statutes in each state so that doctors can augment their appeals with this information and we will provide more guidance on how doctors can initiate appeals under ERISA plans. Please continue to look for updates on all of these initiatives. Kara Murray Insurance Resources Director Insurance Relations [email protected]



FIX MEDICARE PHYSICIAN FEE CUTS ACA has joined forces with other national medical specialty societies and we need YOUR HELP. We have orchestrated a call-in campaign designed to send a resounding message to Senate offices that we will not accept cuts to the 2008-2009 physician fee schedule. The impact of this campaign depends on YOU. Beginning Jan. 1, 2008, cuts will be made to Medicare physician payments resulting in a 15 percent decrease over two years. Earlier, the House passed legislation that would provide for 0.5 percent updates in 2008 and 2009. Now, while the Senate is drafting their bill to address Medicare issues, is the time for ACA members to weigh-in. Use the AMA Toll-Free Grassroots Hotline 1-800-833-6354 to call your Senators on NOV. 6, 7, or 8 and urge them to include positive Medicare physician payment updates in their Medicare package. IMPORTANT: Please also use the ACA Legislative Action Center to make your voice heard. Click here to send your message electronically! The success of this call to action is dependent on the number of calls made. Encourage your patients and colleagues to take action!


Attorney General Hardy Myers today filed settlement agreements with a Florida manufacturer of "spinal decompression devices" and a California chiropractor, who markets promotional services to chiropractors. The agreements resolve allegations that the companies disseminated deceptive advertisements in Oregon that were used by Oregon chiropractors. Named in Assurances of Voluntary Compliances (AVC) filed in Marion County Circuit Court are Axiom Worldwide, Inc. of Tampa, Florida and Altadonna Communications, Inc. and its owner Benjamin A. Altadonna of Danville, California. Neither AVC admits law violation. "Oregon chiropractors must do their own homework before purchasing and promoting medical devices," Myers said. "Medical professionals cannot simply rely on the sellers' claims without investigating for themselves." "Consumers also must be wary of unrealistic health claims that lack adequate substantiation; even those being made by Oregon medical professionals," Myers added. Oregon Department of Justice (DOJ) lawyers, initially using information from the Oregon Board of Chiropractors, found that Axiom manufactures a "spinal decompression device" called the DRX 9000 used by medical professionals to treat back pain. The devices, costing approximately $100,000 each, were sold throughout the country including nine in Oregon. Along with the device, Axiom provided a marketing package that included deceptive sample advertisements. Assisting with Axiom's promotion of the DRX 9000 was California chiropractor Benjamin Altadonna and his company Altadonna Communications. DOJ lawyers found deceptive claims throughout the advertising package including statements that the DRX 9000 had an 86 percent success rate for the treatment of degenerative disc disease, disc herniations, sciatica and post-surgical pain; in fact, the companies did not possess competent and reliable evidence to substantiate the claim. The companies stated that the Food and Drug Administration (FDA) approved the devices and substantiated their claims of effectiveness. DOJ found the device had merely been cleared as similar to preexisting devices. They also misrepresented the DRX 9000 by claiming it was a scientific and medical breakthrough that resulted from NASA discoveries when, in fact, NASA discoveries had no relationship with the device. Under the agreements, both companies must change how they market their products. All promotional claims must be substantiated with "competent and reliable scientific evidence," which means tests, analysis, research, studies, or other evidence based on the expertise of professionals in the relevant area. The agreement also prohibits the companies from misrepresenting scientific studies and patient testimonials. Axiom must pay DOJ's Consumer Protection and Education Fund a total of $100,000. If Axiom complies with the AVC, $25,000 will be suspended. Benjamin Altadonna and Altadonna Communications Inc. must pay the state's Consumer Protection and Education Fund a total of $25,000. Consumers wanting more information about consumer protection in Oregon may call the Attorney General's consumer hotline at (503) 378-4320 (Salem area only), (503) 229-5576 (Portland area only) or toll-free at 1-877-877-9392. The Department of Justice is online at:



