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NYSCA responds to the November 10, 2003 Crain’s New York Business article.

Letters to the Editor Crain’s New York Business 711 Third Ave. New York, NY 10017-4036 Re: Samantha Marshall: More chiropractic visits put strain on employers File: P - 1 Dear Editor; The article by Samantha Marshall, “More chiropractic visits put strain on employers,” carried in the November 10, 2003 issue of Crain’s New York Business, is factually wrong and is more worthy of the kind of tabloid journalism one might expect to find at grocery market checkout counters. Mashall squarely puts the onus for any pending increases in Workers’ Compensation premiums on increased utilization of chiropractic care. Although as an absolute number, chiropractic utilization may have increased over the last few years, in terms of cost, the total amount spent on chiropractic is still a mere fraction of a percent of the $4.27 billion employers paid in workers' compensation premiums of under the Workers’ Compensation system. If there is any increase in Workers’ Compensation premiums, it likely parallels the escalating costs of health care in general, none of which have been attributed to chiropractic care. As studies conducted by forecasting firms, Hewitt Associaties1, Kaiser Family Foundation2, the California Healthcare Foundation3, Price Waterhouse Coopers4 and others illustrate over the last four or five years, health care costs have spiraled upward reaching the double digit stratospheres reminiscent of the early 1990s. However, forecasters place the blame for most of the increases squarely on rising cost of hospitalization and drugs,5 not chiropractic. Ms. Marshall’s statement that, “Costs have begun to rise recently in New York, where blanket coverage of chiropractic care is relatively new” is factually wrong. While chiropractic care has been covered service under the Workers’ Compensation system since 1975, the coverage Marshall refers to is not “blanket” or “new.” In fact, in New York, chiropractors are probably the lowest paid of all providers in the entire Workers’ Compensation Reimbursement system. In contrast to other providers, under the Workers’ Compensation fee schedule, chiropractic rates are capped at a reimbursement level equivalent to fifty percent (50%) of ninety-five percent (95%), or roughly 47.5% overall of the rate paid to a general practitioner, and significantly lower than the rate paid to medical specialists, a situation that has prevailed in New York since 1975. In addition, pursuant to the Workers’ Compensation fee schedule chiropractors are not reimbursed at all for many treatments and procedures they are entitled to perform by law. In addition, any cases controverted by insurers and employers are sent to a Workers’ Compensation Practice Panel for adjudication, as they are for other classes of provider. Ms. Marshall’s contention that “a bill introduced into the Assembly this summer, which has a good chance of passing in the next legislative session, would allow chiropractors to expand their fee schedules,” misses the mark. Bills have been introduced for several years that have had as their intent making the reimbursement of chiropractors equitable with other providers in the Workers’ Compensation system. This is a question of equity and fairness, and given the fact that the Legislature has thus far been unmoved, Ms. Marshall’s intimation that this bill “has a good chance of passing in the next legislative session” and “would allow chiropractors to expand their fee schedules” smacks of an appeal to emotional sensationalism, and is not genuine, professional, journalistic reporting. Ms. Marshall also has her facts wrong concerning the impact of the 1997 chiropractic Insurance Equality Law (effective 1998). Marshall states that, “The 1997 Chiropractic Care Act mandated that injured workers eligible for workers' compensation could receive almost unlimited chiropractic care.” (underlining added). Had Ms. Marshall actually bothered to take the time to read the Insurance Equality Statute she would have discovered that the Insurance Equality Law was an equity statute designed to give patients the same access to and equivalent coverage for chiropractic care in health insurance plans as they would receive for medical care provided to physicians. The 1997 Insurance Equality Law had nothing to do with and had no impact whatsoever on Workers’ Compensation Law, Workers’ Comp carriers or plans or employers. To suggest that the 1997 Insurance Equality Law allowed “the New York workers' compensation system [to] create the perfect climate for excessive use of chiropractic services,” is patently false. It calls into question Ms. Marshall’s ability to be fair, objective and balanced in her reporting. Likewise, Marshall incorrectly states that “chiropractors successfully sued several major insurers two years ago for more equitable coverage.” Had Ms. Marshall actually done any sort of investigation she would have learned that the courts had dismissed the suit holding that chiropractors had “no private right of action” to assume the responsibility for enforcing a law that was completely within the ambit of the State Insurance Department. Finally, Marshall and Crain’s reference to Dr. Daniel Quatro, President of the New York State Chiropractic Association as “Mr. Quatro” is an insult. The Federal government and State governments nationwide extend the courtesy of referring to doctors of chiropractic as “Dr.” in recognition of their extensive educational attainment, which studies show, is on par with other health care providers, including physicians.6 This disrespect is antediluvian and reflects, perhaps, part of the “lingering effects” a federal court found when it held organized medicine guilty in 1987 of a “long-term,7 systematic,8 successful,9 and unlawful”10 attempt to “contain and eliminate”11 the “chiropractic profession”12 by any means, legal and unlawful. In 1987, the Federal Court concluded a permanent injunction against organized medicine was necessary because “[t]here are lingering effects of the conspiracy”; because organized medicine “never acknowledged the lawlessness of its past conduct . . . ”13; and because the 'lingering effects' [of organized medicine’s campaign] still threatened plaintiffs with current injury.”14 Unwittingly perhaps, Crain’s contributes to that legacy. Crain’s does its readers a disservice by communicating information in this article that is just plain factually wrong. This type of shoddy reporting leaves the impression that Crain’s plays fast and lose with the facts and that its attitude is decidedly cavalier, perhaps intentionally so. Crain’s would do well to make sure that its reporters and writers have a firm grasp of the facts before putting any article to press. If this sort of shoddy reporting and editing one can expect from Crain’s, it certainly does not reflect well upon Crain’s, its reporters, editors or its other publications. Sincerely, Karl C. Kranz, DC, Esq. Executive Director New York State Chiropractic Association 1. Hewitt Associates. “Health Care Costs Continue Double-Digit Pace, But May Start Moderating in 2004,” Lincolnshire, IL, October 13, 2003. 2. Kaiser Family Foundation and Health Reserach and Educational Trust. Employer Health Benefits, 2003 Summary of Findings, September 2003. 3. California Healthcare Foundation. Trends & Analysis: Insurance Markets – Health Benefit Costs: Employers Share the Pain, July 2003. 4. Price Waterhouse Coopers. The Factors Fueling Rising Health Care Costs. April 2002. 5. Ibid. 6. Cherkin DC, Mootz RD. Chiropractic in the United States: Training, Practice, and Research. Agency for Health Care Policy and Research (AHCPR), Department of Health and Human Services (DHHS), Publication No. 98-N002, December 1997. Grant number HS07915 AHCPR. 7. Wilk v. AMA, 671 F.Supp. 1465, 1488 (Dist. Ct. N.D. Ill. 1987) 8. Id. 9. Id. 10. Wilk v. AMA, 895 F.2d 352, 357 (7th Cir. 1990) 11. Wilk v. AMA, 671 F.Supp. 1465, 1473 (N.D. Ill. 1987) 12. Wilk v. AMA,895 F.2d 352 (7th Cir. 1990), cert denied, 496 U.S. 927, 110 S.Ct. 2621 (1990). 13. Wilk v. AMA, 671 F.Supp. 1465, 1488 (Dist. Ct. N.D. Ill. 1987). 14. Wilk v. AMA, 895 F.2d 352, 357 (7th Cir. 1990))

Study debunking the long- held belief firm mattresses are beneficial for low-back pain

A new study debunking the long- held belief by many that firm mattresses are beneficial for low-back pain should prompt some consumers to re-think their choices in mattresses, according to the American Chiropractic Association (ACA). A study published in the November 15 issue of The Lancet found that people who slept on mattresses of medium firmness were twice as likely to report improvement in low-back pain symptoms than those who slept on firm mattresses. Doctors of chiropractic have long counseled patients that "comfortably supportive" mattresses are superior to very firm "table board" mattresses, said George McClelland, DC, chairman of the board of the American Chiropractic Association. "A medium-firm mattress will more readily adapt to the natural curvatures in a person's spine," he explained. Dr. McClelland and the ACA recommend the following tips for choosing mattresses: If you're not in the market for a new mattress, and your current mattress is too firm, you can soften it up by putting a 1- to 2-inch-thick padding on top of it -- usually available at mattress and bedding stores. A mattress should provide uniform support from head to toe. If there are gaps between your body and your mattress (such as at the waist), you're not getting the full support that you need. Every few months, turn your mattress clockwise, or upside down, so that body indentations are kept to a minimum. It's also good to rotate the mattress frame every so often to reduce wear and tear. If you're waking up uncomfortable, it might be time for a new mattress. There is no standard life span for a mattress; it all depends on the kind of usage it gets. Be aware that changes in your life can signal the need for a new mattress. For example, if you've lost or gained a lot of weight, if a medical condition has changed the way you sleep, or even if you have changed partners, it could mean that it's time to find a new mattress that will accommodate those changes and help you sleep more soundly. When you're purchasing a mattress, don't be embarrassed to actually lie down on it at the store to check its fit and comfort. Don't just sit on it to test it.

NEW REGULATIONS PROVIDE MORE CLARITY FOR ERISA APPEALS

When appealing a claim denial from an ERISA health plan, it is important to determine the extent of the plan's chiropractic benefits as well as who made the decision to deny the claim and why, said Karen L. Handorf, deputy associate solicitor in the Plan Benefit Security Division of the U.S. Department of Labor (DOL). All of this information is available to patients, and doctors acting as patient representatives, under new DOL regulations. Employers with ERISA health plans are also obligated under the new rules to follow specific steps in the appeals process. Handorf, whose DOL division is responsible for providing litigation and advisory legal services under ERISA, participated in an Oct. 24 teleconference on new ERISA-related court rulings and Labor Department regulations hosted by ACA for chiropractic attorneys and state association representatives. She told the group that, at present, individual doctors and their patients are better off going through a plan's appeal procedure to obtain benefits rather than filing a lawsuit. If you have to file a lawsuit in federal court, the plan's decision is usually reviewed under an "arbitrary and capricious" standard; you are limited to the evidence that was presented to the plan administrator, and you will not be able to obtain anything more than the benefits that were promised. States can regulate insured plans through their state insurance laws, and the courts are interpreting ERISA preemption language to allow for more expansive regulation of insured plans by the states. ERISA, the Employee Retirement Income Security Act, was passed in 1974 and intended to encourage large multi-state employers to provide pension, health care and other compensation to their employees by shielding them from various state laws governing pension and insurance laws and instead requiring compliance with one set of federal laws. The law, however, also made it difficult for individuals to get relief for denied claims or botched treatment. About 80 percent of workers not covered by a government-based health plan receive their health care through an ERISA-protected plan. In response, the DOL this year issued new claim appeal procedures effective for all health benefit plans subject to ERISA regulations. It includes a specific time frame for filing an appeal, spells out the rights of the plan participants and responsibilities of the plans, and requires the plan to indicate why and on what basis a claim was denied. Handorf told participants that the first course of action should be to obtain the health plan's "SPD" or summary plan description, which describes-in plain, understandable terms-what a beneficiary is entitled to and what his or her rights are under the plan. From this, doctors and patients can determine if the denial is based on limitations allowed in the SPD. "It all comes down to how a plan is written..." says Handorf. "I would think that most plans that provide chiropractic benefits would be pretty specific about it." If a claim is denied for reasons of medical necessity, doctors and patients have the right to know the identity of the reviewer (who should have appropriate training and experience in the specific health care field involved) and the reasons for the denial. Once this information is known, doctors should submit any additional evidence supporting their treatment decisions to the health plan to be included in the official administrative record. Attention to such details of the appeals process is essential; otherwise, evidence may not be admissible further down the line.

