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ACA- New Jersey

ACA delegate, Frank A. Stiso, DC and member of the New Jersey Chiropractic Forum has invited Drs. Tino Villani and Lou Sportelli to the May 15, 2003 Forum meeting.

The topic will be Triad and how the chiropractic benefit is being handled through them for Oxford Insurance Company.

Patricia Jackson from the ACA will also be present to offer her advice on all aspects of insurance handling and problem solving.

 

IS THERE A CONNECTION BETWEEN THE ACA, TRIAD, & ASHP?

Many of you have questions about Triad and ASHP (American Specialty Health Plans). You wanted to know if the American Chiropractic Association has any business or financial relationship to these companies as Dr. Lou Sportelli, president of (NCMIC), National Chiropractic Mutual Insurance Company, parent company of TRIAD, and Dr. Kurt Hegetschweiler, Chiropractic Advisor to American Specialty Health Plans, were both past presidents of the ACA?

I have official confirmation from Garrett Cuneo, ACA Executive Vice President (see below).

_________________________________________________________________

ACA's LETTER:

April 3, 2003

Frank Stiso, DC

124 Inman Avenue

Colonia, New Jersey 07067-1822

Dear Frank:

Recently, the American Chiropractic Association (ACA) has received inquiries from number of our New Jersey members concerning the relationship between the association, Triad Healthcare (Triad) and American Specialty Health Plans. In the event that you have received similar inquiries, we would like to inform you that the ACA does not endorse these organizations, nor does it have any financial relationship with them or any managed care organization.

Please feel free to pass this information on to any of your members. Thank you for your assistance.

Sincerely,

Garrett F. Cuneo

Executive Vice President

________________________________________________________________________

I also contacted Dr. Lou Sportelli of Triad and president of the National Chiropractic Mutual Insurance Company, the parent company of Triad. The following are the responses from Lou to my questions. I am a Triad participating DC, as many of you are. THE ACA HAS NO FINANCIAL OR BUSINESS ASSOCIATION WITH TRIAD, NCMIC OR ASHP OR ANY OTHER MANAGED CARE COMPANY.

FOR THE RECORD NCMIC, THROUGH LOU SPORTELLI, DC, MAKES SUBSTANTIAL - VERY SUBSTANTIAL CONTRIBUTIONS TO THE ACA LEGAL FUND, OUR LAWSUITS AND MANY OTHER CHIROPRACTIC PROGRAMS TO PROMOTE AND PROTECT THIS PROFESSION.

________________________________________________________________________

The following are my E-mail letters to Dr. Sportelli and his answers that he gave permission to use:

Letter # 1

Dear Lou

I just received a call from a doctor from North Jersey and involved with the Northern New Jersey Chiropractic Society (County Society). He is as upset as I am with the amount of paperwork & telephone calls with Triad. As ACA Delegate, I am receiving daily complaints about Triad & ASHP and how these companies are running the chiropractic benefits for Oxford and PHS. They want to drop out of the ACA as they perceive that there is a connection as you, Kurt Hegetschweiler & Jerilynn Kaibel are prominent ACA figures. Now they are talking about dropping out of NCMIC.

As you know, there is no financial connection between NCMIC, Triad, ASHP & the ACA. The only connection is that many are ACA members.

( Lou) Frank, under the confidentiality issues, I could not obtain any specifics about the Northern NJ DC other than make an inquiry and Triad informed me that he has several care plans submitted and there were no issues relative...some were modified but all were responded to and satisfactorily because Triad did not have a call back. That is about I can tell you on the specifics. However, I am curious because if you are getting calls (don't know how many - sometime 3 angry calls can cause a seemingly quiet day to

appear as if the world caved in. There are simply very few complaints, calls or otherwise negative activity at Triad. Hell Frank, if these doctors have a problem, why not call Triad and not you? I do believe that the number are very small and most are nonparticipating providers who now have a different accountability and they do not like it. They do not like Medicare reimbursement, HIPAA, Care plans and a hemorrhoid either but that is the way things are.

