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Helping Chiropractors Help People The Official Publication of the Texas Chiropractic Association



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Policies: Annual subscription to the Texas Journal of Chiropractic is included in TCA membership dues. Contact the TCA for subscription rates for nonmembers. The print Texas Journal of Chiropractic is published up to six times per year by the Texas Chiropractic Association under the supervision of the TCA Publication Committee. Opinions expressed are those of the contributors and do not necessarily reflect the policy of the Texas Chiropractic Association or the Texas Journal of Chiropractic. Publication of an advertisement does not imply approval or endorsement by the Texas Chiropractic Association. The association shall have the absolute right at any time to reject any advertising for any reason. For advertising rates contact the TCA Office. All advertising material must be in graphics ready format and submitted as a .jpg, .jpeg, .gif, .swf, or .png file type. The opinions expressed are those of the authors and do not represent the opinions of the TCA.

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Texas Chiropractic Association Helping Chiropractors Help People The Texas Chiropractic Association represents chiropractic professionals throughout the state. TCA serves to protect chiropractic professionals, their patients, and the right for Texans to choose chiropractic as one of their health care options. First formed in 1916, this historic association has existed for nearly 100 years representing the interests of Texans who desire safe and effective health care from chiropractic professionals.

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What Has New Mexico Done? By Dr. Tim McCullough, DC, DABCI Disclaimer: Dr. Tim McCullough is a member of the Texas Board of Chiropractic Examiners. This article does not represent the TBCE, the State of Texas, any individual or organization in Texas. New Mexico chiropractors have passed legislation that will have a profound impact both on the profession as well as the people of New Mexico. A brief historical background is necessary to complete understanding and appreciation of this history making legislation. Exactly what have New Mexico chiropractors done? If you ask several chiropractors what chiropractic is, you will get different answers usually based on that doctor’s philosophy or experience. However, the fact is that chiropractic is what the state legislature determines in their individual state statues, also called enabling legislation - no more and no less. Chiropractic is defined differently in each state and is typically referred to as the chiropractic act. The law does not address chiropractic philosophy, training, or personal belief systems. Knowing and understanding the state’s chiropractic law is the first part of understanding the legal equation. The next part of the equation is to understand the function of the

board of examiners. Most boards, whether chiropractic or medical, are enabled/empowered in the chiropractic/medical act by a state legislature to: 1) make rules - a legislative function and 2) adjudicate claims/disputes - a judicial function. They are a governmental/administrative agency (1) with the police power of the state to regulate the profession. The board is prohibited from formulating laws/legislation. However, they are empowered by the legislature to engage in rulemaking, the avowed purpose of which is to clarify the intentions of the legislature. The line often becomes blurred and the board’s rules/regulations function as law. If any individual or group disagrees with a board constructed rule/regulation the board may be challenged in public hearings, written testimony or in court. This is designed to prevent the board of examiners from becoming a regulatory dictator with no checks and balance. (2) All administrative boards, whether regulating professions, corporations, or conduct are required to comply with the state’s Administrative Procedures Act to engage in rulemaking which guarantees that their actions comply with due process, fundamentally, notice and an opportunity to be heard. Here is an example of how a board of examiners can turn itself into a regulatory dictator. By legislative law/statue the medical profession has no scope of practice limitations. A licensed MD can treat any mental or physical disease or disorder or a physical

deformity or injury by any system or any method. However, the individual MD’s are limited by medical board rule allowing only allopathic medicine in many states and prevented from using natural based medicines for treatment of conditions, usually in the name of public safety. When a board uses the terminology, “In order to protect the public” this is a warning sign that they are in fact restricting behavior in favor of one idea or group over another. Unless an individual or group challenges the board’s action either in public or in court and the rule is removed or changed, it will stand. Chiropractic on the other hand is specifically limited by legislative law in a similar manner as dentist, podiatrist and optometrist. When the board of examiners writes rules according to these limitations stated in the law the rules are usually more restrictive than chiropractic education and training. Since most chiropractic laws do not allow a scope-ofpractice to the extent of chiropractic training and expertise, the rules constructed by the board of examiners are, in the minds of many chiropractors, hostile and restrictive to the chiropractic profession. This is part of the current controversy in Texas. The medical doctors have sued the chiropractic board of examiners several times taking the position that the chiropractors have expanded the scope-of-practice by rule-making rather than the legislative process

and the chiropractors are upset with the board because they feel the board has restricted the profession by rule-making beyond what the legislature intended. So, we have in many states a situation where medicine with no legal restrictions is being limited to allopathy by board rule and chiropractors are limited by law/ statue, but attempting to achieve full scope-of-practice-by-training through board rule. The only effective way to correct this problem is to include full-scope chiropractic and full access to naturally based medications and nutrients in the language of the chiropractic or medical practice acts. This legislative action would also serve to limit the board of examiners from attempting to define chiropractic practice by rulemaking. When the board is allowed to use rulemaking to expand or limit scope-of-practice it functions like a trade union instead of a fair and impartial regulatory agency interpreting what the legislature intended. The chiropractors in New Mexico have taken an historic first step toward correcting this difficult problem by convincing the legislature to pass a law designating the advanced chiropractic physician and granting prescriptive authority. An advanced practice chiropractic physician in New Mexico is granted the authority by legislation to practice full-scope chiropractic as well as access to natural therapies by law. So, the situation of the board determining what a

profession is or is not by board rule is reduced. The authority to prescribe in the language of the statue/law is critical to insure that the scope of chiropractic is determined by the legislature and not by the board of examiners. This history making legislation is the first of its kind in the country and is landmark legislation for chiropractic’s future. Where do drugs come into play in this situation? First, the drug situation in New Mexico has been overblown by the media and the ICA. The first drug on the formulary is sterile water. Second, all of the medications the chiropractors included in the law are naturally based; specifically naming vitamins, minerals, homeopathics, herbals and other natural based substances. Third, the FDA regulations regard any substance used for medicinal purposes as a drug and their goal is to make all nutrients prescription only. They have already started to restrict homeopathic medications and herbs. This situation is ameliorated in New Mexico because the naturally based substances that have been used in chiropractic for over 100 years chiropractors are now authorized to prescribe. So, if tomorrow the FDA makes all these nutrients by prescription only the APC doctors in New Mexico will still have access to them for their patients. The people of New Mexico will have access to these substances through their chiropractor even if the osteopaths and medical doctors’ board prohibit their use.

Drugs were also included because state law in New Mexico requires a physician to have prescriptive authority that includes drugs. In most states chiropractors do not legally qualify as physicians. The authority to prescribe is a step toward equality and crucial for the chiropractic profession. Remember, if your competition by law is unrestricted and you are restricted then the law requires you will be discriminated against. This is why chiropractors often seem to lose in court and health related issues more than the MD/DO. The law requires the courts to discriminate against unequal parties. Prescriptive authority is another important concept to understand and it is critical if chiropractic is to ever obtain any degree of parity. In most states chiropractors can recommend but they cannot prescribe. The authority to prescribe is a step toward creating parity with other providers because it empowers the practitioner’s recommendations with the power of the state. Let me give you an example. If a chiropractor recommends that a child take a digestive enzyme after meals at school the public school does not have to allow the child take the supplement. If a chiropractor in New Mexico with prescriptive authority prescribes a digestive enzyme after meals the school is

legally required to obey because the state has empowered the practitioner with the authority to prescribe that treatment. It is a powerful tool and essential for parity and equality. What is prescribed is not the issue. It is the ability to prescribe empowered by the state that creates parity. In order to qualify to obtain prescriptive authority any profession must meet the states’ requirements and in New Mexico and most states the authority to prescribe drugs is part of the requirements. Prescriptive authority begins to level the playing field in the medical-legal world. If chiropractors had equal status in the law they can demand equality and equal treatment. They would have standing in the court to uphold anti-discrimination laws. Without it the law requires chiropractors must be discriminated against because chiropractors do not have statutory authority to prescribe their treatment. There is another very important point that the New Mexico doctors were careful to include in the legislation. Even though the advanced practice doctor in New Mexico has the authority to prescribe treatments, the board of examiners is prohibited from making rules that require him/her to prescribe a drug like the osteopaths and the medical doctors have been forced to by

their board rule. The chiropractor has the right to use and has the access to natural products and therapies listed in the law. This is a landmark piece of legislation not only for chiropractic to gain equality and parity, it is the first of its kind attempting to ensure a profession will not lose it tenets by board rule. So, what was has New Mexico done? They have passed visionary legislation to insure that the philosophical foundation of naturally based chiropractic can survive into the future. They have also insured that the people of New Mexico will have access to natural chiropractic care even if the FDA makes all supplements available by prescription only and the medical boards restrict the use of natural products in the practice of medicine. They have insulated as much as possible against potential or existing power struggles on the board of examiners that threatens that one group can change chiropractic to their philosophy. They have also taken the first steps in giving the chiropractors in New Mexico true parity so they can sit at the table with the MD and DO in matters concerning the health and welfare of the people of New Mexico. The chiropractic leaders in New Mexico are visionaries and history makers who have led the way in guiding chiropractic politics and law into the future.

