September 2003

An intra‑professional dialogue about HR 2560

Although the American Chiropractic Association (ACA) passed a resolution earlier this year stating that it would refuse to take part in any joint legislative efforts with any other chiropractic organization, its leaders have been permitted to engage in dialogue about important legislation. Although informal, such dialogue can help to exchange information and viewpoints, and clarify many complex issues.

A recent e‑mail discussion between Terry A. Rondberg, D.C., president of the World Chiropractic Alliance, and Jim Edwards, D.C., chairman of the ACA, delved into many of the complexities of HR 2560, the Chiropractic Medicare Freedom Bill. Since both Dr. Edwards and Dr. Rondberg chose to circulate the messages to a lengthy list of recipients, The Chiropractic Journal judged that sharing them with the profession would not be a violation of privacy and would, instead, help doctors better understand the issues involved.

The discussion began after the ACA distributed a confidential memo attacking HR 2560. Many doctors were alarmed that it would decrease their Medicare reimbursements and one contacted Christopher Kent, D.C., and asked for his opinion on the bill. Dr. Kent responded with an explanation via e‑mail.

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From Dr. Christopher Kent

HR 2560 would create a new category for chiropractic services, and provide that chiropractic services could only be provided by a D.C.

M.D.s and D.O.s would no longer be reimbursed for providing the chiropractic benefit. This would render the lawsuit against Medicare unnecessary.

Furthermore, it includes x‑rays, exams, and the use of chiropractic instrumentation. HR 2560 incorporates the widely accepted ACC definition of subluxation. Perhaps the most important provision is the one which states that objective evidence of subluxation is the basis for qualifying. No longer would a patient need a musculoskeletal ache or pain to qualify.

The scare tactic used in this memo is the suggestion that separating D.C.s from the M.D. and D.O. "physician" classification would adversely affect third party pay, and the inference that this would somehow affect state "physician" status.

Medicare coverage does not determine the scope of chiropractic coverage in private insurance. For example, although Medicare does not reimburse chiropractors for x‑rays, most private insurers that cover chiropractic services do.

This has nothing to do with limited "physician" status under Medicare. The fact is despite the current classification of D.C.s under Medicare, only one procedure is covered. Use or non‑use of the term "physician" doesn't change this.

Furthermore, state scope of practice has nothing to do with Medicare reimbursement. All states have broader scopes of practice than the current Medicare program. The fact that Medicare now pays only for manual manipulation of the spine HAS NOT changed the scope of practice in any state. This has been the case for three decades.

Similarly, use of the title "physician" is a state law issue. It has nothing to do with the list of reimbursable Medicare procedures.

It should be noted that M.D.s and D.O.s are not reimbursed under Medicare for all services they are permitted to render under state law.

Quite simply:

1. Medicare relates to what services are reimbursable under that program only.

2. State law, not Medicare, determines lawful scope of practice.

3. State law, not Medicare, governs use of the title "physician."

4. Contract law and controlling state law regulate private insurers. Medicare has not, and does not, determine the scope of services provided in private indemnity policies.

5. Codes will be created, if necessary, fort statutorily mandated chiropractic services. This happened in the earlier days of the program when there was no code for the chiropractic benefit. One was created, A2000.

HR 2560 would solve a longstanding problem. Chiropractic would be recognized as a separate health profession, exams, x‑rays, and instrumentation would be included. The criteria for chiropractic care would be objective indicators of subluxation.

This bill would benefit all chiropractors. It would not be limited to a handful of demonstration sites.

Instead of listening to political hype, I have one simple suggestion for D.C.s who are confused by the issues: Read the bill. It is short and simple. Visit http://frwebgate.access.gpo.gov/cgi‑bin/getdoc.cgi?dbname=108_cong_bills&docid=f:h2560ih.txt.pdf

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From Dr. Edwards

I received a copy of Dr. Kent's comments on Friday and immediately submitted them to ACA Legal Counsel for his legal analysis which is below.

As you will see, there is simply no question that the WCA sponsored legislation is fatally flawed and would actually further the aims of the AMA!

Although H.R. 2560 has little chance of passage, it does has the potential to hurt passage of the chiropractic provision contained in S.1. (that is presently in conference committee). If we are going to avoid harm to the chiropractic profession, this bill must be immediately abandoned.

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The arguments offered by Dr. Rhonberg and Mr Hendrickson misses the point in connection with the E&M Coding issue, completely ignores the relative value issue, and rests on the status of a chiropractor as a physician under state law, a status that would be less secure because of their proposal. I would like to further explore each of these issues.

First, E&M services; the issue is not what services may be provided by a chiropractor under state law, the issue is how those services are identified under AMA‑CPT and how those services are paid. I will check on this tomorrow, but I believe few if any state laws specifically reference evaluation and management services, rather the identify services that chiropractors may perform to properly evaluate, diagnose and treat a patient. E&M codes are fairly recent developments that replaced the prior "office visit codes" to describe the services performed.