The insanity of the logic or should I say illogic...is what does dropping out of ACA, or dropping their malpractice coverage have to do with the issue of managed care or their displeasure with what is happening in the world? ACA is doing all it can do to help the doctors.....they don't "own" the system.

NCMIC is doing fabulous by retaining its A.M. BEST rating of (A) in these troubled times and malpractice crisis. We provided a dividend which is unheard of today....and provide the best malpractice insurance. So they are going to drop ACA and NCMIC.

If they do not like the managed care programs they are in...DROP OUT!!! No one to my knowledge is "forced" to participate in any managed care plan....IT IS A BUSINESS DECISION...not a professional dispute. They can opt out of Medicare, Medicaid, they can elect not to handle W/C or P/I and they

can do what they want as a doctor. What do they want from you Frank? These doctors stay with ASHP....Why? These doctors do not belong to ACA and yet want services...Why? These doctors only call when they have problems...and most of the time it is financial.

(Frank) Lou, there are too many complaints as to just pass off as malcontents. Personally, we receive many different answers from the people at Oxford for the same question. TOO MUCH PAPER WORK AND TELEPHONE CALLS FOR REJECTED CLAIMS THAT SHOULD NEVER HAVE BEEN REJECTED. My children (3) handle the paper-work, notes etc.

(Lou) Again Frank.....you say too many...how many is that? I simply cannot get excited because a dozen malcontents are unhappy with Oxford or Triad. They need to "Get over it!!!" and focus their energy on positive ways to meet our challenges. Frank the comment below is from this weeks ACA EVP e-mail...

1. MANAGED CARE INDUSTRY TAKES ANOTHER ONE ON THE CHIN: PERSPECTIVE FROM ACA LEGAL COUNSEL In what may be perceived as a landmark decision, The U.S. Supreme Court has again diminished the scope of the ERISA preemption of state laws. On April 2, 2003, the court, in a unanimous decision in the trial of Kentucky Association of Health Plans, et al. v. Miller, shielded from federal ERISA preemption a Kentucky statute which provides that any "health benefit plan that includes chiropractic benefits shall... permit any licensed chiropractor" willing to meet plan requirements "to serve as a participating chiropractic provider to any person covered by the plan."

It says....Hurrah...ERISA is now not defeated ...but it also says that "the doctors can participate......"if they are willing to meet plan requirements"...............well if they are not ...they will not be permitted to participate. How is that different from any other plan? Oxford, Triad, etc. If the doctor does not like the plan............they individually and independently can DECIDE NOT TO PARTICIPATE.... That is their most powerful weapon............ complaining does not solve anything. Either they want to participate or they do not. Nothing is causing them to want to stay. NOW.... Triad and Oxford plan pays the DC better than any other plan in the country.....is more cooperative than any other plan..............and yet they get a bad rap. It is a business Frank. Oxford must operate as a business...Triad must operate as a business...the doctors must operate their practices as a business.

(Frank) Lou, I don't know what else to say to colleagues about the complaints as they are coming in from across the state. How would I know how to answer them? Apparently, the promise they were given to solve them hasn't happened yet.

(Lou) Again I must disagree....give me some specifics and we can work on them........ unhappiness with managed care or health care in general is not something Triad can solve. Here is something for you

Frank............have each and every doctor who calls you...STOP! Tell them...that they must put their specific complaints in writing to you and you will forward them to Triad. They cannot be anonymous or ambiguous...SPECIFICS....specifics...specifics.. AND I AM SURE YOU WILL HAVE MINIMAL TAKERS. I am confident that most of this is Urban legend...it is cool to complain, it is the way things are....but when you ask for specifics they cannot respond. While you are at it ...ask them to put on paper what they think the ACA is not doing and what the ACA should do. Ask them how they would run NCMIC better than it is....and tell them you will send these comments to both organizations.

