Written by Galen O. Ballard
Sunday, 25 November 2012 17:28
n September 8, 1965, Dorothy Dandridge, the first black American to be nominated for an Academy Award for Best Actress, was found dead. The cause was an accidental overdose of Tofranil, an anti-depressant.
Moving ahead to February 11, 2012, Whitney Houston, the world renowned singer and actress, was found dead with Xanax and alcohol in her system. Bottles of prescription drugs in her hotel room included Xanax, Valium and Ativan - all anti-depressants prescribed to treat anxiety.
Anti-depressants, anti-anxiety, and insomnia drugs truly have become “The Nightmare on Pill Street!”
In nearly 50 years of prescribing anti-depressants the results are all too frequently the same - drug addiction, mental impairment, irrational and violent behavior, panic attacks, suicide, and death. An estimated 27,000 people a year die from accidental drug overdoses in the U.S.¹ , one death every 19 minutes!
Clinical depression currently ranks second only to advanced coronary heart disease in the total number of days patients spent in the hospital or disabled at home. Pharmaceutical companies have overall yearly sales of $16 billion from anti-psychotics and $4.8 billion in sales of ADHD drugs ². As of 2005, the most recent year for which data were available, about 27 million people, or 10 percent of Americans, were taking antidepressants.³
How did the United States – whose citizens are known the world over for their outgoing self-confidence – emerge as a leading consumer of anti-depressant and anti-psychotic drugs for social anxiety? How do those of us in the profession of holistic health and natural medicine reverse this trend
Manufacturing Mental Illness
The appeal of pharmaceutical drugs is deceptively compelling. The allure that taking a pill can solve our health problems and make us feel good with little or no effort on our part is heavily promoted. In 2007, the pharmaceutical industry was estimated to be spending $4.8 BILLION dollars a year advertising prescription drugs directly to the public. The Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association, is the official manual listing psychiatric and psychological disorders. Many health professionals believe the DSM has created mental illnesses out of ordinary life experiences.
The DSM has a label and a code for most deviations from everyday behavior or passing mood swing that a person may experience4. Do you experience excessive anxiety regarding separation from people to whom you have strong emotional attachments? That’s Separation Anxiety Disorder (SAD) or code 309.21. Recurring bad dreams? That may be Nightmare Disorder, code 307.47. Then there’s the ultimate catchall for vague sadness or uneasiness, General Anxiety Disorder (GAD), code 300.02.
By perceiving ordinary life experiences as certifiable mental illness, the patient becomes treatable by psychotropic drugs and billable through insurance companies.5
Anti-depressants are no more effective than Sugar Pills!
The pharmaceutical industry claims (and advertises) that depression is caused by a shortage of serotonin -- an imbalance the drug companies say can be corrected by a class of anti-depressants called Selective Serotonin Reuptake Inhibitors (SSRIs). These drugs prevent the body from metabolizing Serotonin, thereby increasing its presence in the brain.6 Prior to psychiatry’s proclamation that depression was caused by too little of the neuro-transmitter serotonin, few Americans were taking antidepressants. But by declaring that depression was caused by a serotonin imbalance, which could readily be corrected, Americans suffering from stress, insomnia and mild depression became far more receptive to taking serotonin-enhancing drugs such as Prozac, Paxil, and Zoloft.
Research, however, demonstrates that the pharmaceutical industry's serotonin imbalance theory of depression is erroneous!
Scientists have known for quite some time that serotonin levels are not associated with depression. Research on serotonin has been clear from the very beginning that the most damaging thing that could be done to the serotonin system would be to impair one's ability to metabolize serotonin. Yet that is exactly how SSRI antidepressants exert their effects.
A 2010 study published in the Journal of the American Medical Association (JAMA) found that anti-depressants are basically useless for the vast majority of people who take them. They were only effective on patients with very severe symptoms.7 Psychology professor Irving Kirsch, Ph.D., analyzed clinical data files from the FDA on published and unpublished trials; he found no significant differences between anti-depressant drugs and placebos. What he did find was extreme differences in side effects.8
Is there a Link connecting Anti-depressants to Violent Behavior, Suicide, and Death?
A study out of the University of Southern California in 1996 looked at a group of mutant mice in an experiment that had gone terribly wrong. These genetically engineered mice were the most violent creatures they had ever witnessed. At birth they were lacking the MAO-A enzyme which metabolizes serotonin, thus their brains were awash in this neuro-transmitter. The researchers determined this excess serotonin was the cause for the extreme violence in these mice.9
Paranoia, hallucinations, and violent behavior are all hallmark side effects of anti-depressant drugs! It now appears reasonable that anti-depressants may trigger the very symptoms they were touted to suppress. Much of the bizarre and unexplained violence in this country today may be the result of overmedication with anti-depressants and anti-psychotics.
On November 4, 2011, in Winnipeg, Canadian Judge Robert Heinrichs ruled that antidepressants like Prozac can cause children to commit murder and concluded that a 15-year-old boy was under the influence of Prozac when he fatally stabbed a close friend. The judge's opinion was a landmark legal confirmation of the scientific fact that the newer antidepressants like Prozac, including the SSRI and SNRI anti-depressants, can cause violence and even murder.
Psychotropic drugs are a contributing cause of adverse and dangerous mental instability, sometimes causing the victims to commit suicide or murder.