Chiropractic Can Help Reduce the Toll of Pain and Prescription Drugs on Nation's Health Care System, Says ACA

New studies showing the staggering costs of headaches, back pain and other musculoskeletal conditions on the country's economy and the skyrocketing effect prescription drugs have on insurance premiums should convince the nation's employers and insurers to more fully integrate chiropractic care into employee health plans, according to the American Chiropractic Association (ACA). A November 12 study in the Journal of the American Medical Association found that headaches and back pain are leading reasons for lost productivity and absenteeism in the workforce -- costing more than $61 billion each year. And the 2003 Annual Employer Health Benefits Survey, conducted by the Kaiser Family Foundation and Health Research and Educational Trust, found that higher prescription drug costs are a major factor contributing to increases in health insurance premiums. "Over the years, studies have shown that chiropractic care is effective at treating headaches and back pain and can get workers back on the job more quickly than traditional forms of care," said ACA President Donald J. Krippendorf, DC. "At the same time, chiropractic also helps workers avoid expensive prescription drugs -- making it a perfect fit for employers looking to control health care costs." Back pain and headaches, in particular, are two conditions that doctors of chiropractic have successfully treated for decades -- and several studies have demonstrated chiropractic's effectiveness. Most recently, a study published in the July 15, 2003 issue of the medical journal Spine found that manual manipulation -- the primary form of treatment performed by doctors of chiropractic -- provides better short-term relief of chronic back pain than medication. In 2001, researchers at Duke University found cervical -- or neck -- manipulation appropriate for both tension type headache and cervicogenic headache and noted that "cervical spinal manipulation has a very low risk of serious complications" which may be "one of its appeals over drug treatment." Just a sampling of other studies include: A 1997 study published in Spine found "strong evidence that manipulation is more effective than a placebo treatment for chronic low-back pain or than usual care by the general practitioner, bed rest, analgesics and massage." A 1996 study published in the journal Medical Care found that first contact chiropractic care for common low back conditions costs substantially less than traditional medical treatment and "deserves careful consideration" by managed care executives concerned with controlling health care spending. In 1994, the U.S. Agency for Health Care Policy and Research found that "spinal manipulation is effective in reducing pain and perhaps speeding recovery" within the first month of acute low-back pain symptoms. A 1993 study conducted in Canada and funded by the Ontario Ministry of Health found that "the overwhelming body of evidence" shows that chiropractic management of low-back pain is more cost-effective than medical management, and that "many medical therapies are of questionable validity or are clearly inadequate." For more information on chiropractic care and research on its effectiveness, visit ACA's Web site at www.acatoday.com. The ACA, based in Arlington, VA, is the largest chiropractic organization in the country. The ACA promotes the highest standards of ethics and patient care, contributing to the health and well being of millions of chiropractic patients.

Legislation to Establish Chiropractic Care Parity for Military Retirees, Dependents and Survivors through TRICARE

Attached is a copy of a Congressional "Dear Colleague" letter from Rep. Ed Schrock (R-VA) and Rep. Lane Evans (D-IL) being circulated in today's afternoon mail on Capitol Hill. It asks Members of the U.S. House of Representatives to join as original co-sponsors of an ACA-backed legislative proposal to extend chiropractic health parity to U.S. military retirees, dependents and survivors through the TRICARE program. In recent years, Congress has passed, and the President has signed into law, legislation establishing a permanent chiropractic care benefit for both active duty military personnel and veterans. The Schrock-Evans Chiropractic Parity in TRICARE Bill represents the next step toward ensuring that all of America’s current and former military service personnel, and their families, have access to the chiropractic services they need and deserve. ACA and the Association of Chiropractic Colleges have been involved in discussions concerning this issue since earlier this year and have committed to working closely with Reps. Schrock and Evans to build strong support for the legislation among pro-chiropractic Members of Congress. Accordingly, ACA urges all concerned DCs, CAs, chiropractic students and patients and friends of the chiropractic profession to immediately contact their representatives in the U.S. House to request that they join as original co-sponsors of the soon-to-be-introduced Schrock-Evans Chiropractic Parity in TRICARE Bill. As a chiropractic supporter, it is essential that you take immediate action on this matter by calling your Congressman or Congresswoman at his/her local office or through the U.S. Capitol switchboard at (202) 225-3121. Please urge co-sponsorship of the Schrock-Evans Chiropractic Parity in TRICARE Bill.

Patent Awarded for Pancreatic Enzyme Therapy for ADD, ADHD and Autism

The U.S. Patent and Trademark office has awarded Dr. Joan Fallon patent # 6,632,429 entitled Methods for Treating Pervasive Developmental Disorders. The patent covers the use of digestive and pancreatic enzymes as a treatment for children with ADD, ADHD and Autism. The patent, which will remain in effect until 2019, represents a breakthrough for children with pervasive developmental disorders including ADD, ADHD and Autism. Autism is characterized by profound delays in communication and social interaction and is thought to affect over 1.5 million individuals in the U.S. ADD and ADHD have a prevalence of between 5 and 10% in the population. It is estimated that upwards of 10% of the population is medicated for some type of attention disorder. Dr. Fallon's invention employs the use of digestive and pancreatic enzymes for children with these conditions based upon the presence of a low level of chymotrypsin in the stool. Chymotrypsin is an enzyme secreted by the pancreas in an inactive form which becomes active in the presence of protein in the small intestines as well as a favorable pH. Without sufficient protein digestion, the formation of amino acids, the building blocks of new proteins, cannot occur. The lack of protein synthesis can underlie a significant neurological deficit in the child. Fallon's patent demonstrates that the administration of digestive and pancreatic enzymes produce profound changes in the autistic symptomotology including increases in social interactions, eye contact and speech and reductions in repetitive actions and hyperactivity. It further demonstrates changes in bowel habits including an increase in bowel control and formed movements. In the child with ADD and ADHD, the therapy significantly reduces the levels of medication the child is taking and, in many cases, the child no longer needs the medication, based upon observed increases in attention. "The patent recognizes a deficiency in the children with ADD, ADHD and Autism, and offers a biological solution. Digestive and pancreatic enzymes have been used safely and effectively for children and adults with cystic fibrosis for many years," said Dr. Fallon, inventor and patent holder. "I intend to continue to refine the use of digestive and pancreatic enzymes for these and other indications. This form of treatment opens new avenues for children and adults with these debilitating conditions. Contact: Dr. Joan Fallon 914-779-9300

American Chiropractic Association Describes Chiropractic Approach to Ear Infections

Ear problems can be excruciatingly painful, especially in children. With 10 million new cases every year, ear infections are the most common illness affecting babies and young children and the number one reason for visits to the pediatrician -- accounting for more than 35 percent of all pediatric visits. Before yet another round of "maybe-they'll-work-and-maybe-they-won't" antibiotics or the drastic step of surgery, more parents are considering chiropractic to help children with chronic ear infections, according to the American Chiropractic Association (ACA). See www.acatoday.com . Dr. Joan Fallon, a doctor of chiropractic who practices in Yonkers, New York, has published research showing that, after receiving a series of chiropractic adjustments, nearly 80 percent of the children treated were free of ear infections for at least the six-month period following their initial visits (a period that also included maintenance treatments every four to six weeks). "Chiropractic mobilizes drainage of the ear in children, and if they can continue to drain without a buildup of fluid and subsequent infection, they build up their own antibodies and recover more quickly," explains Dr. Fallon. She'd like to see her pilot study used as a basis for larger-scale trials of chiropractic as a therapeutic modality for ear infections. When treating children with ear infections, Dr. Fallon focuses on the back of the skull and the first vertebra in the neck. After an adjustment to these areas, which helps the fluid in the ears to drain -- and depending on how chronic the problem is and where they are in their cycle of antibiotics -- children can generally fight the infection off themselves. That means, for the average child, between six and eight treatments. If a child's case is acute, Dr. Fallon will check the ear every day, measuring the ear and tracking the movement of the eardrum to make sure that it's draining. "I'll do adjustments every day or every other day for a couple of days if they're acute, and then decrease frequency over time." Dr. Fallon, whose research garnered her the acclaim of childrearing magazines like Parenting and Baby Talk, often sees great success when she treats a child for an ear infection. "Once they fight it themselves, kids tend to do very well and stay away from ear infections completely. Unless there are environmental factors like smoking in the house, an abnormally shaped Eustachian tube, or something like that, they do very well," she says. "I have two large pediatric groups that refer to me on a regular basis. In the winter, when ear infections are most prevalent, I see five or six new children each week from each group," says Dr. Fallon. "It's safe and effective and something that parents should try, certainly before inserting tubes in their children's ears."

FIFTY-ONE ARRESTED IN NEW YORK CITY INSURANCE FRAUD RING

Superintendent of Insurance Gregory V. Serio, along with New York City Police Commissioner Raymond W. Kelly and Brooklyn District Attorney Charles J. Hynes announced on Sunday the arrest of 51 individuals as part of the takedown of a no-fault insurance fraud ring in New York City. The arrests are the first phase of "Operation Gateway," an investigation into a criminal organization that is taking advantage of New York’s no-fault laws by falsifying auto accidents. It is estimated that fraudulent no-fault insurance claims amount to tens of millions of dollars a year in New York State, and hundreds of millions of dollars nationwide. Based on the evidence in this case, the loss is in the tens of millions of dollars. "The elaborate scheme and sophistication of the criminals involved in the case dismantled today proves that criminals are aware of how to circumvent the current no-fault law and make a great deal of money by doing so," said Superintendent of Insurance Gregory V. Serio "The Governor, the Insurance Department and law enforcement agencies, like the New York Police Department and Brooklyn District Attorney’s office, are doing everything within the power of the current law to take these criminals off the street, but until there is legislative action we will continue to see criminals like these who steal tens of millions of dollars from the auto insurance system and cause auto insurance rates to increase for honest New York drivers." A typical no-fault auto insurance scam begins with "runners," or recruiters who arrange to send individuals supposedly injured in an accident to clinics for treatment. The runners obtain phony accident reports and recruit ‘victims’ to send to medical clinics, which are paid off to provide medical tests. Lawyers are also involved who file insurance claims, up to $50,00 per victim which is the maximum amount allowed under New York’s no-fault laws. The organization’s top leaders keep most of the money and paid off those involved. In this case, runners were paid up to $2,500 for every victim they could link to a fictitious accident. The Department participated in the weekend takedown where NYPD detectives posed as insurance company representatives, called them at home to inform them they had been awarded an insurance claim of up to $11,000 and to pick it up in person in Queens. When they arrived to pick up their claim money, they were arrested and charged with fraud. The Department was initially contacted by the New York City Police Department to assist in the investigation in December 2002 after the NYPD received a tip regarding a suspected fraud ring in New York City. Also assisting in the investigation were Liberty Mutual Insurance Company, Kemper Insurance Company, MetLife Insurance Company, Allstate Insurance Company, Progressive Insurance Company, Clarendon Insurance Company, Continental Insurance Company, The Robert Plan, Eagle Insurance Company, GEICO Insurance Company, The Hartford Insurance Company, State Farm Insurance Company, Lancer Insurance Company, the Motor Vehicle Accident Indemnification Corporation, Nationwide Insurance Company, New York Central Mutual Fire Insurance Company, Statewide Insurance Company and Travelers Insurance Company. New York is aggressive in its fight against insurance fraud. To report suspected incidents of insurance fraud call 1-888-FRAUD-NY (1-888-372-8369). It should be noted that an arrest is merely an accusation and that a defendant is presumed innocent until proven guilty.