Current AMA‑CPT policy states that a provider should use the code that " best describes" the service he or she performs, and also under current policy chiropractors may utilize E&M Codes to describe their state authorized services. This, despite the efforts of the AMA to establish a new set of Evaluation and Assessment Codes( E&A Codes) for use by "non‑physicians". ACA and the chiropractic profession have been able to resist the effort to apply these codes to chiropractors in large measure due to a chiropractor's status as a "physician" under federal law.

If the profession were to voluntarily walk away from that status, it would provide the perfect opportunity and excuse for the AMA‑CPT to foist the E&A on the profession with their resulting lower relative values and limited applicability. Without this federal status as "physician, the chiropractic profession would have to rely be at the good will and kind intentions of the AMA in order to retain the ability to E&M codes. If AMA‑CPT even hints that chiropractors as "non‑physicians" should utilize E&A Codes rather than E&M Codes to "best describe" their state authorized evaluation services, then one can expect to see the wholesale down coding of E&M to E&A Codes by every third party payer in the nation. And, Chiropractors who continue to utilize E&M Codes could, and most probably would in time, be viewed to be filing false claims for services since the E&M Codes no longer "best describe" their services. Please also note that federal law now make it a felony for any provider to utilize a "scheme or artifice" to obtain improper reimbursement from any third party payer.

Next, as to the relative value issue for the new "adjustment" code. I will not

restate my points made in my prior memo but only point out that: a. my points have not yet be addressed and b. to emphasis again that the Medicare RBRVS relative values are used by many third party payers beyond Medicare. A reduction in the current relative values in CMT would not only result in an immediate reduction in Medicare reimbursement amounts, but also the reduction would be immediately plugged into every third party payer utilizing RBRVS to reduce the level of reimbursement going to chiropractors.

Finally, to suggest that eliminating a chiropractors status as a "physician" under Medicare would have no effect on state recognition as a physician is, I believe, at best wishful thinking. I don't know of a better jumping off point for opponents of chiropractic in connection with a state initiative to eliminate such state "physician"status, especially since the ICA, WCA and AMA all support the notion that chiropractors are not "physicians" under Medicare. Dr. Rhonberg suggests that chiropractors read the HR 2560, I would agree, and also suggest they read the policy position of the AMA referenced in my prior memo. They should know that when H.R. 2560 states in Section 2 that : "Section 1861(r) of the Social Security Act (42 U.S.C.1395x(r)) is amended...by striking ',or (5)' and eliminating all that follows and inserting a period", it is removing chiropractors from the Medicare definition of a "physician". I think it is time for everyone to step back and ask if the profession really wants to go in the direction suggested by the AMA and H.R. 2560.

Thomas R. Daly, Esq. Odin, Feldman & Pittleman, P.C. 9302 Lee Highway, Suite 1100 Fairfax, Virginia 22031

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From Dr. Rondberg

There are three major points I want to address in regard to HR 2560.

First of all, HR 2560 is not a "WCA bill." It is a bill introduced by Rep. Donald Manzullo and endorsed and supported by the Chiropractic Coalition, of which the World Chiropractic Alliance is a member along with the International Chiropractors Association and Federation of Straight Chiropractors and Organizations, with more than a dozen affiliates throughout the world.

Second, I need to respond to the criticism voiced by ACA lawyer Thomas R. Daly that HR 2560: "completely ignores the relative value issue, and rests on the status of a chiropractor as a physician under state law, a status that would be less secure because of their proposal."

According to Barry Pineles, Regulatory Counsel, the House Committee on Small Business: "The relative value calculations are based on actual costs (with various adjustments that we need not discuss at this point). What the ACA is, in essence, arguing is that since chiropractors' costs are lower but the Medicare statute requires everyone who performs the same service to be charged the same rate by Medicare, chiropractors can...overcharge Medicare (since I will assume that chiropractors' costs for things like malpractice insurance, are significantly lower than physicians' costs). I am not sure that chiropractors want to be in the forefront of making the argument that chiropractors should maintain a system that overcharges Medicare. In fact, I would argue that by reducing the costs to Medicare, chiropractors can make an argument that more of their services should be used relative to others that might perform 'spinal manipulation.'"

Rep. Manzullo and his staff have been working with chiropractic and Medicare issues for a long time and they are extremely savvy about legislative issues on the Hill. It would be presumptuous ‑‑ if not downright insulting ‑‑ to suggest they are incapable of understanding either the impact or the viability of HR 2560.

The third point is the ACA's regrettable decision to openly attack a bill supported by other chiropractic organizations. The Chiropractic Coalition has never tried to interfere with the ACA's lobbying efforts in regards to its S1 demonstration project provision, other than offer HR 2560 as another possible solution. Nor has The Coalition done anything to hurt the ACA's chance of success with its Medicare lawsuit, other than withdraw its financial support (after its members had already donated thousands of dollars to the ACA legal fund).

The Coalition, and its member organizations, are working together in harmony and cooperation to advance a goal that could benefit the entire profession ‑ and we've done so without attacking the ACA.