As far back as 1991, the Citizens Commission on Human Rights (CCHR) organized dozens of individuals and experts to testify before the FDA that people with no prior history of violence became homicidal and suicidal under the influence of antidepressants. To comprehend the full ramifications of these acts of violence and the concurrent use of anti-depressants, more information can be found at ssristories.com. The evidence is becoming overwhelmingly clear: Psychotropic drugs are a contributing cause of adverse and dangerous mental instability, sometimes causing the victims to commit suicide or murder.
Going Back to the Future!
Stress has always been with us. It is simply the body’s nonspecific response to any demand made upon it. Stress was programmed into primitive man to provide him with the fight or flight response necessary for his survival. But modern man is usually in situations where neither fight nor flight are viable options so his stress point – unless it can be assuaged or channeled – elevates to anxiety-producing levels. Anxiety is merely the normal response to prolonged or chronic stress. Depression is the result of being unable to handle chronic stress while insomnia can be precipitated by stress, anxiety, or depression. They are all interrelated and can be treated holistically in an effective manner.
Since the beginning of time, humans have experimented and utilized various herbs and foods for treating mood problems in an effort to maintain health. Achievements in doing so were remarkable because the plant kingdom supplies a wealth of building blocks for calmative, nervine, and muscle relaxant medicines. Unlike drugs, natural medicines address the underlying causes of stress, anxiety, depression, and insomnia while drugs attempt to treat the symptoms. Allopathic medicine is negligent in looking for the real causes of depression, such as thyroid problems, lack of exercise, a bad diet, a guilty conscience, medical problems, allergies, environmental factors, and a host of other possibilities. It’s easier and more profitable to write a prescription for an anti-depressant!
Natural Remedies for common psychological disorders
Specific herbs, minerals, and vitamins have extensive therapeutic histories and have been clinically shown to assuage and ameliorate common psychological disorders and resolve their underlying causes without subjecting the patient to synthetic drugs which are foreign and toxic to the body.
One of the most effective herbals to reduce stress - supported in the literature and by clinical research - is Rhodiola rosea which increases the body’s resistance to stress, anxiety, trauma and fatigue. Classified as an adaptogen, this herb exhibits the ability to increase resistance to a variety of chemical, biological, and physical stressors. Rhodiola also appears to regulate the body's production of cortisol, a critical "stress hormone.10 Clinical studies have also shown Rhodiola to improve physical and mental performance, and specifically the ability to concentrate11 as well as reducing both mental and stress induced physical fatigue.12 Is this herb a viable alternative to plying our children with addictive ADHD drugs?
Hops strobiles from extract is often utilized for its calming and antispasmodic effect on the nervous system.13 Hops are fast acting. A soothing, relaxing calm may be experienced within 20-40 minutes after ingesting the herb.14
One of the most effective natural medicines to reduce anxiety - supported in the literature and by clinical research - is Inositol, a natural tranquilizer proven to help the individual by combating anxiety.15 In a 1995 double-blind study by the Ministry of Mental Health at Ben Gurion University, the efficacy of Inositol was superior to fluvoxamine, a prescription antidepressant, in patients with anxiety disorders. Patients reported side effects of nausea and fatigue with fluvoxamine. Because it is water-soluble, Inositol does not produce toxic side effects.16 Gota Kola is another neural tonic herb which has been utilized as a treatment for nervous breakdown.17
There are several medicinal herbs which have show to be effective in reducing chronic depression. One is Passiflora incarnata, which acts as a natural tranquilizer. Its analgesic effect has been demonstrated in laboratory and clinical tests.18 Passiflora works by increasing the availability of the neurotransmitter GABA (gamma-aminobutyric acid), which has a calming effect on the nerves. Again, Rhodiola rosea has been used for centuries in Russia and Scandinavia to treat both anxiety and depression.19 It has been demonstrated to effectively alleviate mild to moderate depression
The most effective natural medicine to alleviate chronic insomnia has long been an over-the-counter insomnia remedy in Germany, France, Switzerland, Belgium, and Italy. Valerian root is a sedative herb which sleep support studies clearly show improves sleep quality and sleep latency but leaves no “hangover” the next morning as is often observed with pharmaceutical sleeping aids.20 This herb has demonstrated to be especially effective when sleep disorders are the result of anxiety, nervousness, exhaustion, or hysteria.21 Another cause of sleeplessness is magnesium deficiency. Magnesium supplementation is dramatically underutilized by conventional physicians. Seventy-nine percent of adults 55 and over are not ingesting the recommended dietary allowance (RDA) of magnesium. Symptoms of a magnesium deficiency include insomnia, anxiety, hyperactivity and restlessness with constant movement, panic attacks, agoraphobia, and premenstrual irritability.22
European medical practitioners have long utilized natural medicines and herbals to regulate psychosomatic disorders. In Europe, natural medicines are prescribed like other medications and enjoy widespread scientific and medical acceptance. All German medical students, for example, must learn phyto-medicine, and approximately 80 percent of German physicians regularly use natural medications in their practice. Unfortunately, in America pharmaceutical advertising has become so pervasive and successful that psychological drugs have become a first resort, regardless of their lack of effectiveness and their draconian side effects. (The United States is one of only two countries in the world that allow pharmaceutical companies to advertise directly to the consumer.)
The public is finally becoming aware of how dangerous these anti-depressants are as more and more individuals go berserk on them! It’s beginning to exact a toll on our society. As holistic health professionals we understand that drugs are synthetic poisons and we simply cannot condone this poisoning of our citizens for profit to continue! Anti-depressant drugs are turning us into a nation of muddled, brain-addled addicts incapable of controlling our own emotions and behavior! These drugs are medically useless and physiologically dangerous. We have an obligation to speak out and educate our patients and the people we come into contact with and make them aware that superior natural alternatives to psychosomatic drugs are available. If we fail, the joke will be on us!