(1) For historical context, the advent of Administrative Agencies in the U.S. and their enabling legislation, as it impacts/affects upon any profession engaged in healthcare, did not begin until the mid-1910’s. The first medial practice act in Texas was passed in 1913. The philosophical, scientific, and treatment protocols distinguishing allopathy, osteopathic, and chiropractic practice developed twenty-five years earlier in the mid to late 1890’s. (2) Acting ultra vires, or “outside their authority.”

CHIROPRACTIC DIRECTORY COMING SOON 7 Mistakes of BackPain Sufferers By Jesse Cannone

Back pain is one of the most common health issues in the United States, with up to 80 percent of the population suffering the condition at some point in one’s life. “But this exceedingly high number is just the beginning of the problem, because multiple studies indicate that roughly 70 percent of back surgeries fail,” says Jesse Cannone, a back-pain expert and author of The 7-Day Back Pain Cure, ( “It’s so common that there’s a name for it – failed back surgery syndrome, or FBSS.” One recent study monitored 1,450 patients in the Ohio Bureau of Workers’ Compensation database; half of those on disability endured back surgery, half did not. After two years, only 26 percent of those who had surgery returned to work. Additionally, 41 percent of those who had surgery saw a

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drastic increase in painkiller use. “The success rate for the most common treatments is pathetically low, so it’s no surprise people often struggle years or decades with back pain, with few ever finding lasting relief,” Cannone says. “The majority of back surgeries are not only ineffective, but most could have been completely avoided.” He reviews seven common mistakes made by back-pain sufferers: • Continuing treatment that isn't working: One of Cannone’s clients experienced 70 treatments resulting in no relief. “Here’s a general rule to follow,” he says. “If you see no improvement after going through a three-month period of treatment, consider making a change.” • Failing to solve the problem the first time: Take pain seriously the first time. Cannone’s own mother suffered a significant bout of

back pain, which subsided after a few days. But two years later it came back, and the second time was so debilitating she couldn’t work. “If she had taken the first bout more seriously, she probably would have prevented the second, more debilitating bout.” • Thinking you’re too healthy or fit to have back pain: Staying in shape is always a good idea, but it does not make you invulnerable. People who train their body can be more prone to back pain because they often push their body’s limits, says Cannone, who has been a personal fitness trainer since 1998. • Treating only the symptoms: Cortisone shots, antiinflammatory drugs, ultrasound and electrical stimulation only address pain symptoms. “You may get rid of the pain, but the problem causing the pain will persist if not addressed,” he says. “If you want lasting relief, you must address the underlying causes, and it’s never just one.”

• Not understanding that back pain is a process: In most cases, back pain, neck pain and sciatica take weeks, months or even years to develop; the problem may exist for quite a while before the sufferer notices it, except for rare onetime trauma incidents like automobile accidents. Most people sit for hours at a time, yet the body was developed for diverse movements throughout the day. “Think of a car with steering out of alignment; eventually, tires will wear down unevenly and there will be a blow out,” Cannone says. “The same is true with your body.” Just as the damage was a process, recovery is the same and can be time-intensive. • Believing there are no more options left: Not only does back pain hurt and prove physically debilitating; it also tries the morale and determination of the patient. A

sufferer can run the gamut of treatments. But, often, it takes a mixture of treatments that address all of the underlying causes. “Remember, you can’t really treat the root of pain until you know what’s causing it,” Cannone says. “In so many cases, this is precisely the problem.” • Failing to take control: Doctors and other specialists are ultimately limited to what they know and what they’re used to. If you have a debilitating back problem, it should be among your top priorities to learn all you can about it, and how to fix it. Get a second, third and fourth opinion if treatment isn’t working; try out alternative therapies, and consider a healthy mix of treatment. Most importantly, take control; it’s your back, your body and only you can heal it, with help from others.

“I may be critical of how most handle back pain, but that’s because I’ve proven to patients that there are flaws in the traditional approaches as well as more effective alternatives,” Cannone says. “I also feel that I’m offering a hopeful message because of my high success rate.” Jesse Cannone is a leading back pain expert with a high rate of success for those he consults. He has been a personal trainer since 1998, specializing in finding root causes for chronic pain, and finding solutions with a multidiscipline approach. Cannone publishes the free email newsletter “Less Pain, More Life,” read by more than 400,000 worldwide, and he is the creator of Muscle Balance Therapy™.

One Society’s Opinion “There is a huge push for the 'expansion of chiropractic' throughout the US. … The CST [Chiropractic Society of Texas] will never support such an 'expansion' in our profession... The ACA has made it very clear that they are in support of chiropractors prescription rights. For this reason, I urge you to not support the ACA, nor any organization that supports the ACA." -- Newsletter from CST, May 30, 2013, emailed from Chiropractic Society of Texas (

Holistic Chef Provides 5 Recipes that Prove Healthy is the New Delicious By: Shelley Alexander, CHFS With adventurous food tastes and concerns ranging from personal health to ethical agriculture and livestock practices, more people are exploring alternative diets. But that’s not always easy – or palatable. “You have paleo and primal diets, pescatarian and raw foods, vegetarian and vegan, and they all have wonderful merits, especially when compared with the processed foods many Americans continue to eat,” says Holistic Chef and Certified Healing Foods Specialist Shelley Alexander, author of “Deliciously Holistic,” ( “My focus is on easy-to-follow healing foods recipes that make delicious, completely nourishing meals. Some will appeal to those who adhere to a strict diet, such as vegan, and all will make people feel noticeably healthier without sacrificing any of the enjoyment we get from sitting down to eat.” Alexander offers five recipes that can be used for any meal of the day or night, including: • Mango chia ginger granola (raw, vegan): 2 ripe mangos, peeled, cored and sliced in oneinch cubes; 2 cups Living

Intentions chia ginger cereal; 2 cups nut or seed milk. Put ingredients in a bowl and enjoy! The cereal is gluten-free, nutfree, and raw- and vegan-diet friendly, and extremely nutritious. Preparation takes five minutes or less and is hearty enough to satisfy appetites the entire morning. The ingredients can be substituted for dietary needs or preferences. • Portobello mushroom and grilled onion burgers (vegan): Marinade for the mushroom is essential – 2 tablespoons Balsamic vinegar; 1/3 cup extra virgin olive oil or avocado oil; 1 tablespoon wheat-free Tamari or organic Nama Shoyu soy sauce; 1/8 teaspoon smoked sweet paprika; 1 peeled garlic clove (grated or minced); 1/8 teaspoon cayenne pepper; 2 teaspoons organic maple syrup – grade B. The burgers include 4 large Portobello mushrooms – cleaned and patted dry; 1 large white onion (peeled and cut into thick slices); olive or avocado oil to cook mushrooms and onions; 2 sprouted whole grain hamburger buns –toasted; Dijon mustard; ¼ cup baby romaine lettuce – washed and patted dry. Marinate mushrooms and onions for 30 minutes. Drizzle with oil and cook on medium heat for 15 minutes, turning mushrooms halfway through. Serve immediately. • Wild blueberry smoothie (raw, vegan): 3 cups vanilla Brazil nut milk (there is an additional recipe for this); 2 cups fresh or frozen wild or organic

blueberries; 1 peeled banana – organic or fair trade; 2 to 3 cups organic baby spinach; 1 small avocado – peeled and pitted; ¼ teaspoon cinnamon; (optional) a preferred protein powder or superfood. Blend until creamy. Blueberries are an amazing fruit packed with antioxidants, vitamins, minerals, fiber and phytonutrients. • Raw corn chowder (raw, vegan): 4 cups organic corn kernels (best during summer months); 2¼ cups unsweetened almond milk; 1 clove peeled garlic (remove inner stem); 2 teaspoons fresh lemon juice; ½ teaspoon smoked sweet paprika; 1/8 teaspoon pure vanilla extract; ½ avocado (peeled and seed removed); unrefined sea salt and fresh black pepper to taste. Blend ingredients and strain; top with corn kernels and diced organic red bell pepper. Among other nutrients, corn provides lutein – an important carotenoid that protects eyes from macular degeneration. • Dijon honey chicken wings: 1/3 cup Dijon mustard; ½ medium peeled lemon – remove all the white pith; ¼ cup raw honey; 1 teaspoon unrefined sea salt; 2 large, peeled garlic cloves – grated; 1/8 teaspoon fresh ground black pepper; 12 whole chicken wings – rinsed and patted dry; ½ teaspoon paprika. Preheat oven to 400 degrees. Blend ingredients in a blender, except for wings and paprika, until smooth. Add salt and pepper to taste. Remove tips of cleaned wings and store in

freezer for future stock. Place wings on lightly greased baking dish, sprinkle lightly with salt and pepper, place in oven. After 30 minutes baste wings with juices from pan, then brush mustard sauce all over wings, sprinkle with paprika and continue baking for an additional

25 to 30 minutes. Wings should have internal temperature of 165 degrees when done. These are a healthy and tasty alternative to deep-fat-fried wings. About Shelley Alexander, CHFS Shelley Alexander has enjoyed a lifelong love of delicious, locally

grown, seasonal foods. She received her formal chef’s training at The Los Angeles Culinary Institute. Alexander is a certified healing foods specialist, holistic chef, blogger and owner of the holistic health company, A Harmony Healing, in Los Angeles.