DIRECTS EMPIRE BLUE CROSS BLUE SHIELD TO DISCLOSE BASIS FOR DOCTOR RANKINGS Issues Consumer Alert To New Yorkers about Potentially Deceptive Programs In an expanding industry-wide investigation, New York Attorney General Andrew M. Cuomo today issued letters to Empire Blue Cross Blue Shield, Preferred Care, and HIP Health Plan of New York/GHI requesting information on the insurers’ doctor ranking programs. The Attorney General also alerted New Yorkers about potentially deceptive programs driven by financial motives and not consumers’ best interests. “Consumers need to be aware that doctor ranking programs as currently designed may steer patients to the cheapest, but not necessarily the best doctors, letting profits trump quality,” said Attorney General Andrew Cuomo. “Transparency and accurate information are critical when making health care decisions and should not be clouded by conflicts of interest.” In the three separate letters sent today, Attorney General Cuomo: • Requested New York City-based Empire Blue Cross Blue Shield to justify its existing ranking program known as Blue Precision, currently offered to national employers in New York City. • Directed Rochester-based Preferred Care to halt the launch of its planned doctor ranking program and to provide details about the system. • Warned New York City-based HIP Health Plan/GHI to refrain from launching such programs without the prior consent of the Attorney General. In the letter to Empire Blue Cross Blue Shield, serving approximately 533,271 members across New York State, Cuomo also questioned Blue Precision’s strategy to steer consumers to preferred doctors. In a publicly available presentation outlining the program, Empire describes its “sanction” model which pressures consumers to switch doctors by imposing financial penalties. Blue Precision is expected to be operating in 22 states by 2008. The program is already available to national employers such as Wal-Mart, which has deployed the program in Florida. “When making healthcare decisions, it is vital consumers have as much honest information and unfiltered advice as possible,” said Cuomo. “Ranking systems are in their infancy. Consumers should use caution and have an open dialogue with their doctors.” In the letter to Preferred Care, serving approximately185,188 members across New York State, Cuomo also cited concern about the insurers’ "report cards," which include a measure of patient satisfaction based in large part on cost criteria. Attorney General Cuomo is scrutinizing the emerging national trend of physician ranking programs in an effort to ensure consumers are protected. Similar letters have been sent to UnitedHealthcare, Aetna Health Plan, and Cigna in recent weeks, and discussions with these companies are ongoing. Copies of the letters: • Letter 1: Empire Blue Cross Blue Shield Letter 2: Preferred CareLetter 3: HIP Health Plan / GHI For a complete list of county-based enrollment data, visit:

Chiropractic Groups Join Forces to Oppose

The recent UnitedHealthcare (UHC) release has been a wake-call to the chiropractic profession. All corners of the profession are working together in response to this ominous action by UHC, which is apparently meant to restrict chiropractic care of children and adolescents and chiropractic care of patients suffering from headaches. There is absolutely no scientific support for the position taken by UHC, and the chiropractic profession will not stand by while patients are harmed as a result of this unfounded policy, a policy which restricts chiropractic coverage and ultimately the appropriate use and reimbursement of chiropractic care. The chiropractic profession will stand united against this spurious action by UHC. We will take all necessary action to stop this harmful policy from being implemented. The chiropractic profession supports the appropriate application of EBM to clinical practice, whether chiropractic or medical. But we will not sit back and allow our doctors of chiropractic and their expert conservative care to be singled out and treated unfairly -- by being held to a higher standard than our colleagues in other health care disciplines. The attached response to the UHC release was created by the Council on Chiropractic Guidelines and Practice Parameters and is fully supported by the undersigned chiropractic organizations. We anticipate other organizations will be speaking out in support of this response in the near future. Watch for more news on this critical issue. American Chiropractic Association Association of Chiropractic Colleges Congress of Chiropractic State Associations Council on Chiropractic Guidelines and Practice Parameters Foundation for Chiropractic Education and Research International Chiropractors Association ********************************* Joint Cover Letter to United Healthcare October 9, 2007 Mr. Robert J. Sheehy Chief Executive Officer UnitedHealthcare 450 Columbus