Medicare: Quit Giving Directions, Start Providing Solutions
I read the recent article by Dr. Seaman, et al. ["The Medicare Hurdle That Continues to Block Our Professional Progress," April 9, 2012]; the article provided some great information, but misses the real problem.
First of all, in my state of South Carolina we do not get paid for a exam or radiographs. How do they expect us to get this information? At the end of Dr. Seaman's article, he suggests we develop a form that allows for consistent documentation of each Medicare patient visit. Here is the problem: There are no forms, no demos, no case studies and nothing for doctors to look at. Medicare won't give you a case study of what an acceptable case study looks like.
I would like to see what the doctor notes would look like for a patient with low back pain. This could be totally hypothetical. I would pay good money to see what a start-up looks like, what the doctor notes look like for three visits, and then what they would do if on the fourth visit, the patient came in with neck pain. What would their review look like and what would the bill look like?
In any other health profession, particularly medical, you can find case study after case study. This is part of how they learn. All we get in chiropractic are instructions of what a Medicare form should contain – whoop-dee-do. Computer programs provide some examples, but they lack a functional way to practically review previous visits. You can do it, but the time cost isn't worth it. Just one time, I would like to see someone say, "This is what an acceptable case looks like."
I realize that each patient is different, but really, give us one form that Medicare will accept. This is where the problem is! Not one doctor can show you what a completed form looks like. Its a lack of standardized forms that keeps this problem going, making good doctors look bad.
I would spend a good part of a day trying to get all of Medicare's wants and needs in for one patient visit. Really, an exam every visit? It won't be until there is a acceptable form for doctors to follow that chiropractors will get relief from terror on paperwork. I would even pay a peer-review group of chiropractors to review my case and billing if it were realistic. If you really want to save the profession, let's quit giving directions and start providing solutions.
Peter Clouse, BS, RPH, DC
Monks Corner, S.C.
Primary Care: A Principle of Health Care Delivery, Not a Wish List
Dr. Edwards recommends the chiropractic profession "abandon the primary care term and instead focus on ensuring we remain ‘direct-access, first-contact physicians.'" [See "Primary Care: Be Careful What You Wish For" by Dr. James Edwards, April 9, 2012 issue.] This suggests we abandon our principles, our educational mandates and our legal scopes of practice. More importantly, it suggests we turn our backs on those free-thinking people and their families who seek naturally-based primary care.
He suggests those in favor of primary care recognition believe the profession can only survive if we "become (emphasis mine) primary care physicians." To this I submit that we have traditionally provided primary care to the general public, where it counts the most, and are legally recognized as a primary care profession through federal and state law. The Council on Chiropractic Education, recognized by the U.S. Department of Education, mandates chiropractic colleges prepare students in primary care. The Chicago chiropractic primary care study, which Dr. Edwards acknowledges, demonstrates safe and effective chiropractic primary care. The ACA and ICA posit the profession as primary care. Most chiropractic state practice acts specifically recognize and/or provide adequate scope for the DC to provide primary care.
Dr. Edwards also suggests we look at "primary care in the medical model" [with the assumption that for DCs to practice true primary care as stipulated by medicine, they would need to provide vaccinations]. To this I ask, where is it stated or scientifically proven that the "medical model" is to be followed by every free-thinking person in America? Although the current system may be following this model, there is no reason to follow along, especially when it is clearly documented that the model has failed the American people in terms of cost, health status and individual liberty.
This suggestion to fit into one discipline of health care lends credence to those who monopolize America's health care consciousness. Must we yield to the pressures of tyranny and abandon our responsibility to our patients, free-trade principles and good scientific inquiry?
We must proclaim our fellow citizens' right to select their primary care physician in a manner consistent with their way of life and our right to develop our profession consistent with our traditional primary care principles. We must demand that good science and its application to the human condition is not thwarted by the health care monopolists.
Primary care is not on our "wish list." We started with a theory, developed our educational training and clinical skills, and have evolved into a naturally based, whole-body healing art/discipline. Primary care has been accorded us by people exercising their rights to self-determination and responsibility. It is incumbent upon us to exercise our liberty and stand up for those same rights.
If it is not us who provide naturally based primary care, the naturopathic profession will continue to do so (and they should) or another discipline will develop to fill the need. It is our responsibility to help our society uphold and establish health care policies and laws consistent with the constitutional rights of all Americans.
Richard Duenas, DC, DABCN, FICC
West Hartford, Conn.