- Pratt L, Brody DJ, Gu Q. Antidepressant Use in Persons Aged 12 and Over: United States, 2005-2008. NCHS Data Brief. No 76. October 2011.
- IMS Health National Prescription Audit PLUS.
- Study: Number of Americans using antidepressants doubles - FierceHealthcare http://www.fiercehealthcare.com/story/study-number-americans-using-antidepressants-doubles/2009-08-05#ixzz1wO1NEbuS
- American Psychiatric Association. Practice guidelines for the treatment of patients with major depressive disorder. 2nd ed. September 2007. Accessed January 22, 2010
- Friedman, R, M.D., New England Journal of Medicine (NEJM), May 17, 2012
- Kaplan, H.I. and Sadock,B.J. Synopsis of Psychiatry, Eighth Edition, Baltimore: Williams & Wilkins. 1998
- Antidepressant Drug Effects and Depression Severity, Jay C. Fournier, MA; Robert J. DeRubeis, PhD; Steven D. Hollon, PhD; Sona Dimidjian, PhD; Jay D. Amsterdam, MD; Richard C. Shelton, MD; Jan Fawcett, MD JAMA. 2010;303(1):47-53
- Kirsch I, Deacon BJ, Huedo-Medina TB, Scoboria A, Moore TJ, Johnson BT. Initial severity and antidepressant benefits: a meta-analysis of data submitted to the Food and Drug Administration. PLoS Med. 2008;5(2):e45
- Dr. Ann Blake Tracy of the International Coalition of Drug Awareness, testimony on September 13, 2004 before the FDA.
- Gregory S. Kelly, ND, Alternative Medicine Review 6 (3): 293–302
- Shevtsov VA, Zholus BI, Shervarly VI, et al. (Mar 2003). “A randomized trial of two different doses of Rhodiola rosea extract versus placebo and control of capacity for mental work”. Phytomedicine 10 (2-3): 95–105. PMID 12725561
- Darbinyan V, Kteyan A, Panossian A, Gabrielian E, Wikman G, Wagner H (Oct 2000). “Rhodiola rosea in stress induced fatigue—a double blind cross-over study of a standardized extract with a repeated low-dose regimen on the mental performance of healthy physicians during night duty”. Phytomedicine 7 (5): 365–71. PMID 110819
- Wohlfart, R, et al, Planta Medica, vo. 48, p. 224, 1982
- Stocker, H, Schweizer Braverei Rundschau, vol. 78, p. 80, 1967
- Cooper, AJ, Psychopharmacology, vol 61, pp 97-102, 1979
- PubMed: Journal of Clinical Psychopharmacology; Double-blind, Controlled, Crossover Trial of Inositol Versus Fluvoxamine in the Treatment of Panic Disorder
- Mowrey, DB, The Scientific Validation of Herbal Medicine, p 193, 1986
- Ambuhl, H, “Anatomische und chemische untersuchungen an Passiflor incarnata,” Dissertation Number 3830 ETH, Zurich, 1966
- Darbinyan, V.; Aslanyan, G.; Amroyan, E.; Gabrielyan, E.; Malmstroumlm, C.; Panossian, A. Clinical trial of Rhodiola rosea L. extract SHR-5 in the treatment of mild to moderate depression Nordic Journal of Psychiatry, Volume 61, Issue 5 2007 , pages 343–348.
- Leathwood, et al, Pharmacol. Biochem & Behav, vol 17, pp. 65-71, 1982
- Straube, C, Therapie der Gegenwort, vol 107, pp. 555-562, 1968
- Baker, S.M. Magnesium Deficiency in Primary Care and Preventive Medicine, Magnesium and Trace Elements, 1991-1992; 10:251-262
Galen O. Ballard is President of Titan Laboratories and directly responsible for the products division. His background includes undergraduate studies in research at the University of Denver with graduate work at the Universities of Wisconsin and Maryland. Galen may be reached toll free at 1-800-929-0945 or by email at
Written by Dr. Gabe and Sherrie Spruch, All Care Health and Rehabilitation Center
Tuesday, 23 October 2012 20:42
ffective billing and claims submission processes and procedures, both during today’s current challenging economy and in better times, have been key to our chiropractic practice’s continuing health and ability to grow. Improved revenue cycle management has positively and directly impacted the level and overall quality of the patient care we deliver, as better accounts receivable yields dollars for reinvestment in state-of-the-art technologies.
The same can be said for our chiropractic practice brethren. In addition to offering a wider range of patient payment options beyond cash and checks, including credit and debit cards and e-payment, increasingly sophisticated and fully useful software solutions are automating once paper-based clinical and business applications while facilitating integration with collection agencies and clearinghouses.
These solutions serve as inexpensive tools that chiropractic practices leverage to more thoroughly capture revenue from existing patients, while also making it easier to accommodate increasing patient volumes.
We formed the All Care Health and Rehabilitation Center here in Jefferson, IN more than 20 years ago, eons when one considers the now archaic paper-based billing and claims processes then commonly in place. Our practice only a scant two years ago began using billing and notes software and clearinghouse services. We’re still modest in size; our staff consisting of Dr. Gabe Spruch and one other physician, and Sherrie Spruch and three other support staff members. We transitioned to our current system after years of enduring painful and time consuming paper-based processes, followed by a period during which an outside billing service handled our billings and claims electronically.