Blvd. Hartford, CT 06103 Dear Mr. Sheehy: This letter is a joint communication from the undersigned chiropractic organizations. Our organizations represent the mainstream of the chiropractic profession in the areas of professional practice, research and clinical guidelines. We write to you today in connection with the recent special bulletin pertaining to chiropractic services related to children, adolescents and headaches (United Healthcare Network Bulletin, Volume 21, September 2007). It states: "United Healthcare had previously concluded that certain services provided as a part of chiropractic care were unproven. A recent review of the clinical evidence in published peer-reviewed medical literature leads us to further conclude that chiropractic services for treatment of children and adolescents is unproven and services for treatment of headaches is unproven." Attached is an analysis which demonstrates that the above policy is not only flawed but more importantly poses a threat to the health of children, adolescents and those individuals suffering with headache pain who may be insured or otherwise covered under United Healthcare programs and policies. We view your recent policy determination to be a material denial of essential benefits and coverage paid for by employers and other insureds. The broad stroke elimination of these important benefits is, in our view, not only unconscionable but is an abrogation of the promises made to cover chiropractic services to employees, individuals and their dependants. We note that none of our organizations were contacted or consulted in connection with your drastic and unprecedented denial of benefits to adolescents, children and those suffering with headache pain. In our opinion, this raises serious questions as to your intentions and we question to whether your motivation for the bottom line outweighs your responsibility to provide coverage for appropriate and needed healthcare services. We would therefore request the immediate rescission of the above-referenced policy. We offer our assistance to provide whatever input your organization may need to craft policies that are reflective of health needs of chiropractic patients under your programs. We intend to inform our patients, state and federal regulatory authorities, members of the various state legislatures, members of Congress and the public of what we view as your inappropriate and reckless action in the denial of needed healthcare benefits to adolescents, children and those suffering with headache pain under your program. We stand ready to engage in constructive dialog on these matters, but the first step in the process must be the immediate rescission of the policy contained in the above-referenced network bulletin. Sincerely, Glenn D. Manceaux, D.C. President, American Chiropractic Association Wayne M. Whalen, DC, DACAN Chair, Council on Chiropractic Guidelines and Practice Parameters Charles Herring, D.C. President, Foundation for Chiropractic Research and Education Carl S. Cleveland III, D.C. President, Association of Chiropractic Colleges R. Jerry DeGrado, D.C., F.I.C.C President, Congress of Chiropractic State Associations John Maltby D.C. President, International Chiropractors Association ********************************* CCGPP Analysis/Letter to UHC October 8, 2007 To: Stephen J. Hemsley President and Chief Executive Officer UnitedHealth Group 9900 Bren Road East, Minetonka MN 55343 From: Dr. Wayne Whalen, Chairman, Council on Chiropractic Guidelines and Practice Parameters (CCGPP) RE: United HealthCare NetworkBulletin Volume 21 September 2007 Recently UHC released a special bulletin, United HealthCare NetworkBulletin Volume 21 September 2007, concerning chiropractic services related to children, adolescents, and headaches. It states, "United HealthCare had previously concluded that certain services provided as a part of chiropractic care were unproven. A recent review of the clinical evidence in published peer-reviewed medical literature leads us to further conclude that chiropractic services for treatment of children and adolescents is unproven and services for treatment of headaches is unproven." The Council on Chiropractic Guidelines and Practice Parameters, the principal agency in the United States that evaluates literature of interest to chiropractic practice, reviewed this bulletin and has serious concerns, especially over the potential harm to children as a result of this policy. We are also concerned over the health and welfare of those patients suffering headaches, who as a result of this policy will be denied medically necessary and evidence-based chiropractic care. Given the research available on the topics in question, in combination with how evidence is translated into clinical practice, we believe the conclusions and policy limits