The Problem with Groupon By Dr. R. A. Foxworth, FICC, MCS-P I get asked now and again whether offering Groupons is a good idea for chiropractors. The answer, unfortunately, is far from simple. Each state has its own rules about what’s allowable and what isn’t. In Oregon, for instance, two different medical boards have disallowed Groupons for chiropractor and dentists on the grounds that Groupon’s terms violate kick-back fee and split-fee guidelines. Other states are still on the fence. As it stands right now, chiropractors offering Groupons stand a good chance of running afoul of third-party payer regulations. Apart from legal concerns, there are professional ones as well. I don’t know about most of you, but I see Groupons mostly for restaurants, family activities, salons, and travel. And while I do also occasionally see one for a chiropractor, what message does this send potential patients about our profession? Would someone really use a Groupon for, say, a tonsillectomy, a bowel resection or a knee replacement? When we put chiropractic adjustment on the same playing field as a pedicure, how much value are we placing on chiropractic care in the mind of the public? We understand the temptation to get in on a Big New Marketing Thing. It’s tough out there, and DCs, understandably enough, want to stay competitive, attract new business and offer affordable fees, especially for their uninsured, underinsured and partially insured patients. But rather than take a huge risk offering discounts that may well turn out to be illegal, we here at ChiroHealthUSA want to make sure chiropractors stay in compliance and offer discounts LEGALLY.

This is not to say we are big boosters of offering discounts. But we’ve seen that the reality is, any doctor who participates in any health plan already takes network discounts. Our stance remains the same: document correctly, code correctly, bill correctly and, IF you discount, discount correctly! That’s where a Discount Medical Plan Organization (DMPO) like ChiroHealthUSA comes in. We offer a discounting solution that is legal, extremely affordable for patients, and costs the doctor not a single penny. Better yet, we make it easy to find out more about becoming a provider by holding our overview webinar, “Why do I need ChiroHealthUSA?,” every Tuesday at 12:15 PM EST. DCs look to their state associations for invaluable support, and it’s our mission to help. Find out more by registering for our free Tuesday webinar at Dr. Foxworth is a certified Medical Compliance Specialist and President of ChiroHealthUSA. A practicing Chiropractor, he remains “in the trenches” facing challenges with billing, coding, documentation and compliance. Dr. Foxworth is a 1984 Honors Graduate, (Cum Laude), of Cleveland Chiropractic College in Kansas City, MO. He served as Staff Chiropractor for the G.V. Sonny Montgomery VA Medical Center 4 years and is a member of the American Chiropractic Association and a 3 term past-president of the Mississippi Chiropractic Association. He was voted by his peers as Chiropractor of the Year for several years and is currently a Fellow of the International College of Chiropractic. He was appointed to the Mississippi State Board of Health by Governor Kirk Fordice and again by Governor Ronnie Musgrove and served 12 years, two of them as Chairman. You can contact Dr. Foxworth at 1-888-719-9990, or visiting the ChiroHealthUSA website at


Conservative Care First: A Strategy to Reduce the High Cost of Health Care The cost of health care is becoming an ever-larger portion of the federal budget. In 2011, $2.7 trillion was spent on health care in America and $551 billion was spent on Medicare alone. We cannot sustain these rapidly increasing costs. The number of Medicare patients are growing as baby boomers enter retirement age and the care of patients with chronic conditions continue to drive increasing costs of health care. The average health care cost for all Medicare patients in 2006 was $8,344, but the average cost for the top 10 percent of Medicare patients was $48,2001. In May 2013, the Medicare Board of Trustees revealed the Medicare trust fund, as currently configured, will run out of money by 2026. The rapidly increasing prevalence of chronic conditions is an important factor. In 1987, 31 percent of Medicare patients were treated for five (5) or more chronic conditions. In 1997, that number jumped to 40 percent and by 2002 the number had increased to more than 50 percent. An estimated 96 percent of Medicare spending in 2006 was for patients with multiple chronic conditions; 79 percent for those with 5 or more chronic conditions2. The incidence of obesity doubled between 1987 and 2002, along with diabetes, hyperlipidemia and hypertension3. Obesity and diabetes are increasing in all age groups including children and adolescents. Seventy-two million Americans are obese, with estimated annual health care costs of $147 billion4. There are also more that 100 million chronic pain patients in the US according to the Institute of Medicine, with costs exceeding $635 billion annually5. These numbers continue to rise, showing a deterioration of Americans' health status, even as we continue to spend more and more on “health care.” The truth is that we spend very little in the U.S. on “health care;” what we call health care is mostly “disease care” with services and expenditures largely focused on very expensive illness and symptom treatment. This focus must change to promote the use of safer and less expensive conservative care interventions first. We must encourage increased patient education and counseling on risk avoidance and health promotion strategies, including lifestyle modifications that are necessary to avoid or mitigate costly and debilitating chronic illnesses and diseases6. Our health care system is overloaded and medical providers are stretched to see increasing numbers of patients. There are growing shortages in Primary Care Providers (PCP). We must change our approach to patient care. Provider shortages are predicted to increase dramatically but can be safely and effectively mitigated by using all available physician level health care providers at the top of their licenses7. Chiropractic Physicians are educated as conservative primary care providers who serve as portal of entry8 and perform many PCP services9 safely, efficiently and effectively. The full inclusion of doctors of chiropractic (DCs) in America's health care system can help to reduce health care costs, while maintaining excellent clinical outcomes and patient satisfaction levels and without rationing care, reducing access or excluding large segments of America's population. Changing health care to the conservative-care-first (CCF) approach of Chiropractic Physicians, and increasing the nation's focus on health promotion, prevention and wellness, will achieve major reductions in health care costs –

but this will require significant changes in America's health care delivery and the culture of our health care system.

With the decline in Americans' health status, the increase in chronic conditions, the worsening shortage of primary care providers, and rapidly escalating health care costs, significant changes are critical. Authors Marvasti and Stafford note there is a need for “transformational change,” a “fundamental reordering of our health care system” and “reengineering prevention into health care”6,10. But how can this be done?

The major cost drivers in health care are largely related to our approach to treating chronic pain and diseases. We can effectively reduce expensive, high risk cost drivers by reducing the use of unnecessary and/or excessive services11: surgeries (e.g. spine surgeries)10,12, invasive procedures (e.g. spinal injections)10,13, hospital admissions and readmissions14,15, prescription drugs (e.g. opioids and NSAIDS)14,16,17,18, diagnostic imaging (e.g. MRIs and

CTs)11,19,20 and other diagnostic testing20, as well as related hospital infections15,21, surgical/hospital mistakes15,21,22, prescription drug adverse events15,23 and follow-up care necessitated by mistakes and adverse events15. Considerable cost savings will accrue with maximum elimination of the unnecessary and/or excessive portion of these major cost drivers. This can be facilitated by transitioning to a conservative-care-first model of health care. This model will focus patient care first on conservative diagnostic testing and treatment, offered in an out-patient setting, directed toward whole-person wellness -- providing an appropriate trial of conservative care (non-drug, non-surgical approach) and incorporating health promotion and wellness counseling (and coaching) from the start of care.