Frankly, the thought of moving billing and claims processing back under our roof was not something we initially were wildly enthusiastic about.
But we’re glad we did, and are certain that other chiropractic practices either feel the same or are seriously considering going the same route. The revenue cycle management solution has fully automated our entire suite of clinical and business processes, from scheduling and documentation, to accounting, administration and enterprise management. Our overall practice efficiencies and end-to-end payment management have been markedly improved, as has workflow as it relates to reduced billing and clerical errors, reduced accounts receivable and faster payment posting and book balancing resulting from an auto-remittance feature.
Software, by itself, unless used properly and to its full capability, won’t enable chiropractic practices to be as efficient as possible. Built-in analytics tools enable practice administrators to closely examine patient responsibilities like co-payments, deductibles, coinsurance payments and other similar fees. Reviewing these, over time, has enabled us to better identify problem areas and work with patients in addressing the most serious situations for improved revenue flow.
We electronically sub-mit nearly all—99 percent—of our claims.
It’s also critical that solution providers walk physicians and support staff step-by-step, process-by-process to do so. Practices must be aware of each individual insurer’s unique policies and procedures, and learn exactly how to file claims to each. Practices therefore should choose software not only based on its functionality and cost, but also as it relates to a vendor’s ability and willingness to provide strong support before the sale as well as during and after implementation.
The best systems don’t only facilitate claims submission; their developers will also hold claims for chiropractic practices for required edits, dramatically reducing insurer rejections, speeding up payments and maximizing revenue flow. Some vendors will also electronically accept remits on a practice’s behalf, so that all the chiropractic office needs to do is download them into the billing software. Here at All Care Health and Rehabilitation, all we need to do is download a remit and the software automatically pulls up the patient’s claim and posts it to the account on the date of service.
What a time saver! Other revenue cycle management features built into some software solutions provide practices with all pertinent information relating to individual claims and provide the ability to resubmit claims directly through the vendor’s website for a seven- to 10-day turnaround, depending on the insurer. We electronically submit nearly all—99 percent—of our claims. Because not every insurance company accepts electronic claims, it’s also helpful to choose a software vendor that will ease your practice’s burden by filing paper claims for your practice.
As we stated, today’s economic conditions are less than stellar, with high unemployment and frequent changes in employer healthcare coverage. Patients like never before are struggling to meet direct medical costs. Chiropractic practices that offer flexible, consumer-friendly payment options provide patients with increased incentives to make prompt payments, while software solutions from supportive vendors accelerate the revenue cycle through improved billing and claims processes.
Combined, these policies, procedures and solutions generate improved revenues and profitability. The increased cash flow enhances a chiropractor’s ability to provide higher quality care with added resources for medical technology investments, and lower patient, physician and staff member stress levels.
Dr. Gabe Spruch, with his wife Sherrie Spruch, is the co-founder of All Care Health and Rehabilitation Center, launched in 1990 as All Care Chiropractic. Dr. Spruch is both a chiropractic physician and licensed professional acupuncturist. He and his staff work to help patients achieve better health with proper nutrition, exercise, structural alignment and balanced internal energy. You can visit the website at: http://www.allcarehealthandrehab.com/ or call (812) 288-7000. His practice uses ZirMed for their revenue cycle management solution. For additional information, visit the website at: http://www.zirmed.com.
Sherrie Spruch, co-founder of All Care Health and Rehabilitation Center with her husband, Dr. Gabe Spruch, serves as the center’s practice manager. In addition to overseeing day-to-day office operations, Sherrie shares with patients her wealth of knowledge about the importance of natural health care. You can visit the website at: http://www.allcarehealthandrehab.com/ or call (812) 288-7000.
Written by Matthew Llewlyn
Tuesday, 23 October 2012 20:03
hiropractors, like many other healthcare providers, tend to operate individually or in small groups (1-3 providers) with a limited amount of administrative staff to manage cash flow and collect for services rendered. Matt Llewellyn, VP of Healthcare Sales at BillingTree, takes a look at three methods of patient payment processing which chiropractors may use to improve collections and cash flow.
There are distinct challenges in terms of managing cash flow and collecting patient payments for smaller professional practices with limited back-office staff to manage all the administrative processes needed to support the business.
These three optional patient payment processing methods can help practices implement simple procedures to improve operational efficiencies through the use of readily available technologies. The payment options range from the basics of processing paper check payments more efficiently to the more advanced payment options such as SMS and personalized web portals.
Method One: ACH – every check counts!
Although many people elect to pay bills with debit and credit cards, a significant number of payments are still made by check. If your practice accepts paper checks there is no reason for you to continue the paper process to deposit the funds. Why not convert the check to an electronic deposit?
One easy way to convert the paper payment to an electronic deposit is through the use of a scanner that will convert the check to an Automated Clearing House (ACH) transaction. The check is converted to an electronic file which is then sent through ACH payment-processing gateways. ACH payments processing provides more efficient cash management capabilities and lower costs than traditional paper payments processing. Providers that use ACH processing benefit from an accelerated availability of funds, with cleared funds deposited directly into their accounts.
One thing you want to be sure of when converting paper checks to an ACH transaction is that the checks being converted are coded with the correct SEC code. The code used varies based on how the check was received as well as whether the check is from an individual or a business.
Another factor to consider is having the ability to automate check representment when checks do not clear the first time. You will find there are automated processes which will enable you to pre-set times of the month for check representment, choosing times when the patient is more likely to have funds in their account to cover the check.