Sorry Frank..........you know I am responsive....and I consider every legitimate complaint....and I will send you via mail a copy of a recent article by Cooper and Mckee...please read it carefully and let me know what

you think. I have also attached my next DC column for your review. Just a "head-up" on the situation in the "Garden State".

(Lou) by the way.....what is happening in the Garden State...? They are suing CCE???? How insane is that?

(Frank) Lou, our licensing Board, The New Jersey State Board of Chiropractic Examiners is not suing CCE! I believe the lawsuit may involve the Board of Directors of The Council of New Jersey Chiropractors (a state chiropractic organization affiliated with the ICA).

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Letter #2

Dr. Lou:

I received the article "Chiropractic in the United States: Trends and Issues by Richard A. Cooper and Heather J. McKee (Medical College of Wisconsin) Thank you for mailing it.

I have not finished reading the full text but it would be my opinion that anything that comes from a medical college will not be flattering to the chiropractic profession even though they quote sources often. Many of these so-called studies are flawed.

(Lou) Frank - That is the typical response we get in the profession. Don't kill the messenger because you do not like the message. What they have written is how Health Policy People see chiropractic. You or I not liking the document is irrelevant.. that is the point I was trying to make.... Read the document objectively...not through the lens of a DC.) I make no commentary on the document it speaks for itself. Is it flawed yes.. but so what...this is what I am trying to get individuals to see that the criticism we get should be instructive.) We should not recoil because it is correct or flawed...but what can we learn from it to advance.)

(Frank) Lou, I disagree with the assertion that Mercy Guidelines were endorsed by the ACA. My interpretation was that they endorsed the concept of setting fair Standards. These "Mercy Standards" have since been rejected by the ACA, ICA, WCA and every state & county chiropractic organization across America, including The New Jersey State Board of Chiropractic Examiners. To use this "document" to justify denying chiropractic care by Triad or any other managed care insurance company, in my opinion, is without merit. The New Jersey FORUM Standards were unanimously endorsed, not "Mercy".

(Lou) Frank...remember this is what the authors contend.... I will however submit to you that without Mercy. there would be no AHCPR document on Acute Low Back Pain in Adults. Like Mercy or don't like Mercy...Mercy has nothing to do with anything. Guidelines are living documents...and Mercy is now more than a decade old...what does that have to do with anything today? Who said anything about anyone using this document to deny care? The Chiropractic-Trends document had nothing to do with Triad, NCMIC, or any other group. It was sent to you because it is a view of the profession that every chiropractic leader should take to heart.

(Frank) Lou, I also must disagree with the article and their comparisons of Massage Therapy or Home Exercise Programs to Chiropractic. I listened with interest to David Eisenberg, MD, while in San Diego and I do not share his opinions about the Harvard program or his beliefs. I'm not sure what goes on at Harvard Medical School when it comes to chiropractic, but I can certainly tell you what goes on at 124 Inman Avenue Colonia, New Jersey for the past 40 years. It is an insult to be compared to a massage or physical therapist, acupuncturist; and worse to give credence to such dialogue. I can teach an idiot to "rub" or "crack" a back in six weeks or less, but will that person have any idea of the underlying anatomy beneath the patient's skin? That's what separates the men from the boys.

(Lou) Frank...you have your chiropractic protective shield on.... What you like or dislike has nothing to do with what and how the world is moving. Whether it is Harvard, or Stanford, or any other group...the fact remains....Frank...chiropractic has competition in 2003 and it is unlike any other competition we have ever had. Now we can do what General Motors did...and look out their windows and see GM cars....or we can realize that foreign imports are upon us in small, well crafted automobiles. We circle the wagons and shoot inward! What is wrong with you Frank....this has nothing to do with you or your office or your qualifications as a DC. What is does have to do with is what society...the baby boomers are thinking, demanding, and what others who are competing for the same patient population are doing. What separated the men from the boys is how they respond to crisis.... )