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ACC STATEMENT ON DIAGNOSIS ENDORSED BY ACA's HOD

At its annual meeting, the ACA House of Delegates passed the following resolution endorsing the Association of Chiropractic College's clarification of the ACC paradigm related to diagnosis as follows: "A diagnosis is an expert opinion identifying the nature and cause of a patient's concern or complaint, and/or abnormal finding(s). It is essential to the ongoing process of reasoning used by the doctor of chiropractic in cooperation with the patient to direct, manage, and optimize the patient's health and well-being. "The process of arriving at a diagnosis by a doctor of chiropractic includes: obtaining pertinent patient history; conducting physical, neurological, orthopedic, and other appropriate examination procedures; ordering and interpreting specialized diagnostic imaging and/or laboratory tests as indicated by symptoms and/or clinical findings; and performing postural and functional biomechanical analysis to determine the presence of articular dysfunction and/or subluxation. "The Association of Chiropractic Colleges continues to foster a unique, distinct chiropractic profession that generates, develops, and utilizes the highest level of evidence possible in the provision of effective, prudent, and cost-conscious patient evaluation and care." (Note: This does not replace the current definition of diagnosis as found in the ACA Master Plan and other policy statements of the ACA. Motion Carried.)

MEDICARE ANNOUNCES PLAN TO ACCEPT HIPAA NON-COMPLIANT ELECTRONIC TRANSACTIONS

The Centers for Medicare & Medicaid Services (CMS) announced today that it will implement a contingency plan to accept noncompliant electronic transactions after the October 16, 2003 compliance deadline. This plan will ensure continued processing of claims from thousands of providers who will not be able to meet the deadline and otherwise would have had their Medicare claims rejected. 'Implementing this contingency plan moves us toward the dual goals of achieving HIPAA compliance while not disrupting providers' cash flow and operations, so that beneficiaries can continue to get the health care services they need,' said CMS Administrator Tom Scully. CMS made the decision to implement its contingency plan after reviewing statistics showing unacceptably low numbers of compliant claims being submitted. 'Medicare is able to process HIPAA-compliant transactions,' said Tom Grissom, director of CMS' Center for Medicare Management, 'but we need to work with our trading partners to increase the percentage of claims in production.' The contingency plan permits CMS to continue to accept and process claims in the electronic formats now in use, giving providers additional time to complete the testing process. CMS will regularly reassess the readiness of its trading partners to determine how long the contingency plan will remain in effect. The authority to implement a contingency plan was provided by guidance issued by HHS on July 24. CMS recognized that transactions often require the participation of two covered entities and that non-compliance by one covered entity may put the second covered entity in a difficult position. The guidance stated that covered entities that make a good faith effort to comply with HIPAA transactions and code set standards may implement contingencies to maintain operations and cash flow. CMS announced its contingency plan on September 11, but at that time had not made a decision on whether the plan would be implemented. Today's announcement means the CMS plan will be implemented on October 16, 2003. 'We encourage other plans to assess the readiness of their trading partners and implement contingency plans if appropriate,' Grissom said.

New York State Chiropractic Association Leadership Meets with Oxford/Triad

The NYSCA officers and downstate board members met with Oxford representative Drs. James Dillard and Bartley Bryt and Triad officers, Drs. Agostino Villani and Santo Sampini during the NYSCA convention in Rye Brook, NY on September 19, 2003. The purpose of the meeting was to discuss NYSCA member issues with Triad handling of care plans over the past nine months. Much of member complaints focused on onerous paper work (first visit submission of care plans with 30 day extensions); down coding; lack of supportive care approval (even though Triad reports approval of this type of care); difficulty in treating the chronic pain patient and the lack of clinical information on care plans on which treatment authorizations are based. An additional issue that was addressed and immediately clarified was the PCP referral. It was explained that once the patient has obtained the PCP referral, providing they remain in the same plan, the patient does not need a new referral after the initial even with lapses or discharge from care. As far as the remaining issues are concerned, Triad reports changes to the forms to be implemented in the new year. They recommend visiting their website to view the provider manual for proper filing of forms as well as being able to download care plans to be filled out on your desktop. Your NYSCA leaders plan to continue discussions with Oxford to assist them in understanding chiropractic in the managed care environment. We will keep communications open with Triad as long as our members have issues. Your responsibility is to communicate your problems with us. We are particularly interested in supportive care denials. NYSCA - working for you - with you.

Dr. Arthur P. Kojes 12-06-1954 – 09-14-2003

Dr. Arthur P. Kojes 12-06-1954 – 09-14-2003 It is with great sadness that we acknowledge the passing of NYSCA’s Immediate Past President, Dr. Arthur P. Kojes 48, of Flushing New York on Sunday September 14, 2003. Dr Kojes died peacefully at his home with his family at his bedside. He is survived by his wife Eileen, a daughter Caitlin and two sons Matthew and Arthur John. I am sure we will all agree that Dr. Kojes has done much for the Chiropractic profession and will be deeply missed. We ask that you keep his wife, children and family in your thoughts and prayers. A few days before Dr. Kojes passed, he wrote this poem. His aunt read it at his Memorial Service and we thought that we would like to share it with you. I will reach for the stars in my heart and dreams. I will see the bright glimmering light and the warm glow through the heavens. I can not touch them with my hands but I will reach them with my soul. Arthur P. Kojes, D.C.

MCH Offering Chiropractic

At a luncheon in late July at Monroe Community Hospital, Paul Dougherty took a seat at the table with a group of doctors. The symbolism wasn’t lost on anyone. A chiropractor by trade, Dougherty would have been viewed as a quack by this crowd just 20 years ago, but now he’s helping to blaze a trail that is pushing chiropractic medicine into the mainstream. Dougherty heads a newly created chiropractic clinic at Monroe Community Hospital that is believed to be the first of its kind in the country, one that offers chiropractic therapy in the setting of a long-term care institution. Here at the county’s largest nursing home, Dougherty works side by side with doctors to relieve the back and neck pain of elderly residents with chronic illnesses. When pain medications don’t do the job, Dougherty goes to work stretching and cracking the spinal columns of residents like 52-year-old Pat Gribb, who suffers from multiple sclerosis and spends all day in a wheelchair. “ It’s not a comfortable position to be in,” said Gribb, whose back pain was relieved last month when Dougherty stretched her back to unlock several compressed vertebrae. “ I immediately felt the difference.” As late as 1983, the American Medical Association considered it unethical for doctors to refer patients to chiropractors. Today, though, those guidelines encourage chiropractic treatment when doctors think it is in the best interest of their patients. About 500 hospitals in the U.S. now have chiropractors on their staffs, according to the American Chiropractic Association in Arlington, Va. “ That sounds like a pretty good number, but when you consider that there are 6,000 hospitals in the country, we still have a long way to go,” said Jerome F. McAndrews, spokesman for the group. McAndrews said he is not aware of another experiment like the one at Monroe Community Hospital: a chiropractic clinic within the halls of a nursing home. The clinic, jointly operated by the New York Chiropractic College in Seneca Falls, also is a teaching site for students and offers outpatient services. “ We’re not trying to be physicians. That’s not what we do,” said Dougherty, an associate professor at the college. “ But we do think that we have a role to play in pain management.” The clinic began as a demonstration project last year, treating 48 elderly residents with back pain, headaches, neck pains and shoulder stiffness. Monroe Community Hospital officials liked the way that these patients responded to the chiropractic treatments, so they decided to open it to the rest of the resident population. The treatment is not considered appropriate, though, for extremely frail patients. “ The goal is to reduce pain, and however you do it, I don’t care as long as it’s safe and effective,” said Dr. Paul Katz, medical director at Monroe Community Hospital. “ I admit it that when I was in medical school in the ‘70s, chiropractic had a very negative connotation to it,” Katz said. “ But there’s a lot more science behind what they do now, and it’s really given me a greater appreciation for their role.” Chiropractic medicine involves manipulating joints and muscles to improve their function. It is not known why this causes pain to subside, but it may have to do with a relaxing effect on the central nervous system, Dougherty said. Dougherty is the first to argue that more scientific research is needed. In fact, he and Monroe Community Hospital officials have applied for a $750,000 grant from the U.S. Department of Health and Human Services to conduct a three-year study on how elderly patients react to chiropractic therapy. If approved — the government’s decision is due in late August — Monroe Community Hospital will have two study groups: those who get traditional medical treatments for back pain (steroid injections, pain medications), vs. those who get medical treatment plus chiropractic. Outcomes will be measured by using a standard of patient satisfaction and cost effectiveness. “ I think there’s a future in integrating chiropractic with traditional medicine, and it’s exciting to be on the front-end of it,” Dougherty said. Courtesy of The Democrat and Chronicle

GRAND OPENING OF INTEGRATIVE HEALTH CENTER

On Thursday, September 18th, from 4:00 p.m. to 6:00 p.m., the public is invited to attend NYCC's grand opening of its new integrative Seneca Falls Health Center. NYCC President Dr. Frank Nicchi and New York State Senator Michael Nozzolio will officially perform the ribbon cutting dedication at 4:30 p.m., and a cocktail reception will take place immediately thereafter. The Seneca Falls Health Center is currently open for business. Unique in its blend of integrative offerings, the facility is truly impressive. The facility houses a large atrium style central waiting room, 13 spacious treatment rooms, a conference room, an x-ray suite complete with darkroom, hematology lab, four secondary waiting areas, and several doctors' offices. Healthcare services include chiropractic, nutritional counseling, acupuncture & oriental medicine, massage therapy, and beginning September 1, 2003 - medical services by physicians and a nurse practitioner. The Center accepts payment from all major insurance carriers and its hours are flexible, accommodating a wide variety of patients' schedules: Monday, Wednesday and Thursday from 8:30 to 5:30, Tuesday from 12:00 to 8:00, and Friday from 8:30 to 4:00. Local radio personalities "Mike & Mary" of WNYR will interview attendees and doctors, and report the events as they occur through a "live" radio feed. In addition to the free cocktail reception following the ceremony, the grand opening will include free tours throughout the facility, as well as brochures and literature about acupuncture, chiropractic, massage, medicine and the various health center offerings. The Center is located on the NYCC campus on State Route 89 just off Bayard St.

MANUAL THERAPY IS EFFECTIVE TREATMENT FOR NECK PAIN

Manual therapy is more effective and less costly for treating neck pain than physiotherapy or care by a general practitioner, claim researchers in this week's BMJ. The study involved 183 patients recruited by 42 general practitioners in the Netherlands. All patients were aged 18-70 years and had suffered neck pain for at least two weeks. Sixty patients received manual therapy (spinal mobilisation), 59 received physiotherapy (mainly exercise), and 64 received standard care from a general practitioner (counselling, education, and drugs). After 26 weeks, patients in the manual therapy group recovered more quickly than the physiotherapy group and the general practitioner care group, but differences were negligible by 52 weeks. The total costs of manual therapy were around one third of the costs in the other two groups. "Our findings showed manual therapy to be more cost effective than physiotherapy and continued care provided by a general practitioner in the treatment of non-specific neck pain," conclude the authors.