Method Two: Mobile payments are on the rise
By providing the patient with this new payment option your office is expanding the patient preference communication offering.
You cannot walk down the street or be in a public place today and not see individuals using smart phones. There is a growing desire for people to interact with others through their smart phone, and patient-to-provider interaction is no exception.
Do you provide your patients with a “preferred method of communication” option as part of your registration process (i.e. mail, e-mail, cell phone, etc.)? If you do, it's likely that some will select their cell phone as the option. For those that choose to leverage their cell technology, why not offer them the chance to actually pay their bill with their mobile device?
Today, patients can pay their bills through their smart phone, and this manner of payment forms a convenient way for patients who are on the go or who are prone to be more responsive when they are messaged on their mobile device. Technology today enables a patient to establish an e-wallet, secured with the use of a user-defined PIN and command on their phone. Your billing staff can leverage available technology to reduce costs associated with consumer contact, including time sensitive notices and recurring check reminders, as well as the expense of traditional paper billing.
As an added benefit, your office is adapting to the changing environment in which the patient experience is becoming a measured metric in the care cycle. By providing the patient with this new payment option your office is expanding its patient preference communication offering.
Method Three : Electronic Payment Portals – providing patient access to information online
The Government is working hard to increase the adoption of an Electronic Health Record (EHR) and patient portals. If your office is already offering a portal to your patients, adding web payments functionality is a logical next step. If you already accept web payments then that's great news!
A few things to consider when offering web payment options to your patient are:
- User Friendliness – to make the process as easy as possible for the patient to pay
- Type of payment options – can you only make a single payment or can the web solution accept recurring payments?
- Using Personal URLs (PURLs) for patient payment – encourage electronic payments from paper statements and invoices, so customers can quickly pay online.
In summary, there is certainly a shift occurring in patient payment responsibility, wherein the patient will have more out-of-pocket funding for care. In addition, technology is evolving and the way patients prefer to interact is changing in line with this.
The question to be asked and answered is: “Is my practice leveraging available technology which best meets the expectations of my patients, while also improving operational efficiencies and cash flow?”
If the answer is “no” or “I'm not sure,” then consider implementing one or more of the above methods to integrate solutions that will help you answer this question with a resounding “YES”.
Matt Llewellyn joined BillingTree in 2012 bringing over 20 years of experience in healthcare and IT. As Vice President of healthcare sales and new business development, Matt is responsible building on the existing success within the vertical and to identify and implement new partner integrations from within the healthcare market. Prior to joining BillingTree Matt held senior leadership roles at multiple organizations including TVP, Channel Strategies for RelayHealth and VP of Hospital Sales, Western Region, for NDCHealth. You can call at (602) 443-5914 or email:
Written by Mark Studin, D.C., F.A.S.B.E.(C), D.A.A.P.M., D.A.A.P.L.M.
Tuesday, 23 October 2012 19:32
hiropractic utilization in the United States remained static at 12.1 million from 2003 until 2006 as reported by Davis, Brenda and Williams in 2010. This represents 4.12% of the population, considering the 2003 population reported by the Encyclopedia of the Nations. Davis et al. also reported that in the early 1990s chiropractic utilization was 7.7% of the United States’ adults, realizing a net loss of utilization of 3.58% in just a decade. The reasons are many and in spite of the growing interest in the utilization of complementary and alternative medicine (CAM) nationwide, with chiropractic as the largest CAM provider, the numbers are still dwindling. The chiropractic profession must take an honest look at the numbers and realize that it can no longer be "business as usual" or risk that the utilization will continue dwindling until we no longer make the positive impact on society that we currently do.
Fiore in 2012 reported that accurate diagnosing was critical to the success of the chiropractic profession in order to be credible in the health care community. He also reported that many chiropractors hide behind the definition of chiropractic as the "...art, science and philosophy of locating and correcting nerve interference..." and continued on to say "This allows the chiropractic profession to have great latitude...but does not excuse us from making an incorrect diagnosis." In order for us to understand a spinal related problem or any pain, we must not create a correct hypothesis, we must conclude an accurate diagnosis before we construct a prognosis and treatment plan. According to Frank Zolli, DC, the Dean of the University of Bridgeport College of Chiropractic for over 20 years, "every chiropractic student during their doctoral training learns at the most basic level of training that you must have an accurate diagnosis and then create a prognosis before you treat your patient." Dr. Zolli continued by saying that this is taught in every CCE accredited chiropractic college.
With the advent of new and not so new technology, we no longer have to hypothesize or theorize. It's called the MRI and every licensed doctor of chiropractic in the United States has within their scope the ability to refer a patient for an MRI (with the exception of Medicare, as the Federal Government, through their actions and regulations, has much less regard for the well-being of our seniors). Chiropractors have to realize that technology takes away much of the hypothesizing and allows us to conclude with a great degree of certainty an accurate diagnosis: the foundation of the treatment plan.
When we look at disc issues, this gives the chiropractic profession a universal platform to becoming and being considered by medicine to be the "Spinal Primary Care Providers". Back pain, inclusive of disc pathology, is a thorn in the sides of most primary care providers (PCPs) and a diagnosis they universally refer to orthopedic surgeons for lack of a better alternative.Orthopedic surgeons are centered on surgery, with their $225,000+ malpractice costs, and summarily dismiss most non-surgical cases to physical therapists, who in turn render much poorer outcomes, according to Cifuentes et al. in 2011, for back related issues compared to chiropractic care.