CCF providers must be placed on the front line of health care wherever practical; it is here that these providers can have the greatest impact on changing the focus of patient care -- from symptom and disease treatment to

promotion of lifestyle modification, chronic disease prevention and whole-person wellness. CCF providers deliver essential services, as defined by §1302 of the Patient Protection and Affordable Care Act (PPACA)24; they examine, diagnose and set care plans that employ the best conservative options and refer to other providers when patients present with acute medical emergencies or when conservative options are not readily available or appropriate. Optimal savings will be achieved by employing more conservative, less risky and less expensive options - first. The logical first step to jumpstart this important transformation to a CCF approach is to fully employ well established and broadly available CCF providers on the front line of health care. The CCF approach will not be the only change necessary to improve health care and reduce related costs but this change alone will offer a significant step in the right direction. The use of broadly available Chiropractic Physicians

as CCF providers can foster significant improvements in patient-centered care and can significantly reduce health care costs. This approach will ensure more patients receive a trial of conservative care before more costly and higher-risk procedures and interventions are attempted. This approach will also help to reduce the burden on PCP and specialty provider resources, improving access to these valuable resources for patients who truly require more invasive and/or expensive interventions.

Providing patients with the opportunity to choose a CCF provider, and indeed encouraging and directing patients to make this choice, will have a swift and definitive impact on how care is delivered -- effectively changing the focus and reducing the cost of health care. Engaging patients earlier, and more often, with good health habits and wholeperson health care strategies can improve patients' short and long term health and the viability of our health care system in America. The Institute of Medicine has estimated that approximately 75 percent of our health care dollars are spent to treat patients with chronic conditions; $635 billion is spent on chronic pain patients alone. The National Center for Chronic Disease Prevention and Health Promotion (CDC) has noted that a large number of chronic conditions are lifestyle related – due to poor health habits – perhaps as many as 80 percent25. These chronic conditions can be avoided or mitigated by modifying a patient's lifestyle and teaching them good health habits. As physician level CCF providers, DCs are well educated and experienced to fill this transformational role safely and effectively8,9. Some DCs may be used as PCPs for spine care or musculoskeletal conditions26, while others may be used as conservative/CAM PCPs for general health counseling and coordination of care27,28. These strategic uses of Chiropractic Physicians will ensure the maximum application of a conservative-care-first approach and result in significant cost savings and will begin to make much needed changes in the focus of America's health care. A 15-20 percent reduction in America's health care costs would result in $400-500 billion in annual savings. Such significant savings may be achieved with the CCF approach. Studies have shown large savings with use of DCs as first contact doctors. Patients were given the choice of consulting a DC or MD as their Primary Care Provider in AMI studies26,27; those who chose a DC were assured a CCF, whole-person, non-drug, non-surgical approach when appropriate, and referral when necessary. The AMI studies showed 40-50 percent savings on prescription drugs, surgeries, hospital admissions and hospital stays for patients who chose DCs as their PCPs. Another study on a large population of patients in Tennessee showed 20 percent reduction in cost of care for patients with low back pain when they chose to see a DC first, compared to those patients who saw an MD first29. The CCF approach is patient-centered, rational and doable and it holds great potential for reducing America's health care costs. Current access and coverage restrictions placed unilaterally on non-MD/DO providers (and their services) reduces patient choice and increases costs overall30.

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Millions of patients can significantly reduce the cost of their health care with the CCF approach, while achieving excellent clinical outcomes and high patient satisfaction. Using Chiropractic Physicians and the CCF approach to patient care presents a significant solution strategy for America's health care challenges. References Cited: 1 Medicare Spending & Financing-A Primer-2011, Lisa Potetz, Juliett Cubanski, Tricia Newman, The Henry J Kaiser Family Foundation 2

Responding to the Growing Cost and Prevalence of People with Multiple Chronic Conditions, Gerard Anderson, PhD, Johns Hopkins Bloomberg School of Public Health, 2007 3 The Rise in Spending Among Medicare Beneficiaries: The Role of Chronic Disease Prevalence and Changes in Treatment Intensity, Kenneth E. Thorpe, David H. Howard, Health Affairs, August 2006 4 Annual Medical Spending Attributable to Obesity: Payer-and-Service-Specific Estimates, Eric A. Finkelstein, Justin G. Trogdon, Joel W. Cohen, William Dietz, Health Affairs 28, no.5, July 2009 5 Relieving Pain in America- A Blueprint for Transforming Prevention, Care, Education and Research, Institute of Medicine, June 2011 6 7 8 9

Farshad Fani Marvasti, M.D., M.P.H., and Randall S. Stafford, M.D., Ph.D., N Engl J Med 2012; 367:889-891 Patient Protection and Affordable Care Act (ACA); Sec. 2706, Non-Discrimination in Health Care Educational Standards; Council on Chiropractic Education (CCE); 2013 Practice Analysis of Chiropractic; National Board of Chiropractic Examiners; 2010


Outcome of Invasive Treatment Modalities on Back Pain and Sciatica: An Evidence-Based Review, wan Tulder MW, Koes B, Seitsalo S, Malmivaara A, Eur Spine J, January 2006 11 Squandering Medicare’s Money, Rita F. Redberg, Editor Archives of Internal Medicine, San Francisco, May 2011 12 13

MRI Abundance May Lead to Excess in Back Surgeries (Study Shows), Welsh J, Stanford University School of Medicine, Oct. 14, 2009.

Medicare Payments for Facet Joint Services, Department of Health and Human Services, Office of Inspector General, Daniel R. Levinson, September 2008 14 Adverse Drug Reactions Cause Too Many Hospital Admissions, BMJ, July 2004 15

Adverse Events in Hospitals: National incidents among Medicare beneficiaries, Department of Health and Human Services, Office of Inspector General, Daniel R. Levinson, November 2010 16 Alarming Rise in Unintentional Drug Overdose Deaths in Ohio, Ohio State University College of Pharmacy, Ohio Department of Health Violence and Injury Prevention Program, 2009 17 Crossing the Quality Chasm: A New Health System for the 21st Century, Washington, DC: National Academies Press, Institute of Medicine, 2000 18 19 20

Epidemic: Responding to America's Prescription Drug Abuse Crisis, Executive Office of the President, 2011 The Relationship Between Low Back Magnetic Resonance Imaging, Surgery and Spending, Schreibati JB, Baker LC, Health Serv Res, 2011

Exposure to Ionizing Radiation and Estimate of Secondary Cancers in the Era of High-Speed CT Scanning: Projections from the Medicare Population, Meer AB, Basu PA, Baker LC, Atlas SW, J Am Coll Radiol, 2012 21 Hospital Incident Reporting Systems Do Not Capture Most Patient Harm, Daniel J. Levinson, Department of Health and Human Services, Office of Inspector General, January 2012 22 To Error Is Human: Building a Safer Health Care System, Washington DC: National Academies Press, Institute of Medicine, 1999 23 24 25

Incidence and Preventability of Adverse Drug Events Among Older Persons in the Ambulatory Setting, Gurwitz J. H., JAMA 289 (9): 1107-1116 Patient Protection and Affordable Care Act (ACA); Sec. 1302, Essential Health Benefits Requirements

National Center for Chronic Disease Prevention and Health Promotion (CDC); The Power of Prevention-Chronic Disease... the Public Health Challenge of the 21st Century; 2009 26 A Hospital-Based Standardized Spine Care Pathway: Report of a Multidisciplinary, Evidence-Based Process, Ian Palkowski, DC, Michael Schneider, DC, PhD, Joel Stevans, DC, John Ventura, DC, and Brian D. Justice, DC, JMPT February 2011. 27 Sarnat, R.; Winterstein J. Clinical and Cost Outcomes of an Integrative Medicine IPA, JMPT, 2004 28 29

Sarnat, R.; Winterstein J.; Cambron JA, Clinical and Cost Outcomes of an Integrative Medicine IPA; an additional 3-year update, JMPT, 2007

Cost of Care for Common Back Pain Conditions Initiated with Chiropractic Doctor vs. Medical Doctor/Doctor of Osteopathy as First Physician: Experience of One Tennessee-Based General Health Insurer, JMPT 2010 30 Plateaued, Suggesting Role In Reformed Health System-US Spending On Complementary And Alternative Medicine During 2002-08, Matthew A. Davis, Brook I. Martin, Ian D. Coulter and William B. Weeks, Health Affairs, 32, no.1 (2013):45-52. Other References: Chiropractic Summit Partners: American Chiropractic Association, Association of Chiropractic Colleges, Congress of Chiropractic State Associations, International Chiropractors Association, et al; Consensus Document-Doctors of Chiropractic Serving as Prevention and Wellness Providers; 2011 32 Chiropractic Summit Partners; American Chiropractic Association, Association of Chiropractic Colleges, Congress of Chiropractic State Associations, International Chiropractors Association, et al; Consensus Document-Doctors of Chiropractic: Providers of Conservative, Patient Centered Primary Care and Essential Benefits. Helping to Fill the Workforce Gap and Decrease Health Care Costs (The Case for Full and Non-Discriminatory Inclusion of Doctors of Chiropractic in America's Health Care System); 2011 33 Chiropractic Summit Partners; American Chiropractic Association, Association of Chiropractic Colleges, Congress of Chiropractic State Associations, International Chiropractors Association, et al; Consensus Document-Doctors of Chiropractic: A Low Cost Solution to High Cost Health Care; 2010 34 Chiropractic Summit Partners; American Chiropractic Association, Association of Chiropractic Colleges, Congress of Chiropractic State Associations, International Chiropractors Association, et al; Consensus Document-Doctors of Chiropractic Can Improve the U.S. Primary Care Workforce Challenge; 2010 35 Chiropractic Summit Partners; American Chiropractic Association, Association of Chiropractic Colleges, Congress of Chiropractic State Associations, International Chiropractors Association, et al; Consensus Document-Chiropractic Cost Effectiveness; 2009 31