Source

Update of the VA Chiropractic Advisory Committee

DEPARTMENT OF VETERANS AFFAIRS RECOMMENDATIONS OF THE CHIROPRACTIC ADVISORY COMMITTEE Draft #6 July 2003 INTRODUCTION: Public Law 107-135, Section 204 established the Department of Veterans Affairs (VA) Chiropractic Advisory Committee “to provide direct assistance and advice to the Secretary in the development and implementation of the chiropractic health program” within Veterans Health Administration (VHA). The Committee is charged to advise the Secretary on protocols governing referrals to doctors of chiropractic, protocols governing direct access to chiropractic care, protocols governing scope of practice of chiropractic practitioners, and definitions of service to be provided, as well as to provide advice in the development and implementation of the chiropractic health program. Secretary Principi appointed Committee members in August 2002. The Committee has met ___ times to discuss the specific charges to the Committee. The Committee also has extensively discussed how chiropractic care can effectively be integrated into the existing VA healthcare system, and this document includes recommendations regarding implementation of the chiropractic health program. The Committee will, in a later report, provide input on other matters including the educational training and material required by P.L. 107-135 as well as evaluation and quality measures for the chiropractic care program. This document reflects all opinions as expressed by the members of the Committee. When the Committee did not reach complete consensus on a recommendation or Committee members expressed concerns regarding the recommendation, a Comment section following the rationale for the recommendation presents the other opinions expressed. In instances where Committee members strongly disagreed, a dissenting recommendation follows the recommendation endorsed by the majority of the Committee. A summary of the public comments received and reviewed by the Committee is attached as Appendix D. This document relates only to the provision of chiropractic care and is not intended to restrict other qualified healthcare providers from the use of manipulation in the care of patients when licensed and privileged to provide such care. BACKGROUND: Doctors of chiropractic in private practice are responsible for providing appropriate care within the scope of their licensure, education and competency and for making appropriate referral to other health care providers when necessary. Coverage of chiropractic care by health insurance plans varies as do access requirements. Many health insurance plans require referral by a primary care provider, others require only that the patient use a doctor of chiropractic within the plan, and some permit self-referral to chiropractic care. Individuals who pay for the care themselves may directly access chiropractic care. Collaborative professional relationships between doctors of chiropractic and allopathic and osteopathic physicians exist and continue to increase in the private sector as more patients become interested in chiropractic care and more insurance plans provide coverage. In 1995, the Department of Defense (DoD) initiated chiropractic care through the Chiropractic Health Care Demonstration Project (CHCDP). CHCDP demonstrated that chiropractic care was accepted best when the doctors of chiropractic were incorporated within a traditional medical team housed within the main medical facility, rather than functioning as a separate entity. As in VHA, organizational structures in DoD vary among facilities and thus several different organizational models have been used to integrate chiropractic care into its healthcare delivery system on a permanent basis. The Committee visited the National Naval Medical Center, Bethesda, where chiropractic was organizationally placed within a musculoskeletal service line that also included Rheumatology, Orthopedics, Physical Medicine and Rehabilitation, Physical Therapy, Occupational Therapy, and Podiatry. This arrangement has provided an organizational structure that reflects functional working relationships in the care of patients with neuromusculoskeletal conditions. Within DoD, the Navy’s experience indicated that hiring and placement by local commanders coupled with a strong, visible commitment to success from senior leadership resulted in a smoother integration of chiropractic care into an established traditional medical setting. The DoD experience may be instructive as VHA determines how to integrate doctors of chiropractic into its system. VHA is a comprehensive, integrated care system encompassing 163 hospitals, 850 ambulatory care and community-based outpatient clinics, 137 nursing homes, 43 domiciliaries and 73 comprehensive home-care programs. VHA endorses a primary care model of healthcare delivery, in which each patient has an assigned primary care provider who is accountable for addressing a large majority of the patient’s personal healthcare needs, with referrals to specialists when needed. While complete implementation of the model has not yet been achieved, in part due to the large influx of new patients that VHA has experienced in recent years, it remains VHA’s goal. VHA’s health care system encourages an integrated, interdisciplinary, interdependent and collaborative team approach. The composition of health care teams in VHA varies among sites as a result of differences in the size and configuration of VHA facilities, staffing patterns, and local business and medical practices, but the team approach to care serves veteran patients well, as many have multiple health care needs that overlap and influence each other. The Committee has discussed extensively how doctors of chiropractic can be integrated successfully into the VHA health care system. While local variations in services and organizational structures will play a role in this, the Committee believes the key to successful implementation is a collaborative, cooperative approach to the integration of care. Doctors of chiropractic should be an integral part of an integrated team of providers. The composition of such an integrated team may vary between sites, and members of the Committee have provided several descriptions of integrated settings that may assist VHA in its decision-making process (Appendix B). The goals for VHA’s new chiropractic care program should include: • Patients have appropriate access to chiropractic care. • Doctors of chiropractic, physician providers and other clinicians develop collaborative relationships in order to provide the concurrent patient care necessary to meet the needs of veterans. • Chiropractic care is fully integrated into all of VHA’s missions – patient care, education, research and response to disasters and national emergencies – in an appropriate manner. RECOMMENDATIONS AND RATIONALE: A. Qualifications for Employment Recommendation 1: Education requirement. Degree of doctor of chiropractic resulting from a course of education in chiropractic. The degree must have been obtained from one of the schools approved by the Secretary of Veterans Affairs for the year in which the course of study was completed. Approved schools should be: (1) Schools of chiropractic accredited by the Council on Chiropractic Education Commission on Accreditation or equivalent agency recognized by the U.S. Secretary of Education, or (2) Schools (including foreign schools) accepted by the licensing body of a State, Territory, Commonwealth, or the District of Columbia as qualifying for full or unrestricted licensure. Rationale: The Council on Chiropractic Education Commission on Accreditation (CCE) is currently the accrediting body recognized by the U.S. Secretary of Education for Doctor of Chiropractic programs and single-purpose institutions offering the Doctor of Chiropractic program. CCE has been recognized by the Department of Education since 1974 and P.L. 106-117 (the Veterans’ Millennium Health Care Act), Section 303, defines the term chiropractor as an individual who “holds the degree of doctor of chiropractic from a chiropractic college accredited by the Council on Chiropractic Education.” However, prior to 1993, a second organization, the Straight Chiropractic Academic Standards Association (SCASA) was also recognized by the Department of Education and 13 state licensing boards. Limiting recognition to CCE accredited schools excludes from VA employment licensed doctors of chiropractic who graduated from SCASA accredited schools, those who graduated from chiropractic school prior to the creation of CCE, those who graduated from a school of chiropractic before it achieved full CCE accreditation status, and those who, in the future, might graduate from a school accredited by a new chiropractic accrediting organization recognized by the U.S. Secretary of Education. H.R. 2414, introduced June 10, 2003 to amend title 38, United States Code, to provide for the full-time permanent appointment of chiropractors in VHA, states the educational qualification of chiropractors as “hold the degree of doctor of chiropractic, or its equivalent, from a college of chiropractic approved by the Secretary.” This language, which models that used for other professions in Title 38, if passed, will override the current limitation to CCE accredited schools contained in P.L. 106-117. The language of H.R. 2414 was incorporated into H.R. 2357 and passed by the House of Representatives on July 21, 2003 VA currently accepts graduation from an accredited school or a school accepted by a state licensure board for several health care professions (physician, dentist, optometrist), while the qualification standards for other professions permit education from a school accepted by a state licensing board only for graduates of foreign schools. Given the history of accreditation of chiropractic educational programs, and the existence of a second accrediting body that was recognized by the US Department of Education until 1993, the Committee recommends the acceptance of the broader education standard that will not exclude experienced doctors of chiropractic because of variations in the accreditation of chiropractic schools in the past. Comment: Chiropractic state licensure criteria is not standardized across all states nor has the same examination always been used by all states. As a result, some members of the Committee expressed concerns that licensure may not be adequate to assure the same level of training as those programs meeting the standards of a recognized accrediting body. Recommendation 2: Licensure requirement. Current, full and unrestricted license to practice chiropractic in a State, Territory, or Commonwealth of the United States, or in the District of Columbia. A doctor of chiropractic who has, or has ever had, any license(s) revoked, suspended, denied, restricted, limited, or issued/placed in a probationary status should be appointed only in accordance with existing VA provisions applicable to other independent licensed practitioners. Rationale: Doctors of Chiropractic are licensed as independent practitioners in all US jurisdictions. While some variation in licensure law exists among U.S. jurisdictions, doctors of chiropractic are responsible for providing appropriate care within the scope of their licensure, education and competency and making appropriate referral to other health care providers if necessary. P. L. 106-117 (the Veterans’ Millennium Health Care Act), Section 303 defines the term “chiropractor” as an individual who is “licensed to practice chiropractic in the state in which the individual performs chiropractic service.” H.R. 2414, introduced June 10, 2003, to amend title 38, United States Code, defines the licensure qualification of chiropractors as “be licensed to practice chiropractic in a State.” This language, which models that used in Title 38 for other professions, if passed, will override the current in language in P.L. 106-117 and allow VA to use the same criteria as used for other Title 38 professions, i.e., licensure in any US jurisdiction. The language of H.R. 2414 was incorporated into H.R. 2357 and passed by the House of Representatives on July 21, 2003. Recommendation 3: Other requirements Doctors of chiropractic should be expected to meet the other employment requirements, such as citizenship, English language proficiency and physical requirements, established by VA for all other Title 38 employees. Rationale: Doctors of chiropractic should meet the general employment criteria expected of all other Title 38 employees. B. Scope of Practice Recommendation 4: Scope of Practice Doctors of chiropractic shall provide patient evaluation and care for neuro-musculoskeletal conditions including the subluxation complex within the boundaries set by state licensure, VHA privileging and the doctor’s ability to demonstrate educational training and clinical competency in the areas necessary to provide appropriate patient care. Rationale: P.L. 107-135 states: “The chiropractic care and services available under the program shall include a variety of chiropractic care and services for neuromusculoskeletal conditions including subluxation complex.” VHA Handbook 1100.9, Credentialing and Privileging, states: “The term independent practitioner is an individual permitted by law (the statute which defines the terms and conditions of the practitioner’s license) and the facility to provide patient care services independently, i.e., without supervision or direction.” The VHA privileging process includes verification of educational training and clinical competency. Examples of neuromusculoskeletal conditions appropriate for chiropractic care include, but are not limited to, subluxation, back pain, neck pain, headache, and joint sprains and strains. A more comprehensive but not all-inclusive condition list routinely used in chiropractic education is included in Appendix A. Comment: The term “subluxation” as used by allopathic practitioners refers to the slippage of one bone on another, (i.e., a partial or complete dislocation) which is measurable on a radiograph. “Subluxation complex” or “vertebral subluxation complex (VSC)” are terms specific to chiropractic. These terms are used by doctors of chiropractic to describe a joint that they judge is no longer in proper position and/or is not functioning properly and the adjacent tissues associated with the malposition or altered motion of the joint. Subluxation complex may or may not be visible radiographically and may or may not have specific symptoms associated with it. Not all practitioners agree that the subluxation complex is a clinically definable entity. C. Services to be Provided (Privileges): Recommendation 5: Minimum Initial Privileges Minimum initial privileges, based on the state licensure of the doctor of chiropractic, should include: 1. History taking 2. Neuromusculoskeletal examination and associated physical examination 3. Ordering of standard diagnostic plain film radiologic examinations to include spine, pelvic, skull, and rib series and chest (PA and lateral) 4. Determine appropriateness of chiropractic care for the problem(s) for which the patient is being managed. 