Cifuentes concluded that chiropractic care during the disability episode resulted in:
- 24% Decrease in disability duration of first episode compared to physical therapy
- 250% Decrease in disability duration of first episode compared to medical physician's care
- 5.9% Decrease in opioid (narcotic) use during maintenance care compared to physical therapy care
- 30.3% Decrease in opioid (narcotic) use during maintenance care compared medical physician's care
- 19% Decrease in average weekly cost of medical expenses during disability episode compared to physical therapy care
- 43% Decrease in average weekly cost of medical expenses during disability episode compared to medical physician's care
According to the U.S. Department of Health and Human Services in 2008, there were 490.41 million visits to primary care medical doctors (PCPs) in the United States that year, when almost every United States citizen visited a primary care doctor across multiple health care platforms. The penetration of PCPs nationally is somewhere between 95-100% of the population, where chiropractic is 4.12% of the population. Understanding the penetration and influence PCPs have over the population and the positive "evidence based chiropractic results" that medicine has long asked for, the chiropractic profession is now poised to become the "Spinal Primary Care Providers", with one proviso.
We need to take our place as spine specialists and not just subluxation specialists to conclude accurate diagnoses and converse in a language that is universal and inclusive to both chiropractic and medicine. In order to do that, we need to learn disc and spinal pathology as a beginning.
When utilizing MRI, there has to be a criteria or protocol for ordering a scan and then an understanding of the findings. This author has long held that in the presence of a significant radiculopathic or any myelopathic finding an immediate MRI is warranted BEFORE you create a prognosis and treatment plan. In short: don't touch the patient until you know what the diagnosis is. This protocol has been well documented in the literature as evidenced by the Fish, Koboyashi, Chang and Pham, who also concluded that symptomatic radiculopathic findings or central canal stenosis (as found in myelopathies) require MRI for conclusive diagnosis prior to treatment.
When interpreting MRIs it is imperative that each doctor be proficient in interpreting their own film. Lurie et al. reported in 2009 that “…the specific morphology of the herniation was not reported by the radiologist in 42.2% of cases,” meaning that general radiologists inaccurately report what is wrong with your patient almost half the time and you are often delivering a "high velocity thrust", known as an adjustment/manipulation, with wrong information. It is here that you start to become the spine specialist and can guide the PCP in their referral pattern based upon your clinical excellence. The "best of the best" read their own MRI images, no differently than the spine surgeons who will not operate unless they have firsthand knowledge that they know is accurate. Chiropractors are no different.
When interpreting MRI images it is important to understand accurate nomenclature. The following was reported by Bailey in 2005:
Disc Bulge: Synonymous to disc degeneration.
Author's note: a circumferential degeneration over time evidenced by a thinning of the disc with the nucleus pulposis still within the confines of the annulus. The disc bulge or expansion must cover greater than 50% of the disc circumference and is usually close to 100% of the circumference.
Annular Tear: Tear or fissure in the annular fibers, either radially or concentrically.
Author's note: The outer 1/3 of the annular fibers are innervated by the A, B and C fibers commonly known as the recurrent meningeal nerve and as reported by Lee et al. can cause pain in either annular tears or irritated degenerative discs.
Herniation: Displacement of the disc beyond the limits of the disc space.
Author's note: Tear in the annulus where the nucleus pulposis material goes outside the confines of the nucleus.
Focal Herniation: Less than 25% of the disc circumference.
Author's note: Where the herniation covers 25-50% of the disc circumference.
Broad Based Herniation: Between 25-50% of the circumference of the disc circumference
Author's note: Where the herniation covers 25-50% of the disc circumference.
Protrusion Type Herniation: Author's note: Where the base is greater than the apex in any plane.
Extrusion Type Herniation: Author's note: Where the apex is greater than the base in any plane.
According to Robert Peyster, MD, DABR-NR Neuroradiologist, Chief of Neuroradiology, State University of New York at Stony Brook, herniations are traumatically induced.
McMorland et al. (2010) found that 60% of surgical candidates had successful outcomes with chiropractic as an alternative to many disc surgeries. The evidence shows chiropractic was highly effective for patients with distinct one-sided lumbar disc herniations as diagnosed via MRI and had associated radicular (nerve root) symptoms. What about the other 40%?
Over the last 23 years, Magdy Shady, MD, Neurosurgeon, Neuro Trauma Fellow, has worked with this author to develop a clinical protocol to determine when chiropractic was indicated in a disc herniation patient. If there is room anywhere around the cord or root, then adjusting/manipulation is a clinically indicated first line treatment. In the absence of any room around the cord or disc, then chiropractic, based upon the increase in intrathecal pressure created in the adjustment/manipulation, puts active chiropractic care in the second position after the disc has been reduced.
Over the decades, that protocol has been followed strictly to the benefit of thousands of patients, where surgery was needed only in a small population of those patients and the first line treatment was bed rest, cryotherapy or anti-inflammatory medication managed by the neurosurgeon until chiropractic was indicated via a combination of a follow up clinical evaluation and MRI.
Knowing the difference between aggressive chiropractic treatment or waiting a few days or weeks until the swelling has reduced is a result of making an accurate diagnosis, prognosis and treatment plan. That is also the foundation for relationships with PCPs and being part of a health care team involving multiple disciplines where the chiropractor is the "Spinal Primary Care Provider" and coordinator of health care.