(Frank) Lou, it appears that non-chiropractic review companies give us a much more liberal review than our own. This is evident by the recent survey that showed the most complained about managed care entities were: Landmark Healthcare, American Specialty Health Plans (ASHP) & Triad, and not necessarily in that order. It seems we are being eaten by our own. When a patient brings in their benefit booklet it shows they have 30 chiropractic visits per year. It is almost impossible to reach that figure with our "own" "calling" the shots. Who is in a better position to prognosticate on the amount of adjustments it will take to correct a vertebral subluxation, the treating DC, or a DC sitting in a cubicle in San Diego or Sacramento, California whose income depends on holding down costs? It also appears that the "hard data" you guys at Triad are collecting may bury us. It gives the carriers the impression that a disc herniation can be managed in 10 visits or less. These are the complaints and comments that were offered by New Jersey DCs at the recent Triad meetings in Raritan Center and at the Monmouth Ocean County Chiropractic Society meeting. The answers to their questions were never really answered. We were promised that they would be corrected and it appears Triad is making the effort to honor that statement. We are not talking about a few disgruntled DCs. Those rooms were packed. They have legitimate concerns and it is refreshing that Triad came, listened, and will do something. I can't say the same for Landmark Healthcare, as they are the absolute worse! Even the Mercy Guidelines allow more visits than Landmark. Showing us actuarial studies doesn't correct that disc herniation in 10 adjustments or less. I can't do it and neither can anyone else.

(Lou) Again Frank...I do not know where you segued to Managed Care from this document....but I can tell you that the future may not have managed care as we know it...but we will NEVER have care that is not managed. The studies demonstrate that there are proper parameters within which the vast majority of care will fall...the old bell curve...why is it that 99% of chiropractic patients fall outside of the curve...? The disgruntled DC...as I said before do not have to participate...they can opt out!!! They can decide to have their fee paid by the patient...but if their fee is going to be paid by someone other than the patient....they are going to have to succumb to some form of review and clinical necessity. Frank there were several DC's in NY that billed for more than one million dollars!!!!!! to one plan!!! Again I say to you...it is easier to simply eliminate the entire chiropractic profession from a plan than it is to deal with them. Shades of WalMart....who simply elected to eliminate the chiropractors because the evidence showed that they had more people off work and charged more than other providers. How long do you think anyone will allow that to go one. Check the recent WC studies in CA, and elsewhere...the statistics do not bode well for us.

(Frank) Lou, you know I have immense respect and admiration for you. Your CV speaks for itself. You have reached a station in life that is enviable and commands respect. It is also my opinion that at this juncture in your career, you do not want to be remembered as the president of NCMIC, Triad's parent company, with what is being said in New York, New Jersey and Connecticut. The current climate and undertone is tarnishing your image, NCMIC, Triad and the ACA as well. Let's face it you were, and are, a super star with the ACA. What the profession doesn't know about Dr. Lou Sportelli is that through you, NCMIC has donated MILLIONS to this profession, the ACA lawsuits and God knows what else to advance chiropractic. I THANK YOU FOR THAT!

(Lou) Frank...this is a discussion about issues...not about people. I frankly am doing what I know is right...not what some poll says is the right thing to do. I have never lost my moral or ethical compass and I don't intend to stop speaking out about the travesty which some within this profession would have us do...inorder to avoid accountability or responsibility. I am pleased that you have respect for what I have done and likewise...I for you...because you have been there and put your time, effort, energy and commitment into a profession you love.... I love this profession...and my entire 40 year career has been devoted to advancing that profession. Often by having the courage to speak out. I will continue to do what I know in my heart and mind is the best course of action for "me" and for what I believe the future vision of this profession is.

(Frank) Lou, just a heads up from a guy in the profession who has three associates that got used to eating, namely Drs. Michele, Darlene and Frank R. Stiso. This is Frank A. Stiso, DC (THE OLD MAN) I made mine when it was a hell of a lot easier!