Cultural Authority Jargon and the Power of Evidence-Based Care
In the past 10 years numerous articles have been written using the "jargon" of chiropractic cultural authority, all voicing vastly differing perspectives on its importance and providing cookbook recipes about how each author believes we could achieve it. The result of these numerous conflicting voices is ambiguity, which in turn hinders the profession's aspiration for more cultural authority, rather than promoting it. As a result, this balkanization has further fractioned our profession and continues to disorganize any legitimate attempt at a future consensual movement for authority.
More recent suggestions place the end result of more cultural authority before the steps required to obtain it. One such step overlooked is that in order for the profession to obtain any permanent cultural authority, it must first have a cultural identity. A single, recognizable professional identity is by far the most important and necessary step to progress change, and it is continuously overlooked.
Our current professional divide has lead to a seemingly never-ending argument of belief versus science, creating the paradox we have resided in for the past 100 years or more. Are we subluxation technicians? Are we nonsurgical spine specialists? Are we primary care providers masquerading as "back doctors"? Our lack of a definitive domain and identity makes it next to impossible to be granted authority to govern it.
Yet "grassroots" individualized efforts placing the responsibility on the shoulders of each doctor of chiropractic to establish their own cultural authority is the best we can propose. Somehow, it is believed that the efforts of individuals will lead to an overall public agreement on authority. Is this really what the profession needs or deserves?
In a recent article, Arlan Fuhr, DC, provides telling insight into this current mindset within the profession regarding a "grassroots" cultural authority campaign. [See "Building Bridges to Chiropractic Cultural Authority," Part 1 and Part 2.] He states that the profession's current lack of cultural authority "has led many chiropractors to voice a desire for a greater chiropractic cultural influence while placing the responsibility of winning that influence on our academic institutions, researchers and national associations." He goes on to say, "The reality is that any chiropractor in practice who desires to expand chiropractic cultural authority need not wait for testimony from patients or researchers to increase their cultural authority in their community."
Will these types of individualized "grassroots" efforts be effective in obtaining cultural authority or make any kind of change in the overall public perception? The answer is no, as long as a majority of the profession is still confused about what it's trying to obtain authority over. The end result of grassroots campaigns for cultural authority is thousands of individual chiropractors spreading mixed messages and actually pushing us further away from any sort of profession-wide cultural authority or identity.
The notion put forth by Dr. Fuhr resonates the crux of our current dilemma. We are rightfully waiting for a cultural identity, and thus the cultural authority that follows. This must come from our academic institutions, research and our national organizations, because those are the very things necessary for obtaining cultural authority; and we are currently lacking one of those pieces more than the others.
So, what is the Achilles heel of our cultural identity? The tune-up of chiropractic academic programs by the CCE was necessary and a step in the right direction, despite the recent opinions of some. It created a minimum standard to be upheld by anyone graduating with a doctorate of chiropractic, and begins to build consensus regarding expectations of professional knowledge.
Increasing numbers of studies have been published that demonstrate the benefits of spinal manipulation for spine conditions, solidifying the chiropractor's relevance within modern health care. More research is ongoing, but current studies reinforce the necessity of chiropractic care within the current health care system.
The missing piece is that, as a profession, we are desperately in need of a unified national initiative for cultural authority spearheaded by a single, mutually consenting national organization to state our definitive identity, thus enabling the profession to speak with one voice. Many would argue this proposition creates another evidence-based / philosophy-based argument, but I believe this argument has already been settled.
Dr. Fuhr explains this in his article very poignantly by stating, "Chiropractic is squarely settled under the umbrella of ‘health care.' That means the gatekeepers to authority are those that define cultural authority in the Western medical model." This statement wisely and concisely suggests the direction our profession must take. The established Western medical model Dr. Fuhr is alluding to is the evidence-based model of health care, which by its very nature defines how authority is granted, and therefore how as a profession we can obtain it. We have already begun on this path through academic standardization, and are amounting research for scientific standardization. The last piece of the puzzle is identity standardization, which must come from a national organization or entity, not any one individual.
Given the structure of the evidence-based model of health care, we need our organizations to choose to only define our professional identity using quality research that reinforces why spinal manipulation is necessary for conditions demonstrably improved through chiropractic care. Currently, our national organizations use models for defining the profession that astride the scientific and philosophical viewpoints and continue to discredit the profession within the evidence-based community. It is time to focus our identity on only things supported by research, leaving things out of the definition that cannot be demonstrated.
Unfortunately for some, this means that moving forward will require that some opinions count more than others based on the quality of evidence supporting them. But as author Sam Harris brilliantly stated in a presentation, "Whenever we are talking about facts, certain opinions must be excluded. That is what it is to have a domain of expertise; that is what it is for knowledge to count."
Michael Farrell, DC
Grand Island, N.Y.
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