implied by UHC based upon the literature was flawed in many respects. We respectfully request that United Healthcare forward the results of the "recent review of the clinical evidence" referred to in the UHC information release for the CCGPP to evaluate. Please consider the issues identified below. Issue #1: Scope of practice In this bulletin UHC refers to "chiropractic services" presumably and mistakenly equating the licensure of the chiropractic profession with the singular modality/treatment of spinal manipulation. As is known, chiropractic physicians are primary care/portal of entry physicians recognized by statute at both federal and state levels, e.g. Medicare, Medicaid, Department of Defense and Veterans Administration programs, just to name a few. The treatment of special patient populations, e.g. children and adolescents, and specific conditions, e.g. headaches have been established for many years to be well within the scope of a chiropractic practice. Treatment includes not only spinal manipulation, but also active and passive therapeutic modalities, evaluation and management services, instruction on lifestyle modifications, diet and exercise, posture and nutritional advice and other facets of chiropractic practice. Chiropractic is not limited to just spinal manipulation and the UHC bulletin is unclear whether other aspects of a chiropractic clinical encounter are reimbursable. Issue #2: Discriminatory policy/standards In our opinion, it does not appear that UHC’s new standards concerning research and new announced policy were applied in equal fashion across the spectrum of healthcare professions. In fact, if every licensed profession were held to the same unrealistic standard being imposed on the chiropractic profession, virtually no treatment or drug would be reimbursable by UHC. As is commonly known, the FDA did not permit research on children until 2005. In fact most pediatric dosages were prescribed on a hypothetical by-weight basis because of this restriction. Therefore, there remains no significant body of data, beyond case studies, etc. (i.e. no RCTs), supporting the treatment of children by typical medical intervention. Clearly the new UHC policy holds chiropractic physicians to a different set of standards. What medical treatments exist that UHC believes are supported by significant literature? Is UHC denying payment to medical and osteopathic physicians and physical therapists for treatment of children and adolescents and for treatment of headaches? If not, we request that UHC forward the literature supporting the decisions to continue to reimburse those interventions for our review. Issue #3: Research A brief review of the literature revealed numerous papers related to spinal manipulative therapy (SMT) and cervical pain, including headaches. Chronic and cervicogenic headaches remain some of the most prevalent forms of headaches, and chiropractic physicians are particularly well-trained to treat these condition. The CCGPP respectfully requests that UHC produce the review of the literature referenced in the bulletin for our review so we can crosscheck with other available sources to examine the accuracy of the interpretation of those studies. We will further address the issue of headaches under separate cover after we receive UHC’s literature search on the topic. Literature related specifically to children is less voluminous; however, is it truly necessary? What evidence does UHC have in its possession indicating that the spines of children and adolescents respond any differently to spinal manipulation and numerous other passive and active interventions used not only by chiropractic physicians, but medical and osteopathic physicians and physical therapists? What evidence exists that would suggest to UHC that children and adolescents are somehow immune to spine injury/pain? To deny coverage for a special population of patients based upon the lack of research is analogous to denying payment for spinal manipulation for patients living in West Virginia since no randomized trials exist for that population of patient. In our opinion UHC’s logic is flawed in its application of research in a clinical setting. Does UHC possess any literature suggesting that the spines of children and adolescents respond any differently to passive and active modalities and treatment compared to adult populations for which spinal manipulation has proven value? The literature clearly shows that children suffer significant back pain. In fact, in a study of 1,126 children, the prevalence of nonspecific back pain increases dramatically during adolescence from less than 10 percent in the pre-teenage years up to 50 percent in 15- to 16-year-olds. Of 1,122 backpack users, 74.4 percent were classified as having back pain, validated by significantly poorer general health, more