(Lou) Frank, they are ethical, honest....and will continue to eat....and be able to look at themselves in the mirror and say...I am an ethical chiropractor doing what is right ....Go back and read my Dynamic Chiropractic article...it is meant to provoke thought.

(Lou) Frank, first I always appreciate the request for distribution. I have sent you the first one a few days ago...and yes you may also share the one I sent you yesterday. However:

The doctors who are looking for an excuse..."any excuse" will not join. They will find a reason not to do what is their professional responsibility even if the galaxies are not lined up. Frank, these doctors who are members of the ACA should be members for many reasons. 1. Because it is your professional responsibility to support your national organization. 2. If you do not like what is happening, change it! I am surprised that most of the elections in the ACA have no contest. They let the same people represent them whom they feel are not doing the job. How does that make sense? Run for the office yourself if you are unhappy, or find someone who more clearly represents your views...but dropping out solves nothing because then you "have no voice or vote."

The entire issue at the moment is to simply remind these very same doctors that the chiropractic managed care organizations were formed as a result of the larger plans wanting to "carve out" chiropractic. "Carve out" means eliminate...or in some way get a handle on what the doctors of chiropractic were doing. That is the genesis of the chiropractic managed care organizations. There really is no need for any of them to exist independently, however the function that they are asked to do "utilization review" and "determination of clinical necessity" would be done IN HOUSE by some DC or other medical director employed by the insurance company. Do they have such short memories that they forget that chiropractic has never functioned truly in the core-benefit programs of any company? This reminds me of the issues relative to malpractice. Doctors of all kinds decided they did not like the way insurance companies were delivering their malpractice. So they started their own!!! The moment they started their own...they now had to "function" like an insurance company and not like a doctors group. Those that did not simply went bankrupt or were acquired by those with expertise in the medical malpractice arena.

(Lou) Frank, you cannot run any business unless you have business expertise. These doctors who are griping...........I do not truly understand what it is they are griping about. There was a short time in our history the decade in the 80's where anything and everything got paid...and that is why we are in the health care crisis we are in today. No one wanted to deal with the problems...so they continued to increase the rates until healthcare is now Unaffordable to anyone. Somewhere along the line the simple equation must come back to health care. It was the only system where the individual paying the bill was not directly involved with the individual providing the service and the individual obtaining the service. How can that system work? Whether chiropractic likes it or not....if it is to be part of the general health care system.....it will have to abide by some ground-rules and regulations. Otherwise chiropractic services will be delivered outside the system...............and some doctors are opting for that method. Some will even survive in that carriage trade environment. Ultimately the same thing will happen to health care that happened to the "collision" portion of your auto insurance. You (the patient) elects to pay a higher premium for a lower deductible and a lesser premium for a higher deductible. It will then be up to the individual to decide which health care provider will give them the best service for the best price with the best quality and outcome. That is the system of tomorrow. We are only in a temporary transition in health care...

Do you think HIPAA is about patient privacy....NO! IT IS ABOUT FRAUD. When everyone is electronically transmitting their claims................fraud detection software will easily determine fraud, abuse and over-utilization. Frank, do the DC's think they are the only health care profession under siege. Ask any medical, podiatric, dental or optometric provider and see what they tell you. It is not only about chiropractic. I believe you are simply looking to remove excuses.....that will never happen..........If the doctor does not want to accept his or her individual responsibility or does not want to part with dues dollars or contributions toward legislation or litigation (which if successful benefit everyone---and they know that) they will find an excuse. It can be Sportelli, Stiso, or Saddam.... Frank, some of the discussion is not rational or reasonable. They are looking to change a system that we do not own........... nor are we a significant player. If chiropractors went ON STRIKE....who would notice??? Do you think people would be dying on the streets? Do you think that major forces would come into play to avoid the chiropractic strike? Hell no! The profession can be eliminated from programs and no uprising will take place. Chiropractors thought that their patients were loyal to them and would never leave them....and when the early networks came into play (the closed ones) patients left their old time beloved chiropractor for 50 cents. It's about money ...when looked at by the patient. It's about money...when looked at by the doctor. It's about money when viewed from the carriers vantage point. I would ask a simple question to the doctors in New York primarily and New Jersey to a lesser degree...Would they rather not be covered at all......? If so that is an easy request to fill. These doctors need to get some "passion" and "desire" to advance the collective profession...........and that is why they belong...not to have some self serving motive.