5. Provide chiropractic care a. Adjustment b. Manipulation/mobilization c. Manual therapy 6. Manage neuromusculoskeletal care 7. Referral to appropriate provider when chiropractic care is deemed inappropriate or when patient conditions outside the scope of chiropractic care are suspected or detected through examination or as a result of diagnostic testing. Recommendation 6: Other Initial Privileges When permitted by the state licensure of the doctor of chiropractic and the privileging process for the VA facility, additional initial privileges may include: 1. Ordering of additional diagnostic studies a. Imaging studies (e.g., CT, MRI, ultrasound, bone scan) b. Clinical laboratory (e.g., Urinalysis, SMA 24, Arthritis Panel, CBC) c. Other appropriate tests (e.g., EMG, nerve conduction) 2. Order or provide other treatment modalities: a. Physical modalities (e.g., heat, cold, electrical, ultrasound) b. Ergonomic evaluation, posture management c. Orthotics, supportive bracing, taping d. Counseling/education on body mechanics, nutrition, lifestyle, exercise, hygiene. Rationale: There is some variation in licensure law among the U.S. jurisdictions, and a doctor of chiropractic may not practice beyond the scope of his/her individual licensure. The Committee, in Recommendation 5, has identified privileges that all doctors of chiropractic are licensed to provide and recommends that these be permitted throughout VHA in order to provide baseline consistency in practice as chiropractic care is integrated into VHA. In Recommendation 6, the Committee has identified additional privileges that some doctors of chiropractic are licensed to provide, and recommends that these be included in initial privileges when permitted by the licensure of the doctor of chiropractic and the employing facility. The Committee understands that having different privileges for the same category of practitioner within a facility may be confusing, but believes that when consistency in practice within a facility is not an issue, doctors of chiropractic should be used to their fullest legal capability in providing care for neuromusculoskeletal conditions in order to reduce the degree to which patients are inconvenienced by having to see multiple providers for ordering of necessary diagnostic tests or treatments. The Committee also understands that some VA facilities require prior authorization for some diagnostic tests, such as MRIs, and believes prior authorizations required of doctors of chiropractic should be consistent with, but not exceed, existing facility policies. Comment: One member of the Committee recommended that appropriate use of laboratory tests by doctors of chiropractic be monitored to insure that no critical values exist which do not also reach the primary care physician and/or do not receive appropriate follow-up. VHA does not privilege individual practitioners to order diagnostic tests unless they are competent to manage the results appropriately. VHA policy requires that all emergent test results must be immediately communicated to the ordering practitioner by telephone, face-to-face conversation or hand carried report. Abnormal test results that are not emergent but require attention by the ordering practitioner may be transmitted by direct or electronic communication to the ordering practitioner or to a designated surrogate if the ordering practitioner is not available to review results in a timely manner. Electronic communication includes e-mail, fax, or view alerts transmitted to the ordering practitioner. Although notification of the primary care provider is not required by VHA policy, view alerts in the VA electronic medical record system are a mechanism by which emergent values are automatically forwarded to the patient’s primary care provider, as identified in the computer system, as well as to the ordering provider. The primary care provider also may elect to have all abnormal, non-emergent values automatically forwarded. The DoD Chiropractic Health Demonstration Project initially monitored laboratory results for over-utilization and follow-up of abnormal results, but discontinued such monitoring due to lack of positive findings, i.e., no failure to follow-up or refer for abnormal results. Comment: Two members of the Committee wished to have surface electromyography and thermography added to the list of privileges. Respondents to the Job Analysis of Chiropractic conducted by the National Board of Chiropractic Examiners in 2000 rated electromyography was “of little importance” and indicated they rarely referred patient for such studies. Thermography was not rated at all. This type of equipment was not provided for doctors of chiropractic in the DoD Demonstration Project. Doctors of chiropractic wishing to use these modalities could request them in their privileges, but the majority of the Committee does not believe they should be recommended for inclusion in initial privileges. Recommendation 7: Additional Privileges After the initial annual evaluation, the doctor of chiropractic may request additional privileges, which may be granted by the privileging facility consistent with the needs of the facility and the licensure held by the doctor of chiropractic, upon demonstration of appropriate training and competency. Rationale: The Committee understands that the privileges granted doctors of chiropractic will reflect not only the scope of the doctor of chiropractic’s license, but also the mission and resources already available within the facility. In the event that a facility does not initially grant privileges up to the scope of the doctor of chiropractic’s license, training and competency, Recommendation 7 suggests a timeframe for consideration of additional privileges after the facility has had experience in providing chiropractic care. Recommendation 7 also provides for additional privileges not included in Recommendation 6. Recommendation 8: Publication of Information Letter VHA should publish an Information Letter providing guidance to facilities regarding the recommended privileges approved by the Secretary. Rationale: The chiropractic profession is new to VHA and most doctors of chiropractic practice in private practice settings rather than in health care organizations. An Information Letter that provides information regarding privileging of doctors of chiropractic will assist in providing some degree of consistency in process within VHA. An Information Letter provides guidance rather than a mandated policy. D. Access to Chiropractic Care The Committee did not reach consensus on how veterans should be able to access chiropractic care within VHA. Six members of the Committee favored a referral only system and 5 favored a more direct form of access. Therefore, two recommendations are presented. The Committee also made a third recommendation (Recommendation 10) to allow direct access for newly discharged veterans who had been receiving chiropractic care through DoD in order to ensure continuity of care. Recommendation 9: Access to Chiropractic Care Access to chiropractic care should require referral from the patient’s primary care provider or another VA clinician who is treating the patient for the condition(s) for which chiropractic care is indicated. The referral process should be expedited without barriers. Veterans who have been referred to and have received care from a doctor of chiropractic should continue to have access to the doctor of chiropractic for the continuation of care or treatment, consistent with facility policy for specialty care access. Rationale: VHA uses a primary care model of healthcare delivery, with access to almost all specialty care through referral. Allowing direct access to chiropractic care would create a specific exception to that overall model. It has not been VHA’s practice to permit a patient to receive specialty care upon request; rather, another clinician, usually the patient’s primary care provider, must refer the patient. It is felt that the patient’s primary care provider, or another provider who has evaluated the patient, has the best knowledge of the patient’s overall health status and potential contraindications to chiropractic care. Mandating that patients should be able to receive chiropractic care upon request may be poorly received by VA facilities, and may create demands for direct access to other specialty care. Allowing direct access for only chiropractic care may also create animosity toward a new program and interfere with the successful integration of chiropractic care into VHA. The successful integration of chiropractic care into the DoD healthcare system was heavily dependent upon support from upper management and placement of doctors of chiropractic within a health care team where collaborative relationships developed. Although there is anecdotal evidence some VA physicians have significant anti-chiropractic biases, many others do not. Some have indicated openness and acceptance of chiropractic care as evidenced by referrals for fee-basis chiropractic care. Still others are unfamiliar with chiropractic care and have no experience in collaborating with doctors of chiropractic. Integrating doctors of chiropractic into a health care team and using existing operating procedures for collaboration will most likely lead to acceptance of chiropractic care within VHA. (See Appendix B for descriptions of models of integration.) Creating a different model of care delivery for chiropractic will tend to separate and isolate the doctors of chiropractic, with the detrimental effect of decreasing the professional interactions that will lead to greater collaboration and acceptance. While new enrollees currently experience long delays in accessing primary care, existing patients are less likely to encounter significant delays in obtaining routine appointments. Patients with new acute conditions have access to urgent care or, in some facilities, same day appointments. Because the primary care provider or another provider who has been seeing the patient will have previously examined the patient and know the patient’s history, the referral process should not cause significant delays. Some members believe permitting direct access to chiropractic care may lead to patients attempting to use that access to circumvent the primary care backlog, with expectations that doctors of chiropractic can then move them to the head of the line for non-chiropractic care. One member believes that establishing a policy where veterans may self-select chiropractic care may represent a mechanism for doctors of chiropractic to function as primary care providers. Some members also expressed concerns that allowing direct access would quickly overload the capacity to provide chiropractic care. Dissenting Recommendation: VHA facilities should establish processes that will ensure patients are adequately informed about treatment options, including chiropractic care, when presenting to urgent care with acute neuromusculoskeletal conditions appropriate for chiropractic care, when calling to request a primary care appointment for acute neuromusculoskeletal conditions, or when receiving care for difficult, chronic and otherwise unresponsive neuromusculoskeletal conditions. Patients presenting with neuromusculoskeletal complaints who prefer chiropractic care as their treatment option should be referred to a doctor of chiropractic for evaluation and care. Rationale: VHA Notice 99-02, Shared Decision Making, dated June 15, 1999, defines shared decision making as “…the case for letting patients decide which choice is best….A process by which patients are educated about likely treatment outcomes, with supporting evidence, and engaging with them in deciding which choice is best for them, taking into account their preferences, values and lifestyles. ” Patients who present to urgent care or who call for a primary care appointment for acute neuromusculoskeletal conditions, as well as patients with difficult, chronic and otherwise unresponsive neuromusculoskeletal conditions should be provided with complete and unbiased information regarding evaluation and treatment options, including chiropractic care, and be permitted to make a choice regarding their health care. Established patients known to the provider and who are absent any “red flags” or overt contraindications for receiving chiropractic care should be referred appropriately. New patients presenting to urgent care, or established patients who come in after normal hours and are seen by a provider who does not know them, will be examined by the provider on duty, provided information on treatment options, and then referred according to their preference for treatment. Other treatment regimes should not be required before referral for chiropractic care when that is the patient’s preference. Then, if chiropractic care is selected, the doctor of chiropractic will conduct an evaluation and, if chiropractic care is appropriate, provide treatment as indicated. Most of the chiropractic members of the Committee believe veterans should be able to select and have easy access to chiropractic conservative care interventions for acute neuromusculoskeletal conditions and to chiropractic consultation for difficult, chronic and otherwise unresponsive neuromusculoskeletal conditions. This approach would allow patients to access chiropractic care for acute neuromusculoskeletal conditions in a timely manner without utilizing scarce primary care capability. Most of the doctors of chiropractic on the Committee continue to have serious concerns that some VA physicians have significant anti-chiropractic biases, will not refer patients, and will continue to impose barriers, such as requiring other treatment regimes, before referring patients for chiropractic care. They believe requiring the veteran to obtain a primary care appointment and referral may result in the veteran being unable to obtain chiropractic care in a timely manner. While VHA endorses and is moving toward a primary care model of healthcare delivery, with access to almost all specialty care through referral, local variations still exist. These variations result from differences in the size and configuration of VHA facilities, staffing patterns, and local business practices. Currently, patients experience lengthy delays for enrollment for primary care and/or availability of primary care appointments. While VHA is diligently striving to reduce those delays, they remain a fact of life. The result is that patients may be unable to access chiropractic care in a timely manner. Recommendation 10: Continuity of Care for Newly Discharged Veterans Newly discharged veterans who have been receiving chiropractic care through the Department of Defense while on active duty and who have service-connected neuromusculoskeletal conditions, or who are newly returned from a combat zone, or who have applied for service connection for the neuromusculo-skeletal condition for which DoD provided chiropractic care, should have direct access for continued chiropractic care at a VHA facility. Rationale: Newly discharged veterans who were receiving chiropractic care through the Department of Defense while on active duty should be able to receive continuing care from VHA without delays resulting from being placed on a waiting list for primary care enrollment. Any veteran who, at the time of discharge, is receiving chiropractic care for a neuromusculoskeletal condition, through a DoD provided source, is likely to become service connected for that condition. Some veterans are receiving service connected status at the time of discharge under the Benefits Delivery at Discharge program. Newly discharged veterans who did not have the opportunity to participate in the Benefits Delivery at Discharge program and who have applied for service connected status for the condition that was under treatment by DoD doctors of chiropractic also should be allowed to continue treatment without the delay created by the length of time required for adjudication of the claim. Newly discharged veterans returning from a combat zone are eligible for VA care for two years after leaving active duty even without a service connected disability. The President’s Task Force to Improve Health Care Delivery for Our Nation’s Veterans recently recommended that VA and DoD improve their collaboration and sharing of information in order to improve the processes for transition from military service to veteran status. The need to share health information and improve continuity of care between DoD and VA has been a major focus of VA/DoD Joint Executive Council and has been included in the VA/DoD Joint Strategic Plan that was approved April 15, 2003 by the Joint Executive Council. Comment: One member voiced concern that this might create a large pool of people who would attempt to circumvent VHA’s normal referral process by applying for service