limited physical functioning, and more bodily pain. There is widespread concern that heavy backpacks carried by adolescents contribute to the development of back pain. Other contributing factors to the near epidemic of back pain in adolescents are: sedentary lifestyle, obesity, de-conditioning, excessive sitting, poor diet, etc. These issues not only can all be addressed, but are being routinely addressed with successful therapeutic outcomes, in the normal visit to a chiropractic physician. Another study of 54 pediatric patients concluded that patients responded favorably to chiropractic management, and there were no reported complications. Numerous recognized and respected guidelines support the use of spinal manipulation, along with other therapies, in the treatment of back pain. Just this month, the widely-respected journal, Annals of Internal Medicine stated: *Recommendation 7: *For patients who do not improve with self-care options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits—for acute low back pain, spinal manipulation [emphasis added]; for chronic or subacute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation [emphasis added], yoga, cognitive-behavioral therapy, or progressive relaxation. Issue # 4: Clinical skills, financial impact, and patient safety Given the reality of back pain in children and adolescents, why would UHC restrict access and benefits to the profession best suited to evaluate and treat these conditions? Chiropractic physicians clearly possess more education and clinical skills in the area of musculoskeletal diagnosis and treatment compared to general allopaths and physical therapists. If this policy is permitted, young patients and those suffering headaches will have nowhere to turn except to general medicine. Will that shift result in dollars saved? The answer is no. A limited or complete loss of chiropractic benefits will result in a shift and increased payment for traditional care with its inherent higher costs for treatment, diagnostics and risks associated with prescriptions and invasive procedures. Given the fact that our society, especially the young, is already overmedicated, does that policy make good fiscal or epidemiological sense? In CCGPP’s opinion, it does not. We are justifiably concerned that UHC’s policy will force unnecessary drugs on headaches sufferers and on children who suffer back pain and other conditions commonly treated by chiropractic physicians. The side effects of those drugs can easily be avoided by the use of more conservative chiropractic care. Issue #5: Proper use of guidelines In CCGPP’s opinion, UHC failed to consider that evidence/research is only one facet of a best practice strategy in clinical practice. Other equally important elements include clinical decision-making/experience, patient values, documentation, process of care, response to care, and risk stratification. Over reliance on literature is impractical in a clinical setting where unique patient attributes often exceed the strict controls found in most randomized controlled trials. The CCGPP wishes to remind UHC of the following concerning guidelines: • All guidelines serve merely as background information to assist doctors in the clinical decision-making process. • A guideline serves as a "compass" for care, not a cookbook for care. • Guidelines should never be used punitively or as prescriptions for care. • Each patient is unique and treatment recommendations must be based on the specific factors pertaining to the individual case. • Guidelines are only one piece of evidence to consider when considering the medical necessity of care. Other pieces of evidence include: research, clinical experience/decision-making, patient values, risk stratification, process of care, response to care, documentation, etc. Again, guidelines are not cookbooks with rigid dosages for treatment. • Nearly all guidelines are based upon the acute, non-complicated patient. These are not the typical patients found in clinical practice. Issue #6: Civil Rights of children A major concern of CCGPP is the possible violation of civil rights against this special population, children. Discrimination based upon age is not acceptable in any venue. Given the lack of reason, science, logic, clinical applicability, and the apparent double standards imposed on chiropractic versus medical licensees, this policy should be immediately withdrawn by UHC. Forcing children into more invasive medical procedures, including medications, by denying coverage for more conservative treatment should not be acceptable to anyone. We sincerely hope the observations of CCGPP and recommendations contained in this letter are seriously considered by UHC Please provide us with either confirmation that this egregious policy has been rescinded, or the specific literature synthesis upon which you relied as the basis for the policy. We would also like to note that CCGPP, with its extensive literature searching and review abilities, is available to provide both peer-reviewed and consensus information about chiropractic practice that can be useful to all parties, and we do consider United HealthCare as a stakeholder. If there are additional questions, please do not hesitate to contact my office. I can be reached at (619) 258-1144 or by electronic mail at [email protected]. Sincerely, Wayne Whalen, DC, DACAN Chair Council on Chiropractic Guidelines and Practice Parameters