The PCPs appreciate the relationship because it relieves them of the spinal-related patients constantly ending up in their offices as though through a "revolving door" because orthopedics and physical therapy are not the solution and often only serve to delay the exacerbations that end up in the PCP's office over and over.
Becoming expert in disc pathology and reading MRIs is the first step towards becoming a spine specialist and tapping into the 95-100% of the population cared for by PCPs. Having control over an accurate diagnosis and orchestrating the triaging of the patient puts chiropractic in the epicenter of spinal-related care and relieves the PCPs of what they consider a "burden to their practice."
It can no longer be business as usual and becoming proficient in disc, MRI and spine care does not change how you care for your patient, nor the philosophy with which you practice. There is room in both the subluxation and structural models of practice. This level of clinical excellence simply makes you a better doctor and opens doors to allow you to become part of the health care team in your community and will ultimately increase awareness and utilization of cost-effective chiropractic management of non-surgical spinal conditions.
- Davis, M., Sirovich, B., Weeks, W. (2010).Utilization and Expenditures on Chiropractic Care in the United States from 1997 to 2006. Health Research and Education Trust, 45(3), 748-761.
- United States Population (2012), Encyclopedia of the Nations, Retrieved from: http://www.nationsencyclopedia.com/Americas/United-States-POPULATION.html
- Fiore, J. (2012). Subluxation vs. Herniation: A New Paradigm for Chiropractic. The American Chiropractor, 34(8), 14-18.
- Primary Care Workforce Facts and Stats No. 1, The Number of Practicing Primary Care Physicians in the United States, (2008) U.S. Department of Health and Human Services, Retrieved from: http://www.ahrq.gov/research/pcwork1.htm
- Cifuentes, M., Willets, J., & Wasiak, R. (2011). Health maintenance care in work-related low back pain and its association with disability recurrence. Journal of Occupational and Environmental Medicine, 53(4), 396-404.
- Fish, D., Kobayashi, H., & Pham, Q. (2009). MRI prediction of therapeutic response to epidural steroid injection in patients with cervical radiculopathy. American Journal of Physical Medicine & Rehabilitation, 88(3), 239-246.
- Lurie, J. D., Doman, D. M., Spratt, K. F., Tosteson, A. N., & Weinstein, J. N. (2009). Magnetic resonance imaging interpretation in patients with symptomatic lumbar spine disc herniations. Spine, 34(7), 701-705.
- Lee, J. M., Song, J. Y., Baek, M., Jung, H. Y., Kang, H., Han, I. B., Kwon, Y. D., & Shin, D. E. (2011). Interleukin-1β induces angiogenesis and innervation in human intervertebral disc degeneration. Journal of Orthopedic Research, 29(2), 265-269.
- Bailey, W. (2005). A practical guide to the application of AJNR guidelines for nomenclature and classification of lumbar disc pathology in Magnetic Resonance Imaging (MRI). Radiology, 12(2), 175-182.
- McMorland, G., Suter, E., Casha, S., du Plessis, S. J., & Hurlbert, R. J. (2010). Manipulation or microdiskectomy for sciatica? A prospective randomized clinical study. Journal of Manipulative and Physiological Therapeutics, 33(8), 576-584.
Written by Dr. Miles Bodzin & Dr. Ray Foxworth
Tuesday, 23 October 2012 19:02
etween our two companies, Cash Practice and ChiroHealthUSA, we hear from hundreds of doctors a month who think they want to transition to an all cash practice. The reasons are varied, but are most commonly related to frustrations in dealing with insurance companies, hearing about or being involved in a recent audit, dwindling reimbursements and increased demand for pre-cert paperwork or documentation.
We also find there are many misperceptions about going all cash. Such as, going ALL cash means you are finally free to do what you want in making recommendations to all patients about their care. You can opt-out of every network and disregard terms of the PPO agreements. And, the BIG LIE many have heard is if you are all cash, you are immune to all the rules and regulations from your Board of Examiners, all the way up to CMS and the OIG, when it comes to proper documentation, billing, coding, discounting, state and federal inducement violations and other red tape including HIPAA.
As is usually the case, the truth lies somewhere in the middle. Going all cash or transitioning to a more cash-based practice can be liberating in many ways, but it is not a panacea. If your State Board of Examiners has outlined the minimum standards for documentation, you are still bound by those standards, regardless of who is paying the bill.
If you see patients who may be insured, they will expect to be provided with a proper receipt reflecting your diagnosis with the proper ICD-9 codes, the procedures you performed with proper CPT codes and, if the patient submits the receipt to their insurance carrier for consideration, you may certainly expect to receive a request of records to support medical necessity. And, while you may have been “PAID” by the patient and think you are in the clear 100%, if your record keeping and coding is not up to par, you can probably expect a complaint filed with your board from a patient who may have SWORN they did not intend to send in receipts to the insurance carrier since you are all cash.
Now, as soon as we write this, we are going to hear from someone who says, “My attorney says if I have them sign this form that they won’t file, or that they can’t file a claim when they pay cash, I’m in the clear.” If that is the case, good for you and make sure you have that attorney on retainer because there is NOTHING worse than dealing with a “ticked-off” patient who decides later that they want their insurance company to pay them back and YOUR notes or records are sub-standard. So much for being immune from rules and regulations by going all cash!
Another area where doctors often think going all cash brings them freedom is in making treatment recommendations and offering varied forms of payment plans or pre-paid plans, especially if the patient is paying cash. Once again, while there is some freedom from not being involved in insurance networks, there are other rules and regulations that may come into play.