connected benefits in order to continue to receive chiropractic care without a primary care provider. Recommendation 11: Inpatient Care Doctors of chiropractic may see inpatients, including patients in VHA’s long term care facilities, upon referral from another VHA provider, but will not have admitting privileges. Rationale: Almost all chiropractic care in the private sector is provided in outpatient settings. If chiropractic care is indicated during an inpatient stay, the attending physician should request it through the consult process. Recommendation 12: Chiropractic Care in Community Based Outpatient Clinics (CBOCs) Chiropractic services should be provided in a CBOC when the parent facility determines that the need exists and when the resources are available to provide such services. The existing fee basis program can be utilized if staff or contract doctors of chiropractic are not available at the CBOC. Rationale: VHA’s CBOCs vary in size and resources. Decisions regarding provision of chiropractic care in CBOCs should be made as a part of overall facility/VISN planning for optimum provision of services. Chiropractic services provided at CBOCs will use the same guidelines and protocols as the parent facility. Recommendation 13: Fee Basis Care Chiropractic care should continue to be available through the fee-basis program. An evaluation may be required prior to authorization of fee-basis care; however, the authorization mechanism should be consistent with the requirements for all other fee basis authorizations within the facility. Rationale: Chiropractic care should continue to be available to patients who live in areas distant from a VHA facility providing chiropractic services. Recommendation 14: Occupational Health Programs Doctors of chiropractic can be utilized in the VHA facility’s occupational health program. Rationale: At the National Naval Medical Center (NNMC), Bethesda, the doctors of chiropractic participate in the occupational health program by providing chiropractic care for work-related injuries, providing workplace ergonomic evaluations and recommendations, and providing classes in back care and ergonomics. The chiropractic staff believes that their initial involvement in treating NNMC staff played an instrumental role in acceptance of chiropractic care at that facility. This recommendation is offered as an option that individual facilities may wish to consider. NNMC is different from VA facilities in that many of the NNMC personnel are active duty military, and receive all of their health care there. VHA personnel are civilian employees who are covered under the Federal Employee Compensation Act (FECA). While VHA would be able to bill Department of Labor for treatment of work-related injuries by VHA doctors of chiropractic, the chiropractic services that may be reimbursed are limited by the FECA to “treatment consisting of manual manipulation of the spine to correct a subluxation as demonstrated by X-ray to exist.” Comment: Two members of the Committee do not agree that this recommendation should be included, as it does not pertain to providing services to veterans. While VA employees may receive treatment of work-related injuries at a VHA facility if they wish, availability of such care is limited by the capacity of the treating service to provide services to employees without interfering with the care of veterans. A number of Committee members believe it is unlikely the doctors of chiropractic will have time to evaluate or treat employees or to teach classes. There was strong disagreement from one member regarding the provision of ergonomic evaluations or classes by any provider, as there is no evidence that such evaluations and classes lead to any health gains and some randomized trial evidence indicates such classes lead to increased back pain claims. E. Referrals to and from Doctors of Chiropractic Recommendation 15: Screening of Patients The doctor of chiropractic should screen patients to identify the following “red flags” or contraindications to manual therapy. a. Possible fracture from major or minor trauma in an osteoporotic patient. b. Possible tumor or infection in patients with a history of cancer, recent fever, unexplained weight loss, recent bacterial infection, IV drug abuse or immune suppression c. Possible cauda equina syndrome noted by saddle anesthesia, recent onset of bladder dysfunction, progressive neurologic deficit or major motor weakness in the lower extremity (not sciatica), unexpected laxity of the anal sphincter or perianal/perineal sensory loss. Rationale: The presence of these conditions suggests the need for medical consult prior to receiving chiropractic care. Recommendation 16: Referral Service Agreements VHA should encourage the development of referral service agreements between doctors of chiropractic and both primary care and other specialty providers regarding the types of conditions appropriate for referral to chiropractic care, and the pre-referral testing that will be useful to optimize the provider’s time. The authorization mechanism for chiropractic referrals, follow-up, and recurrent care should be consistent with the facility’s business practices for other referrals. Rationale: In VHA models of health care delivery that do not allow direct access to specialty care, the goal of the referral process is appropriate access to chiropractic care for veterans with acute or chronic neuromusculoskeletal conditions (to include the subluxation complex) amenable to chiropractic care. A number of VHA facilities have developed service agreements to expedite the referral process. Chiropractic patients typically present with a wide variety of neuromusculo-skeletal complaints; however, the large majority of patient complaints are related to back pain, neck pain, headaches and peripheral joint pain. (See Appendix A.) While VHA’s electronic medical record facilitates communication among multiple providers, development of service agreements can be used to clarify expectations regarding coordination of care and case management. Development of service agreements may also assist in the joint education of doctors of chiropractic and other VHA providers regarding the provision of care for neuromusculoskeletal conditions and the subluxation complex within VHA. Comment: The subluxation complex (or vertebral subluxation complex) is an entity unique to chiropractic, as recognized by many State practice acts. Many chiropractic techniques are designed specifically to care for the subluxation complex, which may or may not be associated with neuromusculoskeletal symptoms (i.e., the subluxation complex may not be symptom specific or symptom dependent). Some members of the Committee do not agree that this is a clinically definable entity. Comment: Chiropractic members of the Committee believe that patients presenting with vertebral malposition, abnormal spinal segmental motion, soft tissue tenderness and compliance, and asymmetric or hypertonic muscle contractions, are appropriate for referral to a doctor of chiropractic. Non-chiropractic members of the Committee believe that physical therapists, physiatrists or doctors of osteopathic medicine also are qualified to provide evaluation and care. Comment: Chiropractic care often requires multiple patient encounters over a period of time. Patient response may range from complete recovery after a single treatment to a stabilization of the patient’s condition without total resolution of the problem. It is the opinion of some chiropractic members of the Committee that, in the latter case, patients often benefit from periodic care over an indefinite period of time. They believe that while such an ongoing treatment regime may seem counter to effective case management, in many cases, the alternatives – no care or more aggressive care – may leave the patient in a more debilitated condition or involve more expensive or invasive medical care. Other Committee members insist that there is no convincing evidence that periodic chiropractic care over an indefinite period of time provides any health benefit or can prevent the use of other health care procedures for any health condition. Recommendation 17: Referrals from Doctors of Chiropractic Doctors of chiropractic may make referrals to other VHA services and/or providers as appropriate, subject to facility protocols. Rationale: In some cases, doctors of chiropractic may need to refer to other providers for specific services, e.g., orthotics or supportive bracing, if direct provision of those services are not within the privileges of the doctor of chiropractic, or social work service for family issues. The doctor of chiropractic also should have the ability to request further diagnostic evaluations and medical consultations with appropriate services (including specialists) within the VHA facility or system if potential contraindications to chiropractic care are identified. The doctor of chiropractic may encounter situations in which a patient presents with a medically urgent condition that requires immediate referral. Making such referrals directly when the need becomes evident during a patient visit will expedite appropriate intervention. F. Integration of Chiropractic Care into VHA Recommendation 18: Coordination of Care The doctor of chiropractic and the patient’s primary provider, in conjunction with other appropriate VHA providers, should develop a collaborative treatment regime when patients present with concurrent neuromusculoskeletal and non-neuromusculoskeletal problems. Rationale: The VHA health care system encourages an integrated, interdisciplinary, interdependent and collaborative team approach to patient care. A holistic, integrated approach is essential for many VA patients who have multiple health problems. Recommendation 19: Co-management of Care As a member of the VHA health care team, doctors of chiropractic should co-manage patient care for neuromusculoskeletal conditions as appropriate, along with the patient’s primary provider, other team members, and specialists. Rationale: Doctors of chiropractic should provide co-management of care when patients present with concurrent complex neuromusculoskeletal and non-neuromusculoskeletal problems. Recommendation 20: Placement of Doctors of Chiropractic within a Health Care Team Doctors of Chiropractic should be integrated into the VHA health care system as a partner in a health care team. Rationale: The Department of Defense Chiropractic Health Care Demonstration Project demonstrated that chiropractic care was accepted best when the doctors of chiropractic were incorporated within a traditional medical team housed within the main medical facility, rather than functioning as a separate entity. The Committee describes several models of integration in Appendix B. Decisions regarding placement should consider the functional working relationships appropriate to the care of patients with neuromusculoskeletal conditions in the facility. Teams may be organizationally defined or exist in a functional capacity. The doctor of chiropractic should be a part of whatever team is most likely to deal with initial presenting complaints related to the neuromusculoskeletal system. Recommendation 21: Site Selection The VISN Clinical Managers should provide recommendations for sites they believe will be most successful in integrating chiropractic care into a facility while meeting the needs of veterans. Rationale: P.L. 107-135 requires that chiropractic care be offered at a minimum of one VHA site in each VISN. Site selection for the initial placement of doctors of chiropractic should, to the extent possible, be driven by the interest and acceptance of chiropractic at facilities in each VISN, as well as by the most advantageous use of resources. Recommendation 22: Doctor of Chiropractic Staffing Each facility providing chiropractic services should have enough doctors of chiropractic on staff to provide patient care. Patient volume may determine whether the positions would be full-time, part-time, or contract. Rationale: Customarily, at least two doctors of chiropractic are necessary to be able to provide coverage and continuous patient care during vacations or other absences, and to provide for peer quality review. The DoD Chiropractic Demonstration Project provided two doctors of chiropractic at each site. Additional doctors of chiropractic may be required based on patient demand, subject to availability of VHA resources. Recommendation 23: Support Staff Personnel functioning as chiropractic assistants should come from existing job classifications, receiving additional on-the-job training from the doctor of chiropractic. Clerical staff for scheduling and other administrative clinic duties will also be needed. Rationale: Chiropractic assistants provide assistance in patient care, similar to that provided by nursing assistants in other clinics. Facilities have the latitude to write new position descriptions, which are then locally classified under existing job series and titles. Clerical staff may be shared if the doctors of chiropractic are co-located with collaborating providers, but the addition of a new service and additional providers may require additional clerical support. Recommendation 24: Space Clinic space assignments should be consistent with existing provider space assignments. Ideally, each examination room should be 12 by 20 feet and contain a sink. Rationale: The space required for a chiropractic examination table is larger than that required for most general medical examination rooms and more consistent with that found in a physical therapy or physical medicine area. The standard chiropractic examination table is 2 feet by 7 feet 5 inches, and sufficient space must be available on all sides for the doctor of chiropractic to move about during treatment. Desirable clinic space requirements include a reception/waiting area (which can be shared with other clinics) and two examination/treatment rooms per doctor of chiropractic. As has been noted for primary care clinics, an excess of two treatment rooms facilitates the ability to see a greater number of patients. Office space for the doctors of chiropractic should preferably be in close proximity to the patient care area. Recommendation 25: Co-location with Collaborating Providers and Services Where feasible, the doctors of chiropractic should be located with or near collaborating providers or services. Rationale: Co-location will facilitate communication and interaction with other providers and enable sharing of reception/waiting space, administrative support staff and space, and potentially some equipment. It is, however, important that providing space for chiropractic care not penalize or create hardship for other services. Recommendation 26: Equipment Chiropractic adjusting tables and specialized diagnostic evaluation equipment particular to chiropractic needs will be needed. See Appendix C for list of equipment and supplies needed for each examination room. Rationale: In addition to standard office and examination equipment, some specialized equipment is needed for chiropractic evaluations. Chiropractic table types vary with some designed for specific types of care. Facilities should consult with the doctors of chiropractic before purchasing tables. Comment: Two doctors of chiropractic on the Committee wished to have equipment for surface electromyography and thermography added to the equipment list in Appendix C. Respondents to the Job Analysis of Chiropractic conducted by the National Board of Chiropractic Examiners in 2000 rated electromyography as “of little importance” and indicated they rarely referred patient for such studies. Thermography was not rated at all. This type of equipment was not provided for the DoD Demonstration Project. This equipment would be needed only if doctors of chiropractic received privileges to perform these tests. See Recommendation #6. Recommendation 27: Orientation A standardized orientation program on how chiropractic care is to be integrated into VHA