OUM’s Wellness Works Program Awards Four Scholarships

BRENTWOOD, Tenn. The OUM Chiropractor Program, a national provider of chiropractic malpractice insurance since 1983, recently awarded four Wellness Works Scholarships to chiropractic students across the United States. The scholarship funds were raised through the generous financial support of Biofreeze, Chiropractic Economics, Chiropractic Products, Dynamic Chiropractic and Today’s Chiropractic Lifestyle, five prominent companies dedicated to the advancement of the chiropractic profession. These scholarships were awarded to Jeremy Hozjan, Charlene Lohmueller, Eric Timperley and Nam Tran for their exceptional essays that can be viewed by logging onto Jeremy Hozjan decided to pursue chiropractic as a profession because he wanted a dynamic career that was both rewarding and challenging. He feels that chiropractic provides him with opportunities for success both personally and professionally. Upon receiving his Doctor of Chiropractic degree from Sherman College of Straight Chiropractic in June 2008, Hozjan plans to open a wellness-based family practice in Charlotte, N.C. After obtaining an undergraduate degree from Georgetown University’s School of Foreign Service in 2004, Charlene Lohmueller decided that she wanted to pursue a career in chiropractic instead of Foreign Service. She desired a profession that would allow her to build deep roots in a community and help people improve their health so that they could also contribute to the community. Lohmueller will graduate in November 2008 from New York Chiropractic College and plans to open a chiropractic office on the East Coast. Eric Timperley first learned about chiropractic care from his father who is a practicing chiropractor. He saw firsthand the benefits of chiropractic care as his father treated him for sports injuries. After seeing how the profession affected his family, he decided to follow in his father’s footsteps. After he graduates from Parker College in August 2008, Timperley plans to move back to his hometown of Lincoln, Neb. and open a chiropractic practice emphasizing pediatrics and maternity. Nam Tran, a native of Alberta, Canada, learned about the benefits of chiropractic when his father, who was seriously injured in an auto accident, began to receive chiropractic treatment. After he saw his father go from being completely disabled to gradually regaining his life back, Tran knew he wanted to pursue chiropractic as a profession. Upon graduation from Parker College with a Doctor of Chiropractic degree Tran plans to find an associate position at a family practice in Dallas, Texas. If you are a vendor interested in participating in the Wellness Works Program or a student interested in applying for the scholarship, please call 800-423-1504 or log onto


Volunteers needed for the ING New York City Marathon 2007

Dear Medical Volunteers On behalf of New York Road Runners, thank you for your interest in volunteering for the ING New York City Marathon 2007 Medical Team. The marathon will be held on Sunday, November 4. Enclosed is the Medical Volunteer Application for you to complete and return to me. Dr. Stephen Perle University of Bridgeport 225 Myrtle Ave Bridgeport, CT 06604 (If you are on campus at the University of Bridgeport, my mailbox is outside of Dean Zolli’s office on the middle floor of END Hall. Do not put them under my door – please use my mailbox The attached application says to mail the application to the medical director, Dr. Maharam. If you have received the application along with this email please send the application to me rather than Dr. Maharam. He wants captains and coordinators to bundle the applications. Make sure to note that I am the captain that recruited you on the attached form. All applications are due to me by September 26, 2007. NO EXCEPTIONS. I will accept faxes and emailed applications. Faxes can be sent to me with a cover sheet addressed to me at 203 576-4351. As a Medical Team volunteer, you will receive a credential for your race day assignment as well as an official medical t-shirt, rain poncho, orientation booklet, and thank-you certificate. We are offering a choice of two orientation and credential pickup sessions