! "#$%&'( ! &)*$+*'( * "&,'& ( Prospering with ObamaCare: The Chiropractic PosturePractice Scenario


It's decided: ObamaCare will become our new American healthcare system. Like it or not, the economics of US healthcare will be guided by a new rulebook, one which puts Americans into silver, bronze or gold insurance plans... or face an increasingly punitive tax. As the arguments continue between faceless bureaucrats and regulators on who wins, who loses a little and who loses a lot, remember this:

‡ It takes years to change a healthcare system- 2014 is just

‡ ‡ ‡

beginning of what has already been legislated, and taking away any new benefits will become far more difficult as time goes on. People always want the best they can get for themselves Boomers are getting older, and older people suffer with more back, joint and muscle pain Back pain has been rising since 1992 (not surprising in an increasingly sedentary society), with more doctor visits-MD, PCP and chiropractic-- more drug prescriptions, and more surgeries

So like it or not, the healthcare system will change. PostMVA care models and PIP are changing. Insurance coding will change dramatically with ICD-DVWKHFRGHVZHÂśUH used to become obsolete. But change brings opportunity as well as danger, so OHWÂśV look at what's some likely changes coming between now and 2020 as ObamaCare becomes the healthcare framework for the next few decades. The Obvious- Healthcare utilization will go up. "I'm paying for it with my tax dollars, so I am going to use it." The Very Probable- National expenditures on healthcare will go up....and there will be more controls on price and utilization And Also- Tech will disrupt healthcare, from off-shore radiology tele-medicine to cell camera otoscopes and do-ityourself iphone EKG apps. The Less Obvious- People will get used to paying for more non-urgent care in cash as more controls are put into place The Less Obvious, but Very Probable- Opportunities will grow for chiropractors (along with massage therapists and


other manual therapy providers) who physically touch people to build strong relationships, especially when they also empower and help them get the best value for their money. A posture focused practice builds awareness with a photo and common-sense concepts, and then educates people towards stronger posture with focused individualized exercise. Helping people manage their own problems builds perceived value, and sets the stage for a long term health relationship. As sedentary boomers slump into old age, a PosturePractice can help them stand taller to not only manage their back pain and arthritis to feel (and often look!) perceptibly better, but actually improve other aspects of their health - NMS to respiratory to gastrointestinal. Especially when the wait to see a medi-gov doctor stretches from days to weeks to months. Bottom Line: Patients who honestly know they are getting value for their dollars in a relationship are more likely to spend those dollars in that relationship, especially when they can see a difference in a posture picture, and feel an improvement in how they can move their body. Next PosturePractice Corner: Beginning with the First StepA Posture Picture COM I NG SOON: Why Common-Sense Will Rule. (If people FDQÂśW easily communicate it to their friends, they won't. But if they can, they may.) Dr Steven Weiniger is author of Stand Taller ~ Live Longer: An Anti-Aging Strategy, and Posture Pictures: Assessment, Marketing, Screenings & Forms, and lectures internationally on exercise and posture rehab.Dr. Weiniger has been featured in numerous articles on posture, anti-aging and exercise in professional journals as well as mainstream media including )2;1HZV2SUDKÂśV2[\JHQ network, Natural Health Magazine, American Fitness and Bottom Line Health. He promotes the brand identity of Posture Expert for DCs, a concept presented to NCLC, COCSA and numerous colleges and state associations, and serves as Managing Partner of, which provides posture, chiropractic, massage and wellness information and referrals to local Posture Exercise Professionals (CPEP). Contact Dr. Weiniger at or

Your Perception, Your Reality, Your Choice By: Chris G. Dalrymple D.C., F.I.C.C. "I wish things were different." "I wish that we were better liked." "I wish that people would just see the good that we are trying to do." We often hear such "wishes" surrounding our profession. A wish is a desire or a longing. A wish is not an action carried to a result. The results that one achieves in life are based upon the actions that one takes, or doesn't take. The actions taken (or not taken) are determined, in large part, by the tools that you use to carry out those actions, and the tool that you chose to use is determined by "your reality," and "your reality" is determined by your perceptions. To state this as a cliche: "If you think you can or you think you can't, you're right." Therefore, more than just changing your tools or your actions, if you want to change your results you need to change your perception of your reality. Lest you think that this is some metaphysical gobbled-gook, take note that Albert Einstein stated in 1950 "A human being is a part of the whole, called by us 'Universe', a part limited in time and space. He experiences himself, his thoughts and feelings as something separated from the rest — a kind of optical delusion of his consciousness. The striving to free oneself from this delusion… to try to overcome it is the way to reach the attainable measure of peace of mind."

might be more attractive than “we sell our service.” 2. The tools that we use to share our reality will also affect our results. Fast-acting marketing tools and techniques reach as many prospects as possible, as quickly as possible, and demonstrate your overwhelming value so that prospects can easily say, "Wow, where have YOU been!?" Can you see how “active buzz” is more attractive than “passive notification” or even isolation? 3. Finally the action that you take, or don’t take, will have a direct impact on our results. We must take action, understanding that sharing our reality is a marathon which cannot be finished (or even started) unless we take the first steps forward. This process is natural and ongoing whether you are aware of it or not. It IS part of your life--the actions that you take, and the actions that you don't take will determine your results. Achieving results is not difficult, and it doesn't necessarily cost any money, but it does require the difficult mind work needed for real change. To change a result often requires a change in perception.

Why is it labeled in the diagram below "your reality" and not just "reality?" Because we are in a prison and we can only experience a portion of reality. The achievement of results in life are affected by our perceptions, our tools, and the actions that we take (or don’t take). They all come into play. 1. Perception plays a LARGE part in determining our outcomes. If we change the way we perceive ourselves and our value, we will have an impact on our results. Can you see how “we improve lives”

In which direction will your perceptions of "You & Your Message" travel through time?

• Will you just be "positive" but take no action and thus "go nowhere?"

• Will you "take positive action" in order to move yourself toward a desired outcome?

• Will you just be "negative" and take no action and thus "go nowhere?"

• Will you "take negative action" in order to move yourself toward a desired outcome?

• Will you take action and "go somewhere", but not have stopped to consider whether your direction is positive or negative?

• These, of course, are the extremes, but it's your perception, your reality, your choice.

• Will you just "ponder the past" without taking any action and thus have memories, but achieve no results?

ACA Reports: The "Sixth and Seventh Character" of ICD-10 - What is it?

not available with ICD-9 and our present system leaves the doctor struggling to find ways to communicate medical necessity to the payer.


By: Jill Foote, Insurance Quality Analyst II

ICD -10 is composed of codes using between 3 and 7 characters. A code meets ICD-10's highest specificity requirements by using all seven characters. We begin by finding the three-character category heading of the code in the tabular list, which is divided by chapters. An overview of the chapters can be viewed at ICD-10-CM Chapters. http:// audioconferences/icd-10/icd-10cm_chapters.pdf.pdf

The sixth character communicates to the payer whether or not it is a subluxation or dislocation.