should be developed and presented to clinical and administrative staff at each facility prior to the actual implementation of a chiropractic service. VHA should develop a basic orientation program for doctors of chiropractic that can be modified for differences in facilities. Rationale: VHA staff will need an orientation regarding the availability of chiropractic care, including how patients may access the care. Doctors of chiropractic will also require orientation to VHA, including orientation to the services provided at the facility and care processes, in addition to the general orientation all new employees receive. Assignment of mentors who are accepting of chiropractic care to the new doctors of chiropractic may assist in orientation and integration. Recommendation 28: Ongoing Education of Providers Doctors of chiropractic should participate in facility interdisciplinary educational activities in order to encourage collaboration and gain familiarity with the care provided by other services. Rationale: Once the chiropractic service has been implemented, additional interdisciplinary educational encounters will need to be provided to address new concerns or questions as well as to encourage collaboration among staff. Observation and participation in hospital rounds and patient care conferences may assist doctors of chiropractic in enhancing current skills as well as continuing to educate them regarding the variety of veteran patient conditions and needs. In addition, these educational encounters will serve to inform other professional staff regarding the services provided by doctors of chiropractic. Recommendation 29: Education of Patients VHA will provide standardized information to patients regarding the availability of chiropractic care. Each VISN will provide information to patients on how to access chiropractic services within the VISN. VISN Directors should assure the widest dissemination possible using multiple modalities. Rationale: VHA published a patient education brochure regarding chiropractic care in May 2001,and distributed it through the VISN Clinical Managers. It is unclear how widely it was used, and many patients who have inquired about chiropractic care report that they have never seen it. VHA should make all veterans aware that chiropractic care is a part of its Medical Benefits Package. The Committee will provide recommendations at a later time regarding content and methods of distributing educational materials. Comment: One member of the committee stated that the information provided to patients should provide a “balanced perspective on the evidence” of the effectiveness of chiropractic care to insure patients are able to make informed decisions. Recommendation 30: Quality Assurance Chiropractic care should be incorporated into each facility’s quality assurance program. Rationale: Chiropractic care should conform to VHA quality assurance processes in a manner that is consistent with other providers/services and the requirements of the Joint Commission on Accreditation of Healthcare Organizations. The Committee will provide recommendations at a later time regarding quality measures for the chiropractic care program. Recommendation 31: Performance Measures VHA should develop performance/outcome measures for chiropractic care. Rationale: VHA’s experience has shown that the use of performance/outcome measures is useful in improving the quality of care provided to veterans. The Committee will provide recommendations at a later time regarding performance measures. Recommendation 32: Evaluation of Chiropractic Care Program A formal evaluation of the challenges and benefits of providing chiropractic care within VHA should be completed by the conclusion of the third year of implementation. Formal progress reports should be completed at least annually. Rationale: This evaluation should include the variations in organizational placement and models of delivery utilized across the VISNs and a determination of how these variations impacted the implementation of the chiropractic service. Data to be analyzed should include, at a minimum, the number and characteristics of patients receiving chiropractic care, waiting times for access to chiropractic care, and the impact on the use of the fee basis program for chiropractic care. It is essential that evaluation factors be established and data collected in a prospective manner so VHA managers and doctors of chiropractic will be able to use the data for program improvement. Mechanisms should be established to enable the sharing of information regarding successful implementation strategies as well as lessons learned. The Committee anticipates that Members of Congress will request such data. Therefore formal progress reports should be produced at least annually. Recommendation 33: Medical Staff Voting Privileges All doctors of chiropractic, once credentialed and privileged by a VHA facility, should be members of the Medical Staff and have full voting privileges. Rationale: To fully integrate chiropractic care into the VHA healthcare system, doctors of chiropractic should be full voting members of the Medical Staff. In most VHA facilities, both podiatrists and optometrists are voting members of the medical staff. Comment: Two members of the Committee stated that medical staff voting privileges should be at the discretion of the local facility and consistent with existing VA guidelines. Recommendation 34: Continuing Education Doctors of chiropractic employed by VHA should be expected to obtain continuing education as required for the maintenance of licensure and competency. VA should fund such training in accordance with existing VA policy. Rationale: VHA expects all professional staff to maintain and enhance competency through continuing education programs. Doctors of chiropractic should be able to access funding for educational programs in the same manner and to the same degree as other staff. Recommendation 35: Oversight and Consultation for the Chiropractic Program VHA should create a mechanism for providing oversight of and consultation on the implementation of chiropractic care. This may be accomplished through the appointment of a chiropractic advisor, similar to the position of the physician assistant advisor or the directors of podiatry and optometry, or a field advisory committee. Rationale: All other professions have representatives to provide advice and input to the Chief Patient Care Services Officer and the Under Secretary for Health. A structure for obtaining input from practicing doctors of chiropractic is essential to the success of the chiropractic care program within VHA. All current occupational representatives within Patient Care Services are field-based and perform these duties on a part-time basis. A full-time chiropractic advisor/director position could occur only as a VACO position, and there are distinct benefits in having a field-based practicing clinical doctor of chiropractic in this position. As a profession new to VHA, it will be important for the person in this position to have a hands-on working knowledge of VHA operations. In addition, field-based positions allow for the recruitment of the best-qualified individuals rather than just someone who is willing to move to Washington, DC. Comment: Two members of the Committee recommended a field advisory committee with a rotating chair. Two members of the Committee suggested that, given the challenges associated with the system-wide implementation of a new and somewhat controversial program, an office for chiropractic oversight and advisement at the Central Office level should be considered. Recommendation 36: Committee Membership Doctors of chiropractic should be included in the membership of appropriate facility, VISN, and national clinical and administrative committees, work groups and task forces in a manner consistent with the participation of other providers. Rationale: Doctors of chiropractic should provide input through membership on committees, work groups and task forces that discuss, evaluate or make recommendations regarding or otherwise impact the provision of chiropractic care. Recommendation 37: Academic Affiliations VHA should provide opportunities for educational and training experiences for senior chiropractic students and recent graduates from chiropractic programs, consistent with graduate preceptor programs sponsored by chiropractic educational programs. These educational experiences should expose the student to a wide range of services provided in the VHA facility to broaden the participant’s understanding of clinical care and to help the student to experience chiropractic care in a multidisciplinary setting. Rationale: Health professional training is one of VA’s missions. VHA is noted for its leadership in providing clinical experiences for a variety of health care professions. Recommendation 38: Research VHA, in conjunction with its chiropractic providers and chiropractic educational programs, should conduct clinical research relevant to the type of conditions and services provided by doctors of chiropractic. Emphasis should be placed on common service connected conditions. Research related to integration of multidisciplinary providers into teams should also be undertaken. Rationale: Neuromusculoskeletal conditions are among the most common reasons for service connected status. VHA has a unique opportunity to develop research programs to evaluate the efficacy of chiropractic care in the treatment of these conditions as well as to evaluate the dynamics of developing and integrating multidisciplinary teams. APPENDIX A CONDITIONS COMMONLY SEEN BY DOCTORS OF CHIROPRACTIC (Not all inclusive) Chiropractic patients typically present with a wide variety of neuromusculo-skeletal complaints; however, the large majority of patient complaints are related to back pain, neck pain, headaches and peripheral joint pain. Doctors of chiropractic commonly manage the conditions on this list, which is provided as information for persons not familiar with the scope of chiropractic practice. This list does not imply that only doctors of chiropractic can manage these conditions or that other health care providers are not trained to manage these conditions. One Committee member stated that there are no evidence-based studies to support the therapeutic value of spinal manipulative therapy for some of these conditions. A doctor of chiropractic on the Committee pointed out that a doctor of chiropractic may manage some conditions, such as osteoporosis, with dietary and exercise recommendations, rather than spinal manipulation. The DoD Demonstration Project limited the doctors of chiropractic to treatment of “spine-related neuromusculoskeletal complaints or problems”. Since completion of the Demonstration Project, DoD has expanded the scope of practice for the doctors of chiropractic to “neuromusculoskeletal problems.” 1. Subluxation 2. Chronic pain 3. Strain/Sprain (traumatic) 4. Lumbosacral strain/sprain 5. Intervertebral disc syndrome 6. Sacroiliac syndrome 7. Cervical strain/sprain 8. Symptomatic Scoliosis 9. Thoracic sprain/strain 10. Torticollis (acquired) 11. Myofascial pain syndrome 12. Acute cervical pain 13. Osteoporosis 14. Osteoarthritis 15. Peripheral neuropathies 16. Migraine 17. Posterior facet syndrome 18. Chronic daily headache (tension) 19. Vertebrogenic headache 20. Scheurman's disease 21. Carpal tunnel syndrome 22. Rotary cuff tendonitis 23. Mechanical disorders (thoracic) 24. Chest wall syndrome 25. Tendonitis (traumatic) 26. Disc syndrome (cervical) 27. Bursitis (traumatic) 28. Compartment syndrome 29. Patellofemoral syndrome APPENDIX B MODELS FOR INTEGRATED CARE DELIVERY The following models of integrated care delivery may be useful to VHA administrators and clinical staff in planning to incorporate chiropractic care into VHA facilities. The Committee believes chiropractic care should be integrated into existing multi-disciplinary care delivery models, in a manner consistent with current business processes and the privileging and use of other health care providers. While the different organizational structures and functional processes found among VHA facilities will influence how chiropractic care is integrated at any given facility, the Committee believes the following principles should be used: • The systems and structures used to integrate doctors of chiropractic should facilitate the timely, efficient provision of care to veterans. • Decisions regarding care delivery should focus on the provision of care, not the location of care. • Decisions regarding care delivery should focus on the skills a person needs to provide that care, not the profession of the person. Model 1: Integration into primary care setting or service line. This model replicates a method used for integrating psychiatry into the primary care setting at the West Los Angeles VA and other facilities. A doctor of chiropractic (DC) would be physically located within the primary care area. The DC would see patients on referral from primary care providers, usually on a same day basis for initial evaluation. The DC also would be able to provide immediate evaluation and care for patients who call or walk in with acute neuromusculoskeletal complaints when it is the patient’s choice to see a DC. Patients would be referred back to their primary care provider with specific recommendations if chiropractic care is not indicated. When chiropractic care is indicated, the patient would be scheduled for visits with the primary care clinic chiropractor. The patient’s neuromusculoskeletal condition may be co-managed by the primary care provider and chiropractor, or for patients whose chief complaint is neuromusculoskeletal, the DC may become the principal provider of care with collaboration with other team members as needed. Organizational placement for administrative purposes may or may not be under primary care, and would depend on the overall organizational structure of the medical center (i.e., traditional services vs. service lines.) Advantages: • Doctor of chiropractic is available in the primary care area for short, informal consultations, which may obviate the need for a formal consolation, thus increasing efficiency. • Allows quicker access to chiropractic evaluation and initiation of care. • Improved patient satisfaction as a result of immediate referral during one visit. • Care is viewed as continuous over time rather than as discrete treatment episodes, improving coordination of care across disciplines. • Allows more efficient utilization of the primary care providers. • The doctor of chiropractic becomes a functional member of the primary care team, and as such, is present and provides appropriate input during educational sessions and patient care planning conferences. Disadvantages: • Finding space in existing primary care areas. • The chiropractic area within the primary care setting would become the de facto chiropractic clinic with additional patients being referred from other providers (e.g. orthopedics.) increasing space needs. • Need for duplicate equipment (e.g., chiropractic tables; other modalities such as electrostimulation, ultrasound, hot packs, if DC is privileged to provide these modalities) if there is a separate chiropractic clinic located elsewhere. • Need to coordinate chiropractic visits with physical therapy if DC is not privileged to provide the modalities mentioned above. • Staffing needed to maintain availability of DC if/when patient load increases. Model 2: Integration into a specialty service or service line with liaison to primary care. This model replicates the method used for integrating physical therapists into primary care at the VA Salt Lake City Healthcare System. When veterans present to primary care, the emergency department, or call with an acute neuromusculoskeletal complaint, the provider would be able to page a DC who is available to evaluate the patients. Both providers might examine patients collaboratively and discuss options for care with the patient. When the p