I think you are not going to ignite many doctors with telemarketing.... You cannot be a little bit pregnant....you are or you aren't..... that is the way it is with commitment....you have it or you don't.

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(Frank) Lou, I know the articles you forwarded are trying to be objective and I do view it from a DC lens. I was trying to tie this in with what is going on with Triad, Landmark & ASHP. Other carriers do not put this much pressure on us - why our own? How do you substantiate that?

Do I have your permission to share this and other answers with colleagues that ask me these same questions? They are threatening to drop out of the ACA & we presently are targeting New Jersey, Ohio, Connecticut and Pennsylvania with our telemarketing. Im doing the best I can for New Jersey DCs and I don't want to give these guys any excuses not to join and regrettably that is what is happening as they use you & Kurt as past ACA presidents. They think there is a link between your companies and the ACA.

 

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If Chiropractic Were a Business Would You Invest In It?

A View Beyond the AMA

By: Louis Sportelli, D.C.

DYNAMIC CHIROPRACTIC ARTICLE

Perhaps after 40 years of practice and having had the opportunity to serve in many capacities within the profession, my view of the current status of the profession has been altered by the changes witnessed throughout my career. Some of the developments have been monumental seminal events advancing the profession and others have been truly actions which border on professional genocide. This column is meant to hopefully provide a non-emotional review of a recent article entitled Chiropractic In The United States--Trends and Issues. My hope is that this article will provoke discussion among the leadership of the profession from every aspect of involvement.

Like the decades-long standoff between the United States and the former Soviet Union, chiropractors have grown accustomed to, but not comfortable with, the scrutiny and criticisms of the allopathic political machine. And as with the end of the Bolshevik experiment in 1989, the resolution of the Wilk case has brought the profession a new array of forces, positive and negative, to contend with. It is important that we understand the new political and economic climate that we operate in, for the relatively simplistic old politic is no more and will never be again.

"Sore Throat" has given the AMA a long bout of laryngitis, but in its place, a variety of new voices can be heard. Weve been pleased by some, such as the AHCPRs 1994 endorsement of spinal manipulative therapy (SMT) for acute low back pain in adults (1), the Manga Report on the costs of chiropractic care (2), and several positive reviews by the RAND Corporation (3-5). In addition, our ears have burned with new rounds of scathing criticism from sources such as the National Council Against Health Fraud, the National Association of Chiropractic Medicine, and books such as Chiropractic: The Victims Perspective, (6) Spin Doctors (7), and the most recent show by Penn & Teller (9). These harken back to Ralph Lee Smiths 1969, AMA-inspired At Your Own Risk (8) and prompt a severe emotional reaction which can interfere with clear thinking.

Amidst this din of praise and condemnation, we may fail to hear the feedback from a new type of scrutineer, the health care policy researcher. Health care policy has become a profession in its own right and draws upon the knowledge bases of several fields, including actuarial (statistical) analysis, clinical epidemiology, history, economics, political science and sociology. Although health care policy researchers have their own prejudices (as do we all), they usually turn their gaze upon chiropractic without the condemnation and animosity that we have come to expect from political medicine. With respect to chiropractic, their goal is not to "contain and eliminate," but rather to understand our position within the health care marketplace and to plan in the interest of society as a whole.