While the deadline for ICD-10 is still more than a year away, now is the time to become familiar with ICD-10 coding terms. The U.S. Department of Health and Human Services (HHS) has indicated that there will be no grace period for ICD-10 implementation. A good starting point is to familiarize yourself with the "characters" that make up an ICD-10 code. (Please feel free to review the basics of ICD-10 by visiting ACA's Q & A on ICD-10, before reading this article.) http:// ICD10FAQs.pdf There is no need to dread ICD-10. Implementation will benefit patients in the long run. How? Through use of additional characters, ICD-10 makes it possible for the provider to paint a more accurate picture of the patient's condition. This new coding "language" allows for comorbidities, etiology, causation, complications, manifestations, degree of functional impairment, detailed anatomic site, phase/stage of treatment, lateralization, localization, joint involvement, sequelae, and even age-related conditions. This level of detail is

For example: Chapter 19 Injury, Poisoning & Other Certain Consequences of External Causes S33 "Dislocation and Sprain of Joint and Ligaments of Lumbar Spine and Pelvis" Not unlike ICD-9, ICD-10 codes are invalid if they have not been coded to the highest level of specificity. The fourth character indicates the specific body part and helps the code come "alive" as it begins to communicate to the payer a more complete portrait of the patient's condition. S33.1xx_ "Subluxation and dislocation of lumbar vertebra"

S33.11x_ "Subluxation and dislocation of L1/L2 lumbar vertebra"

S33.110_ "Subluxation of L1/L2 lumbar vertebra" S33.111_ "Dislocation of L1/L2 lumbar vertebra" The seventh character of ICD-10 is often a required character in codes involving musculoskeletal diseases (Chapter 13, M00-M99), injuries and poisonings (Chapter 19, S00-T88). The purpose of the 7th character is to communicate to the payer the "type of encounter" such as initial (A), subsequent (D), or sequela (S). If a code requires a seventh character, you will see it listed with an underscore "_" in the last column of the ICD-10 code, as shown in the prior examples. An example of the process of coding subluxation with all seven characters: S33.11 Subluxation and dislocation of L1/L2 lumbar vertebra ----S33.110 Subluxation of L1/L2 lumbar vertebra S33.110A initial encounter

The fifth character communicates to the payer the level of the subluxation or

S33.110D subsequent encounter S33.110S sequela

ICD-10 has yet to arrive, but the need to become familiar with the process is critical. The structure is in place, so why not start by making a list of commonly used

ICD-9 codes in your practice and finding the ICD-10 GEM (General Equivalency Mapping) so you will be ready?

Information on GEMs can be found online at: CMS GEMS

Reference. Once you have found the three-character code that is similar to the ICD-9 code, begin applying the technique of coding to the highest level of specificity. This is performed by further subdividing the layers of differentiation within the diagnosis by use of the fourth through the seventh digits, which follow the decimal, and communicate greater detail. Understanding the structure of ICD-10 will assist you in developing the accurate and detailed documentation that is necessary for successful ICD-10 coding.

More Than Urban Legends By Dr. R. A. Foxworth, FICC, MCS-P President, ChiroHealthUSA Certified Medical Compliance Specialist Urban legends are kind of fun, if only for the sheer, shivery surprise factor. You've probably heard the one where someoneusually a young woman at home alone and often a baby sitter-gets a terrifying series of phone calls. The police trace them and find out the calls are coming from inside the house. Screams, mayhem and white knuckles on the remote control aren't far behind! There's a similar threat brewing from inside your house-your practice-and we wish we could tell you it's just an urban legend. Frighteningly, however, it's all too true. Thanks to recent changes from the Centers for Medicare and Medicaid Services (CMS), the biggest threat to the survival of your practice could now come from your patients

themselves. In late April, the CMS issued a new rule that would substantially boost the rewards for whistleblowers, i.e., anyone reporting information that leads to the recovery of funds from practices just like yours who might have inadvertently fallen into Medicare fraud or abuse simply by unknowingly offering dual fee schedules or time-of-service discounts above and beyond the safe 5-15% limit that correlates with an OIG opinion about your discount relating to your collection costs. This isn't the first time the government has encouraged citizens to turn each other in; the IRS has been giving anyone who provides tips on tax fraud a significant cut of the proceeds for years. In fact, the government has generated over $2 billion in revenue since 2003, and it paid out $16 million to whistleblowers last year alone. The government has the proof that this is a system that works, so they are taking it to the next level by expanding to recruit your

patients now to keep an eye on YOU! By contrast, the CMS, who has been paying out rewards for monies recovered since 1998, has to date been playing it lowkey. In all that time, they've paid out just $16,000. This new rule proposes to change all that. Looking to generate the kind of revenue the IRS enjoys, the CMS is proposing to increase payouts substantially. Looking at the new system, a patient who hops from practice to practice to report Medicare fraud could earn as much as $10 million! Don't just take our word for it here: press/2013pres/ 04/20130424a.html With this much money at stake, your innocent-looking new patient could be looking at you as their new "retirement plan." Keep in mind, with the recent changes in the economy many of your Medicare patients have lost a large chunk of their retirement, and this may be a very enticing "opportunity" to them as a result!



AUDIT Don’t take unnecessary risks by running ads offering discounts or free services that could be considered inducements... Patients aren’t the only ones who read your ads! CMS/Medicare and insurance companies are investing more resources in the enforcement of provider agreements, and with fines of up to $10,000 per occurrence for inducement violations, many practices are just one audit away from a financial disaster. Offering discounts to your cash and underinsured patients can be legal if done properly! Over 1,800 doctors are doing it the RIGHT way... Are you? And that’s not all... Over 100,000 patients appreciate their doctors for keeping health care affordable for their families; join ChiroHealthUSA and yours will too!

No joining or credentialing fees. You set your own discounts. You stay in control. And if that’s not enough, ChiroHealthUSA is proven to help converting shopper calls into new patients, and can help transition patients from insurance to cash, as well as offering options for HIGH deductibles plans and affordable family plans. Don’t risk it; contact us now and start practicing with peace of mind!

1-888-719-9990 / JOIN US EVERY

You can have a one page simple financial policy as a member of ChiroHealthUSA. Request a sample copy today! Send an email to with FORM in the subject line. Mention the code TXCA when registering for the webinar for a chance to win a $250 Amex Gift Card!




Very few DCs knowingly and intentionally engage in Medicare fraud-but now that we're all under the microscope from both regulatory agencies AND our own patients, it's more important than ever that our billing, fee schedules, coding and referral activities be audit-proof-and whistle-blower proof. Here's how to keep you safe from the danger that now lurks within: • Document everything. That means documenting your policies and proceduresespecially those relating to compliance and regulation. Put everything in writing, and make sure your policies are spelled out in a formal manual and available to every member of your team. Document your patient care correctly by documenting each episode of care. If you are not sure what that means or where you should begin, we can help you get the assistance you need by introducing you to specialists in the field of compliance. • Train your team. Compliance is a process. It will not be done in a day. Once installed, it will need to be maintained, as regulations change, as your procedures change and as your personnel change. When you have defined your policies and your procedures, you need every member of your team appropriately trained. Make sure you systematically train, review and document your training. Just like with patient

care, if it isn't written down, it didn't happen. • Join a DMPO. Too many doctors are still incorrectly discounting their fees or creating dual fee schedulesusually because they want to help their patients receive the care they need at a price they can afford. In reality, these DCs are putting themselves at tremendous risk. Remember, all it takes is one new patient with money on their mind to bring your practice down. An easy way to help your patients and stay clear of whistleblowers is through the use of a Discount Medical Plan Organization (DMPO), which is a safe and legal way to offer your patients discounts. There's no cost to you to become a provider. Go to to sign up for a webinar to learn more about getting a start on building your compliant officeand staying safe from the threat that could be sitting right out in your waiting room--today.

ACA Reports: HIPAA Update By: Julie Lenhardt, Director, Insurance Advocacy, American Chiropractic Association With the advent of EHR, clearinghouses, electronic claims filing, and other means of transferring information

electronically, the responsibilities covered entities (providers) have with regard to privacy and security have become more complicated because a portion of those responsibilities now influence your relationships with vendors. With the implementation of the final HIPAA Omnibus Rule, the regulations' requirements have been extended even further to include the subcontractors of those vendors. What that means is that covered entities should be planning now to accommodate these changes. Additionally, covered entities should also be aware that there are changes to the breach standard - what is required when a covered entity determines that protected health information has been compromised. Business Associates: A Business Associate is defined as "...a person or entity that performs certain functions or activities that involve the use or disclosure of protected health information on behalf of, or provides services to, a covered entity." Previously, this meant a Business Associate was only the organization or individual with whom a covered entity directly did business. However, under the Omnibus Rule, this definition has been expanded to include any subcontractor that handles protected health information (PHI) on behalf of the Business Associate, even if their relationship with the covered entity itself is indirect.