for medical volunteers, and one for team captains. In order to work on the Medical Team on marathon day, you must attend an orientation and stay for the entire session (6:30-9:00 p.m.). Note that you must bring photo identification to the session you choose to attend. Parking is not provided. Please forward the attached application and this email to anyone you know that would be interested in volunteering. You will only be contacted if there is a problem with your application. No one will contact you to tell you that you are part of our medical team, just show up for one of the two orientations. Volunteer Orientation Date: Monday, October 29, or Tuesday, October 30 (choose one) Place: Hilton New York 1335 Avenue of the Americas, between 53rd and 54th Streets Registration: 6:00-6:30 p.m. Orientation: 6:30-9:00 p.m. Please be sure to add your orientation date to your calendar, and keep this email for your reference. Feel free to call me at 203 576-4248 or email me [email protected] if you have any questions. Sincerely, Stephen M. Perle, D.C., M.S. ING NYC Marathon, Chiropractic Coordinator & Triage Captain

Physician Scores on a National Clinical Skills Examination as Predictors of Complaints to Medical Regulatory Authorities

Robyn Tamblyn, PhD; Michal Abrahamowicz, PhD; Dale Dauphinee, MD; Elizabeth Wenghofer, PhD; André Jacques, MD; Daniel Klass, MD; Sydney Smee, MSc; David Blackmore, PhD; Nancy Winslade, PharmD; Nadyne Girard, MSc; Roxane Du Berger, MSc; Ilona Bartman, MA; David L. Buckeridge, MD, PhD; James A. Hanley, PhD ABSTRACT Context Poor patient-physician communication increases the risk of patient complaints and malpractice claims. To address this problem, licensure assessment has been reformed in Canada and the United States, including a national standardized assessment of patient-physician communication and clinical history taking and examination skills. Objective To assess whether patient-physician communication examination scores in the clinical skills examination predicted future complaints in medical practice. Design, Setting, and Participants Cohort study of all 3424 physicians taking the Medical Council of Canada clinical skills examination between 1993 and 1996 who were licensed to practice in Ontario and/or Quebec. Participants were followed up until 2005, including the first 2 to 12 years of practice. Main Outcome Measure Patient complaints against study physicians that were filed with medical regulatory authorities in Ontario or Quebec and retained after investigation. Multivariate Poisson regression was used to estimate the relationship between complaint rate and scores on the clinical skills examination and traditional written examination. Scores are based on a standardized mean (SD) of 500 (100). Results Overall, 1116 complaints were filed for 3424 physicians, and 696 complaints were retained after investigation. Of the physicians, 17.1% had at least 1 retained complaint, of which 81.9% were for communication or quality-of-care problems. Patient-physician communication scores for study physicians ranged from 31 to 723 (mean [SD], 510.9 [91.1]). A 2-SD decrease in communication score was associated with 1.17 more retained complaints per 100 physicians per year (relative risk [RR], 1.38; 95% confidence interval [CI], 1.18-1.61) and 1.20 more communication complaints per 100 practice-years (RR, 1.43; 95% CI, 1.15-1.77). After adjusting for the predictive ability of the clinical decision-making score in the traditional written examination, the patient-physician communication score in the clinical skills examination remained significantly predictive of retained complaints (likelihood ratio test, P < .001), with scores in the bottom quartile explaining an additional 9.2% (95% CI, 4.7%-13.1%) of complaints. Conclusion Scores achieved in patient-physician communication and clinical decision making on a national licensing examination predicted complaints to medical regulatory authorities. Authors: Robyn Tamblyn, PhD; Michal Abrahamowicz, PhD; Dale Dauphinee, MD; Elizabeth Wenghofer, PhD; André Jacques, MD; Daniel Klass, MD; Sydney Smee, MSc; David Blackmore, PhD; Nancy Winslade, PharmD; Nadyne Girard, MSc; Roxane Du Berger, MSc; Ilona Bartman, MA; David L. Buckeridge, MD, PhD; James A. Hanley, PhD Author Affiliations: Departments of Medicine (Drs Tamblyn and Dauphinee) and Epidemiology & Biostatistics (Drs Abrahamowicz, Winslade, Buckeridge, and Hanley, and Mss Girard and Du Berger), McGill University, Montreal, Quebec, Canada; Ontario College of Physicians and Surgeons, Toronto, Ontario, Canada (Drs Wenghofer and Klass); Quebec College of Physicians, Montreal (Dr Jacques); and Medical Council of Canada, Ottawa, Ontario (Dr Blackmore and Mss Smee and Bartman). The Journal of the American Medical AssociationVol. 298 No. 9, September 5, 2007