In several states, Boards of Examiners have promulgated rules about pre-pay plans and require escrow accounts to be utilized.
In several states, Boards of Examiners have promulgated rules about pre-pay plans and require escrow accounts to be utilized. Why? You can bet it is because of patient complaints related to refunds! Also, there are some states that consider collecting in advance for health care services to be the “business of insurance” and you must have an insurance license issued by the state.
Finally on this topic, keep in mind that if you are seeing a patient with insurance, even if YOU are out of network, the patient has certain obligations as a policyholder, such as paying the required deductibles and copayments. Be aware that if you, even as an out of network provider, offer pre-payment plans that include any discounts on the patient’s cost-sharing portions, the insurance company may not be liable for any payment or reimbursement back to the patient.
Diversified Isn’t Just a Chiropractic Technique
We are seeing that more and more doctors want to become less dependent on insurance. And there are some who want to go 100% cash, but they are not the norm. For most doctors, the smart move is to do what your investment banker might suggest, “Diversify”. Meaning, don’t be 100% anything! Have a good mix of insurance, personal injury, workers’ compensation and build up your cash side of the practice. This will bring you the ultimate in practice stability and peace of mind by not having your practice disappear overnight if all your financial eggs are in one basket. For doctors who were ALL PI or workers’ comp and practiced in states where changes to these payment methods were implemented, ask them what it is like the day AFTER the law changes and PI or workers’ comp vanished.
As long as you understand that the transition to a cash-based practice does not make you invisible from regulators or grant you immunity, then we encourage you to consider diversifying your practice to include more cash-based patients and become less dependent on insurance.
Transitioning to Cash-Based Practice has MAJOR Benefits Even When the Patient Has NO Insurance Benefits!
There are three major benefits of placing your patients, particularly cash patients, on long-term care plans. The first benefit is you rarely have patients drop out of care because "the pain went away" or "the insurance ran out". Those are the two most common excuses doctors will state as the reason patients drop out of care. And both are completely neutralized when placing a patient on long-term care plans. So you end up with better treatment compliance.
There are three major benefits of placing your patients, particularly cash patients, on long-term care plans.
The second benefit is a result of the prior benefit. You get better clinical results, get more referrals and become more profitable as a practice. It is pretty obvious that if your patients are staying on your care plans, they will get better and will be more likely to refer friends and family.
We also need to state that if you are recommending long-term care plans, you better be able to deliver on the promises you make. We are not talking about just providing "pain relief" type care for a longer period of time.
Let's be real. If you want to deliver on the promise of wellness, you better be able to demonstrate improvements in the patient's well-being. There are some great tools and resources available for doing just that.
When recommending long-term care plans, obviously there will be a fee for your services. It is crucial that the way you collect the fees for your care plan is setup correctly. We should start by stating what NOT to do. The idea of offering a plan of care where the end goal for all patients is to prepay for the program (i.e. prepay for a year of care) is not recommended. Why? The challenge is, prepaying for anything (outside of chiropractic) is not the norm for people and, as noted before, could be considered the business of insurance in some states.
People are used to "financing" everything these days. Look at how TV commercials promote a car. Do they advertise the price of the car? No, they tell you the lowest monthly lease payment available. They do that because they know that the majority of people make a purchase decision with the "monthly payment" in mind rather than the total price.
So, offering your patients a long-term care plan that offers payment options is what we recommend. By offering options, the patient will pick what works best for them. The options are monthly payments, a larger down payment with smaller monthly payments and a prepayment for the folks that want to choose that option where it is legal. We find that most people choose one of the first two options.
The last thing about collecting the fees for these plans is to consider using an auto-debit program to collect these payments. Our experience has shown that the more often people think about the money you are charging, the more likely they will stop care. We have a policy in place to remove every situation we can that reminds them of the money. So, no statements are mailed. No third-party financing (i.e. Care Credit or similar plans). We securely keep their credit card or bank account information on file in a PCI compliant program and run the payments on the agreed upon date. This is no different than having a routine to submit claims every Tuesday or on the 1st and 15th. With a proper auto-debit system, it can be BETTER than insurance since there is NO waiting for reimbursement or claims rejections!
The bottom line on transitioning to a more cash-based practice is to do it for the right reasons. We encourage all of our clients, even those who choose to go 100% cash, to remember that regardless of the payer type, you should document correctly, code correctly, bill correctly and, if you discount or offer payment plans, make sure you are handling those correctly and start practicing with more peace of mind.
Dr. Bodzin is the Founder and CEO of Cash Practice Inc, a web-based company that provides The 4-Step Process for Reducing Your Dependence on Insurance and New Patients.The Wellness Score, Cash Plan Calculator, Auto-Debit, and Drip-Education Email Systems give the practicing chiopractor tools for implementing the four steps. Dr. Bodzin speaks internationally on running a cash-based practice for Associations, Parker Seminars, Philosophy Groups and for many of the coaching companies. Dr. Bodzin can be reached at 1-877-343-8950,
or by visiting www.CashPractice.com.
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. He has served as president of the Mississippi Chiropractic Association, former Staff Chiropractor at the G.V. Sonny Montgomery VA Medical Center and is a Fellow of the International College of Chiropractic. He founded ConservaCareCorp, the first chiropractic network selected by the State of Mississippi to serve over 195K covered lives in the State Health Plan. You can contact Dr. Foxworth at 1-888-719-9990,
or visit the ChiroHealthUSA website at www.chirohealthusa.com
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