This means that all business associate agreements must be updated to include these changes. Existing agreements may continue to be used until they are amended or renewed, or until September 22, 2014, whichever is earlier. A sample agreement can be found here: privacy/hipaa/understanding/ coveredentities/ contractprov.html In addition, the Omnibus Rule also made changes to liability where business associates and their subcontractors are concerned. Previously, if there was a breach, (if PHI was shared inappropriately) business associates did not have any liability to the federal government. Under the Omnibus Rule, business associates are now directly liable for breaches of PHI. Such breaches include both civil and monetary penalties. This change does not shift liability away from covered entities should a breach be discovered. It does, however, mean that business associates must now implement full compliance programs and that business associates must enter into business associate agreements with their subcontractors. Another important change under the Omnibus Rule is that there is a new breach standard. Previously, HHS defined breach to mean the "acquisition, access, use, or disclosure" of PHI that "compromises the security of privacy" of PHI to the degree that the acquisition, access, use, or disclosure "poses a significant risk of financial, reputational, or other harm to the individual." HHS

determined that the concept of harm was not being construed as they intended. Therefore, under the Omnibus Rule, any impermissible disclosure or use is considered a breach unless it is proven that there is a low probability that PHI was compromised via a detailed risk assessment by the covered entity and business associate, if applicable. The risk assessment should include, at the very least: • The nature and extent of the PHI involved, including the types of identifiers and the likelihood of re-identification; • The unauthorized person who used the PHI, or to whom the disclosure was made; • Whether the PHI was actually acquired or viewed; and • The extent to which the risk to the PHI has been mitigated.

of a state or smaller jurisdiction (such as a county, city, or town), the covered entity or business associate must also notify a prominent media outlet that is appropriate for the size of the location with affected individuals. • Notice to HHS: Information regarding breaches involving 500 or more individuals (regardless of location) must be submitted to HHS at the same time that notices to individuals are issued. If a particular breach involves 500 or fewer individuals, the covered entity is required to report the breach to HHS within 60 days after the end of the calendar year in which the breach occurs via the HHS web portal.

Under the Breach Notification Rule (which is not new and has not changed under the Omnibus Rule), covered entities are obligated to provide the following notifications in the event they determine that there has been a breach:

• Notice by Business Associates to Covered Entities: A business associate of a covered entity must notify the covered entity if the business associate discovers a breach of unsecured PHI. Notice must be provided without unreasonable delay and in no case later than 60 days after discovery of the breach.

• Notice to Individuals: Affected individuals must be notified without unreasonable delay, but in no case later than 60 calendar days after discovery. The notices must be written in plain language and include basic information that is detailed in the Interim Final Rule. Under certain circumstances, a substitute notice may be used.

Already in 2013, HHS has collected over $15 million in settlements in cases involving HIPAA violations, so it is in your best interest to make sure that you are up to speed with all of the changes that were made by the Omnibus Rule. Ensure that your compliance program has been fully updated to meet these new requirements.

• Notice to Media: If a breach affects more than 500 residents

! "#$%&'( ! &)*$+*'( * "&,'& ( Engaging People with their Favorite Subject - Themselves


When you see yourself in a photo via Facebook tag, phone capture or old school printout, who do you look at first and hardest? Right- YOU! We humans are wired to look at ourselves. This normal tendency is why a standardized posture photo is a great tool to get someone's attention and begin a conversation to promote the importance of chiropractic for treating bio-mechanical problems, athletic performance, active living and aging well.

GRQÂśWFRDFKWKem. Cueing people toward their perceived best posture provides a more subjectively reproducible baseline and a strong beginning point to strengthen posture control and build a new baseline of StrongPostureÂŒ.

HOW TO TAKE A POSTURE PI CTURE The first step in taking a picture is to perform a static posture exam, which is simply the concrete action of looking at a SHUVRQœVVWDQFHIURPWKHIURQWEDFNDQGVLGH,WœVDJUHDW ZD\WRWUDLQ\RXUVHOIWROHDUQDERXWHDFKLQGLYLGXDOœVXQLTXH body, as wHOODVEXLOGFUHGLELOLW\DVWKH³3RVWXUH([SHUW´



%\LQVWUXFWLQJVRPHRQHWR³6WDQGVWUDLJKWDQGVKRZPH\RXU EHVWSRVWXUH´\RXDOLJQWKHLUVXEMHFWLYHSHUFHSWLRQ ,œP standing straight) with your objective observations (Look at this distortion).

When looking at posture in a static exam or pKRWRGRQœW worry about trying to understand everything, just observe asymmetry and distortion. Look from the bottom up and note how their head is balancing on their torso, and their torso over their pelvis and center of pressure (CoP) of the feet. When taking the picture a consistent background, positioning and procedure are essential to minimize image variation over time for both in-office clinical and community-based events. A flat wall or a grid works well for the background. Give your subject these instructions: 1. ³6WDQGFRPIRUWDEO\DQGORRNVWUDLJKWDKHDG´ ³7DNHDGHHSEUHDWKLQDQGOHWLWRXW´ D,I\RXUSDWLHQWLVVWDQGLQJVWLIIRU³DWDWWHQWLRQ´DQGWR HTXDOL]HWKHORZHUH[WUHPLW\DQGSHOYLVVD\³0DUFKLQSlace IRURUVWHSV´ ³6WDQGWDOODQGUHOD[HG1RZ, VKRZPH\RXUEHVWSRVWXUH´ Cueing is important for consistent images for comparisons over time. To effectively create posture consciousness and build an internal benchmark for the patient sa\³EHVW SRVWXUH´RU³VWURQJSRVWXUH´DVRSSRVHGWR³MXVWUHOD[´7KH JRDOLVWRVHHZKDW³JRRGSRVWXUH´PHDQVWRWKHP ,QRWKHUZRUGVZKDWœVWKHLUSHUFHSWLRQRIZKHUHWKHLUERG\ should be? People naturally try to assume a good posture, so


This creates an Aha! Moment when the patient sees their SRVWXUHSLFWXUHDQGUHDOL]HV³,NQRZ\RXVDLGWRVKRZ\RX P\EHVWSRVWXUHDQG,WKRXJKW,ZDVVWDQGLQJVWUDLJKW´ A digital photo is a practical, inexpensive and clinically intelligent way to track progress. Adding a grid allows the DC to infer many of the observations we used to make on 14x36 x-rays, at lower cost and without harmful radiation. People are engaged to see changes at the end of a phase of care or when you show progress (or decline) with annual posture picture comparisons. Increasing awareness and posture consciousness is the springboard for a narrative story communicating the relationship between their concern with pain, performance or wellness, the biomechanics of their body, and the services you provide. COM I NG SOON: Why Common-Sense Will Rule. (If people FDQœW easily communicate it to their friends, they won't. But if they can, they may.) Dr Steven Weiniger is author of Stand Taller ~ Live Longer and lectures internationally on exercise and posture rehab. Dr. Weiniger has been featured in professional journals and mainstream media including )2;1HZV2SUDKœV2[\JHQQHWZRUN1DWXUDO+HDOWK, American Fitness and Bottom Line Health. He serves as Managing Partner of, which provides posture, chiropractic, massage and wellness information and referrals to local Posture Exercise Professionals (CPEP). Contact Dr. Weiniger at or

Resistance is Futile By Dr. R. A. Foxworth, FICC, MCS-P President, ChiroHealthUSA Certified Medical Compliance Specialist There will always be those amongst us who have great affection for old school style: stovetops over microwaves, LPs over CDs, handwritten letters over email. You might even be one of them. For you, the good news is that you can opt out of filing electronic Medicare claims and continue to submit them the oldfashioned, paper-based way. But, and you knew there was going to be a but, if you want to actually get paid you're going to have to surf the wave of the future and accept reimbursement by Electronic Funds Transfer (EFT). It's all part of recent Medicare changes made as part of the Insurance Portability and Accountability Act (HIPAA). Resistance is futile. Here's the relevant formal language of the act, outlined in a message from Part B Medicare Administrative Contractor (MAC) Palmetto GBA: "Existing regulations at 42 CFR 424.510(e)(1)(2) require that at the time of enrollment, enrollment change request or revalidation, providers and suppliers that expect to receive payment from Medicare for services provided must also agree to receive Medicare payments through electronic funds transfer (EFT). Section 1104 of the Affordable Care Act further expands Section 1862(a) of the Social Security Act by mandating federal payments to providers and suppliers only by electronic means. As part of CMS' revalidation efforts, all suppliers and providers who are not currently receiving EFT payments are required to submit the CMS-588 EFT form with the Provider Enrollment Revalidation application, or at the time any change is being made to the provider enrollment record by the provider or supplier, or delegated official." The reason for the change is obvious: the government will save approximately a bazillion dollars by not printing and mailing checks. But the implication is more subtle. If the government is looking to save and recoup money wherever and whenever it can, what do you suppose will happen to you and your practice if