GOVERNOR SIGNS NEW YORK CHIROPRACTIC CONTINUING EDUCATION BILL

Governor George Pataki on August 5, 2003, signed into law A.978/S.316.b, legislation that requires chiropractors to acquire continuing education credit as a condition for licensure re-registration. This law goes into effect January 1, 2004. Many other professions in the state including dentists, podiatrists, pharmacists, attorneys and others already have a CE requirement in place. New York joins 47 other states that require chiropractic continuing education. What this means for doctors of chiropractic: + Each chiropractor licensed in New York, excepting those not engaged in chiropractic practice, is required to complete thirty-six (36) hours of acceptable formal continuing education credit per triennium. 6Twelve (12) of the 36 hours required may include self-instructional course work as approved by the Education Department (in consultation with the State Board for Chiropractic.) + Chiropractors must certify at each triennial registration that they have met the requirements of the law; must maintain adequate documentation of acceptable formal CE to support such certification and be able to provide such documentation to the Department upon request. + Doctors of Chiropractic may obtain all 36 of their approved CE credit all in one year within any triennial period or they can spread them out over the triennial period. - Credits for one triennial period, however, may not be carried over, credited or transferred to any subsequent triennium. + DC’s whose re-registration period expires before the first triennial period following enactment of this legislation will have their CE pro-rated a t a rate of one hour per month. A DC who has not satisfied the mandatory CE requirement will not be issued a triennial registration and may not practice chiropractic until a conditional registration is issued by the Department and the individual agrees to make up any deficiencies which the Department may require. 6 The Department cannot extend conditional registration beyond one year. +Chiropractors who are not engaged in the practice of chiropractic are exempt from the CE requirement. Nonetheless, they must file a statement with the SED declaring their exempt status. Continuing Education versus Continuing Competency Importantly, the legislation contains a provision that insures that the legislation cannot be used by the Education Department as a way to require or implement continuing competency testing or certification for chiropractors. The passage of CE legislation in recent years is partly an effort to staunch any effort on the part of the Education Department to require continuing competency testing as opposed to continuing education as a requirement for re-registration and re-licensure. NYSCA President Acknowledges Team Effort NYSCA President E. Daniel Quatro, DC, acknowledged the efforts of the New York Chiropractic College and its president Dr. Frank Nicchi in passing this important piece of legislation as well as the leadership effort of the New York Chiropractic Council, the NYSCA’s legislative coalition partner. Quatro also acknowledged others who stood behind the effort, including NYSCA’s legislative counsel, Don Mazzullo, Esq., and his team - Ric Scanlon, Mary Anne McCarthy, Esq. Amy Kellogg, Esq. Also acknowledged were NYSCA general counsel Ross Lanzafame, Esq. the Past Presidents of NYSCA Dr’s Leonard Venezia and Arthur Kojes, NYSCA Vice President Dr. Mariangela Penna and Dr. Lynn Pownall, NYSCA Board member. “With their steadfast leadership, help and assistance we were able to stave off the prospects of continuing competency in lieu of continuing education.” Quatro said.

New Mailing Address for Downstate Comp Claims

As part of the Board’s ongoing effort to improve services, increase efficiency, and limit costs, a new centralized mailing address for all mail related to workers’ compensation claims has been established. This P.O. address is in close proximity to the Board’s mail scanning facility in Binghamton, NY. To help the Board improve our efficiency, effective September 8, 2003, all insurers, attorneys, licensed representatives and health care providers involved with claims being processed in New York City, Long Island, Westchester, Rockland, Putnam or Orange Counties must direct all claims related mail correspondence to the following centralized address. Failure to do so could result in unnecessary delays in processing of claims. New York State Workers’ Compensation Board PO Box 5205 Binghamton, NY 13902 All claim related mail for the remainder of the state should continue to be sent to the appropriate district office addresses. All non-claims related mail should be sent to the appropriate department or office.

NEW YORKERS USING EXTERNAL REVIEW LAW ARE WINNING ACCESS TO NECESSARY CARE

Superintendent of Insurance Gregory V. Serio and State Health Commissioner Antonia C. Novello announced that thousands of New York State consumers are exercising their health insurance rights and are winning access to necessary care under the State's External Review Law, according to the latest External Review Report released today. "New Yorkers have been empowered by the External Review Law and are availing themselves of this important appeal mechanism when their essential health coverage is denied by the insurer," Serio said. "Since this Law became effective on July 1, 1999, more than 5,000 consumers have requested external appeals. With an average of 46% of external review cases overturned, this means that over 2,000 New Yorkers have access to health insurance care that would not otherwise have been made available to them. This year’s External Review Report illustrates that under Governor Pataki’s leadership consumers are educated on their health insurance rights and using this knowledge to ensure necessary coverage." "Thanks to Governor Pataki, New Yorkers enjoy the most comprehensive patient protections in America," State Health Commissioner Antonia C. Novello, M.D., M.P.H., Dr.P.H., said. "The success of the external review process demonstrates that patients in our State know their rights and are taking advantage of the opportunity for a prompt, independent and professional appeal when they believe an insurer has made an arbitrary decision. This Law better ensures that medical treatment decisions are made by doctors and their patients, and that New Yorkers receive the quality health care they need and deserve." The External Review Annual Report, released by the State Insurance and Health Departments, provides a comprehensive overview of New York's External Review Program and includes a description of external review results from the past year. The report also provides information about the external review programs of other states and compares the experience of other states to that of New York. Highlights from the report include: The Insurance Department has received 5,000 requests for external appeals, over 1,300 in 2002. Since July 1, 1999, 1,110 denials of coverage by health insurers have been overturned in whole, 267 denials have been overturned in part and an additional 722 denials have been voluntarily reversed by health plans before an external appeal agent rendered a determination. 183 expedited external appeal requests have been assigned to agents for review since July 1, 1999. An appeal must be expedited if the patient's physician attests that a delay in treatment would pose an imminent threat to the patient's health. Agents must render a decision on expedited appeals within three days. In 2002, 44% of medical necessity denials were overturned in whole or in part by external appeal agents while 50% of experimental or investigational treatment appeals were overturned. External appeal requests are submitted to the Insurance Department, which screens requests for eligibility and completeness and assigns the appeal to one of the state's three certified external review agents. The External Appeal Annual Report, applications to request an external appeal, and external appeal information are posted on the Insurance Department’s Web site at www.ins.state.ny.us. The Insurance Department’s external appeal hotline, 1-800-400-8882 assists New Yorkers in filing external appeal requests. The Insurance Department also has staff on-call seven days a week to handle expedited appeals.

NYCC To Offer Acupuncture Program

Seneca Falls - New York Chiropractic College of Seneca Falls, NY, received approval from the New York State Board of Regents to establish upstate New York's first Master of Science programs in Acupuncture and Oriental Medicine. In addition to the action taken by the New York State Board of Regents, the Middle States Commission on Higher Education has accredited the College’s proposed masters degrees in Acupuncture and Acupuncture & Oriental Medicine, as well as its proposed Bachelor of Professional Studies degree. Amending the school's charter to reflect its new programs, New York Chiropractic College will now offer coursework leading to degrees of Masters of Science with majors in Acupuncture and Acupuncture & Oriental Medicine, and the Bachelor of Professional Studies degree with a major in Life Sciences. Graduates from either masters degree program will fulfill a requirement for eligibility to take state licensure examinations for the practice of acupuncture. The College’s primary focus will continue to be chiropractic, and the school’s name, New York Chiropractic College, remains unchanged to reflect its continued emphasis on chiropractic Acupuncture is an ancient healing art that has enjoyed a resurgence of interest as scientific research continues to confirm its health benefits. The therapeutic procedure involves the insertion of fine gold or silver needles into the body's acupoints and rotating them. Electrical signals (electro-acupuncture) may be used instead of manual stimulation, particularly for relief of pain and neurological disorders New York Chiropractic College immediately will start processing applications for enrollment in its new Master of Science Acupuncture and Acupuncture & Oriental Medicine Master of Science programs scheduled to begin in September 2003, and expects an enrollment of approximately 40 students. It is anticipated that students who matriculate full time will take 32 to 36 months to earn their Master’s degree Students will need at least 90 college credit hours to enroll in the Master’s programs. A Bachelor of Professional Studies degree program also will be available to those students without a bachelor’s degree who are accepted for admission in the College’s Acupuncture and Chiropractic programs. For students wishing to be admitted into either the Acupuncture or Acupuncture & Oriental Medicine programs, the College will begin accepting applications in January 2003. Further details regarding the new programs are available at (800) 234-6922, #3040