A recent discussion of "Chiropractic in the United States: Trends and Issues" (10) from the Health Policy Institute at the Medical College of Wisconsin is perhaps illustrative of the less hostile, but far more methodical examination that we have increasingly undergone in recent years. This 32-page report summarizes a variety of contemporary issues confronting the chiropractic profession, including reimbursement, managed care, cost analysis, practice patterns, philosophy, patient-centered care, research, and emerging competition. Fully one-third of the article is taken up by the references which support the authors contentions. We may and will disagree with some or much of the perspective offered, but it is clear that Cooper and McKee (10) have done their homework. Theirs is a sobering summary of where we are collectively, and what may lie ahead:

"In previous decades, chiropractors did not want their profession to be considered a form of medical practice. Even now, many see themselves as practitioners of a distinct art. Having crossed the chasm into the reimbursed world of health care, they must now prove their quality, effectiveness, and value. The profession is buttressed by satisfied patients and sympathetic politicians and by the general longing for someone who will listen and be supportive. However, as our aging nation struggles to define the health care system that it can afford, it is uncertain whether this will be enough."

Many who will read this article will be moved immediately to condemn it because of its early references to such things as the "studies" that purport to show that certain studies show a comparability of the costs of chiropractic versus medicine. These "studies" only compared office visit fees and did not show the costs of hospitalization, surgery (necessary or unnecessary), or medications. In other words, they were clearly invalid studies. Then there is the $1 educational booklet "study" by Cherkin, as if it had value. Does this article by Cooper, et. al., have limitations? Yes, but putting the obvious aside, the outside world will be viewing our profession as these individuals have done.

Many of our traditional shortcomings still haunt us. There is not enough research. Although we have enjoyed success in outcome studies of patients with some musculoskeletal disorders, the mosaic of outcomes has many missing pieces. Claims for superior benefits of chiropractic care even for musculoskeletal conditions are being questioned by independent researchers at this time, and competing claims for benefit from practitioners of massage therapy, exercise regimens and behavior therapy find empirical support in the available data base. The cost-effectiveness of chiropractic services is also increasingly being challenged by these competitors. And beyond Type M conditions, our researchers have barely scratched the surface of what must be investigated. Despite the reasons, albeit economics, human resources, politics, the facts do not change. Notwithstanding repeated demonstrations of patients superior satisfaction with "the chiropractic encounter," Cooper and McKee remind us that "having gained greater entrée to third-party reimbursement, chiropractic has been forced to face the challenge that there cannot be two standards, one for chiropractic and another for conventional medicine." Satisfaction is but one piece of that mosaic of outcomes which will increasingly determine health care policy.

As ever, our inability to agree among ourselves about who we are and what we do limits us. Do we wish to be seen as complementary, alternative, or both? Are we primary care physicians, integrative practitioners, musculoskeletal specialists, or biotheological practitioners? Are we broad-spectrum, alternative care providers who combine significant manipulative skills with modalities such as massage, electrotherapies, acupuncture and nutritional counseling? Or are we non-diagnosing, subluxation specialists with no limitations and for whom prevention means life-long treatment? If the former, do we recognize the potential loss in cost-effectiveness that unrestrained use of "modalities" and access may bring? If the latter, do we appreciate the reduction in legitimacy and professional autonomy that the narrowest of chiropractic orientations implies? Do we seek integration with, or insularity from, the wider health care system? Our lack of coherent self-definition is not lost on policy makers. It will be a requirement to advance in the 21st century health care system, which needs to be done soon.

Where once we enjoyed the luxury of relatively few competitors in our domain, the field has grown to include many medical and non-medical practitioners. Manual therapies and related treatments for NMS conditions are offered by physical therapists (who have been gaining in independent practice rights and a movement toward a doctorate degree), by rapidly growing armies of massage therapists and acupuncturists, and to a lesser extent, by renewed interest in manipulation among osteopathic and allopathic doctors. Notwithstanding our decades long claims about the superiority of chiropractic adjusting over other forms of manipulation, neither outcomes data nor market patterns (patient preferences) are available in support of this view. Where once we were practically the only ones singing the praises of manual intervention, now we are becoming a voice in the chorus. Though our successes in the political arena have opened the doors to many third-party reimbursement plans, the oftentimes punitive limits on manipulative and ancillary services we can offer erodes our financial viability.