they determine you've been overpaid and decide to go after you? Clearly, it's more important than ever to get your financial house in order. If you're billing correctly, coding correctly and discounting correctly, you can breathe easy-you have no need to be worried about fund recoupments. But, if like many doctors, you're not 500% confident in your practice's financial foundation, it's time to act--now. Here are a simple few steps to keep the government wolves (or, if you prefer, the Borg) from your door. 1) Implement Your Compliance Program Compliance is the law and a requirement of the Affordable Care Act, but it's also your best protection against running afoul of Medicare issues. Bringing your practice into compliance is a process, not an event, and one in which we're extraordinarily wellpositioned to help. As a result of attending many state association meetings and other events across the nation to educate our profession about the benefits of using a Discount Medical Plan, we've had the opportunity to get to know some of the brightest minds in our profession, including compliance experts. Our friends are your friends. If you don't have a Compliance Program in place, just give us a call at 888-719-9990 and ask for a compliance referral. Depending on the size and complexity of your practice, whether it's a solo practice or a fully integrated DC/MD/PT practice, we'll do our best to steer you to an expert that best suits your needs. 2) Get Your Fees Straight If you're not confident in the legality of your fee schedule, if you haven't implemented a valid Hardship Program, or if you don't have written policies and procedures about how your practice manages its finances, you've got a glaring problem (and a red flag for the government) that needs to be fixed. Call ChiroHealthUSA and we will be happy to refer you to one of the many consultants we work with that can help with get this area of your practice cleaned up once and for all. We work with consultants that have educational materials that walk you through

the process if you are a do-it-yourselfer, or we can refer you to consultants that will assist you every step of the way. 3) Join a DMPO Today ChiroHealthUSA is a Discount Medical Plan Organization (DMPO). DMPOs allow you to offer legal network based discounts for your uninsured, under-insured or partially insured patients. That's a big deal to most doctors, many of whom report that concern for their financially challenged patients tempts them to lower their fees or to offer time of service discounts in excess of the 5-15% range considered reasonable by the OIG in one of their opinions. Don't fall victim to leaving money on the table, or allow your practice to be at risk of incurring fines for inappropriate discounts or inducements. Join ChiroHealthUSA today and start practicing with more peace of mind. There is NO cost for you to join and our free webinars teach you how to protect yourself and get your financial side of the practice in tip top shape! Go to to register today.

What Lies Ahead The Texas Chiropractic Association (TCA) has completed the 2013 Legislative session, but work continues preparing for the 2015 session. The American Chiropractic Association (ACA) has announced its vision for the future and reported on the interactions between these state and national chiropractic associations. Let us review these visions and activities as they have recently been reported. ACA'S VISION FOR THE FUTURE The ACA has committed itself to a vision for the future for the next ten years. Says the ACA, "we commit ourselves to the highest clinical and ethical standards, freedom of choice of healthcare providers and the pursuit of optimal health for the healthcare consumer." Within the next ten years the ACA hopes

to help bring about collaboration with other health care disciplines and integration of the chiropractic doctor into all health care delivery models that enhance individual health, public health, wellness, and safety. ACA also will work to introduce change into the public policy, legislative, and regulatory arenas that will result in a more effective health care system for the United States. They will seek improved health care access and freedom of choice for the American people without discriminatory obstacles. Increased value of health care for patients, policymakers, and the public will be the result of high professional and educational standards of the chiropractic profession and healthier and more productive lives for the American People are the sought after outcomes. ACA President Keith Overland D.C. offers his "topten list" of ideas to accomplish these goals:

• •

Create strong public demand for our services. Increase professional integration and collaboration with health care providers in clinical and educational arenas. • Develop formal residencies and post-graduate educational opportunities both in the last year of education and upon graduation. • Remove arbitrary limitations preventing patient access in federal, state, and commercial health care models. • Deliver the message that we are a physician-level, portal-of-entry provider. • Improve intraprofessional enforcement against inappropriate conduct by a small minority of DCs. • Support funding for research that would allow intraprofessional development of a full breath of best practices, guidelines and standards. • Review all 50 states' laws and encourage a uniform minimum standard allowing DCs to practice to the fullest extent of their education. • Never depute our internal professional issues in public. • Reverse the growing trend perpetuating the divisive belief that some in the profession follow chiropractic philosophy and others do not. We need to grasp … a foundation of therapeutic conservatism, naturalism and holism.

WORKING CLOSELY AT THE STATE LEVEL The ACA State Affiliation Program is intended to benefit the profession and its patients by bringing together the strengths of the ACA and state chiropractic associations. While the national association generally has information and resources beyond what is available to the state organizations, the state organizations possess local infrastructure of active members working for the profession is its chief strength. The exchange of representation--state representatives to the ACA and ACA representatives to the state organization--insures that a balanced state/national perspective is maintained. The Texas Chiropractic Association was represented at each of the four ACA House of Delegates meetings held during the past year. The TCA Representative, Michael Martin D.C., has been appointed to the State Affiliation Committee and has been working within the ACA committee structure to further oversee, develop, and grow the State Affiliation Program. Currently the ACA Insurance Liaison Program and the TCA Insurance Relation committee have worked to integrate information and resources into their committees and operations; The Public and Media Relations Committee of the TCA has worked to access ACA information and provide needed assistance at the regional level; The TCA leadership is also making use of ACA information and developing necessary infrastructure. Other aspects of the TCA are also beginning to collaborate with ACA resources: Continuing Education, Governmental Affairs, Membership Development, and Information technology are a few. During the past year advancements have been made and more are coming on line in the current year. TEXAS LEGISLATURE 2015 The 83rd Texas Legislature was barely completed before the TCA began to develop its plans for improving the standing of our profession through the legislative process. Such plans include much more interactive dealings with the Texas Board of Chiropractic Examiners, a greater engagement in the rule making process of the TBCE, and seeking closer relationship with various key legislative personnel.

We continue to develop our ability to make use of grass roots activation, and continue to maintain a list of possible legislative activities to pursue in legislative sessions to come. YOUR INVOLVEMENT IS NECESSARY It is often promoted, but seldom documented the direct effect that membership in your professional associations brings. Have you ever considered what would be lacking if there were no organization to work on behalf of the profession as a whole? Here is but a short list of some of the things that happened this past year that would have left the chiropractic profession lacking if there were no effective state or national chiropractic association:

The Texas Medical Association would have removed your right to render a diagnosis--TCA and TBCE pursued the defense of this legal authority, only the TCA "took it all the way to the Supreme Court of Texas." • Various anti-chiropractic bills would have passed if the TCA Governmental Affairs team had not been present to insure that discriminatory legal language did not become State Law. • Various pro-chiropractic bills would not have gotten as far as they did. We fell short of attaining our goals, but with continued year-round education of our legislators some of these bills may stand a better chance in 2015. Continued persistent effort is required. • The Patient Protection and Affordable Care Act (National Health Care) may very well have included language discriminatory to the chiropractic profession if the ACA was not diligent in watching and working to prevent it. This diligence continues to be required. The American Medical Association has publicly stated that it is their desire to see discriminatory language inserted into the federal law. • The strong pro-chiropractic directive of the House Armed Services Committee official committee report accompanying the FY 2013 National Defense Authorization Act would not have been included. This report asserts that the services provided by doctors of chiropractic for our uniformed services is of "high quality" and has become a "key" benefit within the military health care system.

Pro-chiropractic congressional representatives may have lost their elections without the help of the ACA. • Certain large insurance companies might have continued their discriminatory chiropractic policies if the ACA had not intervened for injunctive relief. • Other large insurance companies might have continued their "all or nothing" contracting relationships with doctors of chiropractic if the national organization had not negotiated a policy change. • Media assistance would be lacking if the ACA and TCA were not available to members of the media to answer their questions, and successfully represent the profession in its entirety.

who is a part of a body of people engaged in an occupation or calling-- and be a professional--one who makes a public declaration of that occupation. Be a chiropractic professional and join your state and nation chiropractic associations.


These accomplishments, and there are certainly many more than these few, would not have been possible without the active support of membership dues in these state and national chiropractic associations. Your membership in your state's chiropractic organization and in the national chiropractic association are vital to insure that the profession remains a viable option for doctors who seek to restore normal function to the body. Dr. Overland concisely states what lies ahead: "as a profession we have an opportunity facing us like no other in our history. Our entire U.S. health care system is transforming. The payment mechanisms and delivery systems are changing, and evidence and cost savings are required. The work-force shortage is opening opportunities for all providers. Most important, people are looking for healthier lifestyles. But when illness strikes, they can first utilize a highly effective treatment that is the most conservative, least invasive and safest approach to health care. That, my colleagues, is chiropractic." What lies ahead is what has always been there-opportunity, change, and lots of work. The question is will WE join together to make the work load lighter, or will "each individual" seek to remain an "island unto himself?" What lies ahead is divided we fall. United we stand. Take a stand for chiropractic. Be a professional--one

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July / August 2013  

The Texas Journal of Chiropractic July/August 2013 Issue

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