Complicating the problems attributable to our meager data base and our inability to self-define is our continuing tendency to "exaggerate" what is known about the chiropractic healing art. While acknowledging "considerable political acumen" within our profession, Cooper and McKee warn that chiropractic "risks damaging its legitimacy in both the public and political arenas" by making unsubstantiated claims. In this age of accountability, of evidence-based practice and of managed care, the old rhetoric and penchant for testimonials that once built our client base now threatens our credibility. An assertion for the value of chiropractic services that is not buttressed by strong evidence does us more harm than good, for even if we prefer to ignore the holes in the data base, others will not! If we wish to be the recognized experts in our own field, we must become the most trustworthy and credible purveyors of hard data about chiropractic, manipulation, and whatever else we choose to encompass.

Like it or not, the brave new world of health care in the 21st century is upon us, and now more than ever before chiropractors are under the microscope. But now we are examined by a new breed of profession-watchers, by scholars and policy makers whose purposes and biases are not necessarily those of our traditional adversaries. Indeed, the new observers of the chiropractic scene are not inherently friends or foes, but they bring a much more powerful lens to their task...the methodology of health policy research.

There is opportunity here if we are willing to grasp it. Cooper and McKees analysis, and accumulating works like it, provide a glimpse of ourselves from beyond our own borders, as others see us. It is a relatively objective view that portrays us within the larger scheme of the profession and societal needs. Whether or not we agree with all they perceive, we ignore such analyses at our peril.

Read the article and try to retain an objective analysis of what Cooper and McKee have written. It is perhaps a great starting article and foundational base for a much needed future strategic planning process. I ask a simple question: "If chiropractic were a business and you were to do the proper due diligence prior to making your decision, would you invest in it? We must make the necessary investment to fully analyze this article and many others which will certainly be on the horizon. Chiropractic can no longer shout in the deserted woods and hope that no one hears us. It is time for every practitioner to do a self analysis to determine what direction they want the profession to go and then participate in that goal by voicing your opinion to your national and state leaders and by joining your association. Your membership is the price of admission to the new health care profession of tomorrow.

References:

1. Bigos SJ, Bower OR, Braen GR et al. Clinical practice guideline Number 14: acute low back problems in adults. Rockville MD: Agency for Health Care Policy & Research, December 1994

2. Manga P, Angus D, Papadopoulos C, Swan W. The effectiveness and cost-effectiveness of chiropractic management of low-back pain. Ottawa: Pran Manga & Associates, 1993

3. Coulter ID, Hurwitz EL, Adams AH et al. The appropriateness of manipulation and mobilization of the cervical spine. Santa Monica CA: RAND Corporation, 1996

4. Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Phillips RB, Brook RH. The appropriateness of spinal manipulation for low-back pain: project overview and literature review. 1991a, RAND Corporation, Santa Monica, California (Document #R-4025/1-CCR/FCER)

5. Shekelle PG, Adams AH, Chassin MR, Hurwitz EL, Park RE, Phillips RB, Brook RH. The appropriateness of spinal manipulation for low-back pain: indications and ratings by a multidisciplinary expert panel. 1991b, RAND Corporation, Santa Monica, California (Document #R-4025/2-CCR/FCER)

6. Magner G. Chiropractic: the victims perspective. Amherst NY: Prometheus Books, 1995

7. Benedetti P, MacPhail W. Spin doctors: the chiropractic industry under examination. Toronto: Dundurn Group, 2002

8. Smith RL. At your own risk: the case against chiropractic. New York: Pocket Books, 1969

9. Penn & Teller Bullshit Alternative Medicine January 03

10. Cooper RA, McKee HJ. Chiropractic in the United States: trends and issues. Milbank Quarterly 2003; 81(1): 107-3

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