It is unfortunate that the ACA has refused to adopt the same "live and let live" policy. Instead, it openly attacked HR 2560 in Congress and throughout the profession. By circulating a memo containing misrepresentations and erroneous conclusions, it has provided our critics with another opportunity to "divide and conquer," and tarnished our reputation among legislators.

Further, the ACA has continued to make deliberately offensive comments about the WCA, categorizing it as "Dr. Rondberg's WCA," and even going so far as to misspell my name in a legal brief.

The ACA has repeatedly criticized other chiropractic organizations for failing to "cooperate" with it on various issues. It is obvious from this latest attack on the International Chiropractors Association, World Chiropractic Alliance, Federation of Straight Chiropractors and Organizations and the other organizations affiliated with The Chiropractic Coalition, that the ACA is the primary obstacle to unity in this profession.

It is our sincere hope that, in the future, the ACA will direct its efforts toward productive goals rather than trying to impose its will on the profession. If it would concentrate on its own objectives, it would have better success achieving them and would have less need to blame others for its failures.

The World Chiropractic Alliance, together with the other members of The Chiropractic Coalition, will continue to lobby for passage of HR 2560 in a positive manner, representing it as an alternative to the S1 demonstration project.

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From Dr. Edwards

Although it is tempting to refute each of the "3 major points" my friend Terry made, I have decided to just allow Tom Daly's response to speak for itself.

For those of you that do not know Mr. Daly, I can tell you that he without peer when it comes to legislative, regulatory, reimbursement and legal expertise in regard to issues affecting the chiropractic profession. He is viewed as the profession's premiere expert on these matters ‑‑ not only by the ACA ‑‑ but also by the National Association of Chiropractic Attorneys who named him 1997 "Attorney of the Year" for his work on the new CMT codes and their relative values in Medicare's RBRVS (and which are now at issue in the Manzullo bill). Tom Daly is highly trusted and respected because the many victories accomplished over the last several years are in no small measure, a direct result of Mr. Daly's wise counsel and expert advice.

Here is Mr. Daly's response to Dr. Rondberg's latest e‑mail:

With all due respect to Mr. Pineles, who is undoubtedly very able counsel to the Committee, I don't believe he fully understands the point we are trying to make. According to the chiropractic representatives on both AMA‑CPT HCPAC and RUC HCPAC, HR 2560 would require a change in the current CMT codes from "chiropractic manipulative therapy" to something like "chiropractic adjustment therapy".

The new "CAT" codes would then go under the process of review by the RUC for the assignment of new relative values. In that process, the profession would no longer be able to compare the relative values to the osteopathic manipulation codes OMT, as was successfully done in 1996, because of the change in definition from manipulation to adjustment.

In addition, the current CMT Codes include: 1) some history, 2) some examination. and 3) some clinical decision making; that only a physician can perform. These are not include in non‑physician services, such as 97140 (manual therapy techniques). HR 2560 would remove chiropractors from the definition of physician and therefore the new CAT codes could not include the higher valued physician component, but rather would be valued along the same lines of the much lower valued non‑physician manual therapy codes.

We should also stress again that this entire process would open up the chiropractic codes to review and comment by the opponents of chiropractic in the RUC process. It is akin to opening up the a state scope of practice law for open comment and revision by hostile opponents. It is a highly competitive and intense review process. Putting a new set of codes that cannot be cross walked to existing CPT codes, and no longer contain a "physician" element is a recipe for disaster based on the best expert judgment of the chiropractic representative who have worked these issues since 1996.

We would also note that these individuals were never contacted to assess the potential impact of HR 2560 on the use of E&M Codes or the relative values of the existing CMT codes. We respectfully submit that such an analysis should have been done before embarking on a legislative proposal that has the potential for such far ranging effects. We have stated from the outset that Cong. Manzullo is a champion of the chiropractic profession whom we deeply respect. However, HR 2560 while well intentioned is, in our view, fatally flawed with the potential for devastating effects on the chiropractic profession.

Finally, on a personal note, please express my apologies to Dr. Rondberg for the prior misspellings of his last name. It was not intentional and I know the frustration of having one's last name misspelled.

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From Dr. Rondberg

The ongoing dialogue about HR 2560 is exactly what is needed and I sincerely thank Dr. Edwards and Mr. Daly for their willingness to discuss the potential ramifications of this bill. We may never totally agree about the best legislative approach, but we are accomplishing a great deal just by talking things over.

In his most recent message, Mr. Daly expressed several concerns about the bill, and I am beginning to understand what may be the essential stumbling block for him and the ACA.

He noted that "HR 2560 would remove chiropractors from the definition of physician and therefore the new CAT codes could not include the higher valued physician component, but rather would be valued along the same lines of the much lower valued non‑physician manual therapy codes."

This one statement gets to the heart of the matter. Mr. Daly, and many other ACA doctors, are worried that if chiropractors are no longer labeled "physicians" under Medicare, their services will be valued less than those of medical doctors. Of course, since the relative cost for chiropractic care is lower than that of medical care, reimbursement costs will very likely be lower. That's what everyone has been trying to prove to Congress that chiropractic can reduce health care costs.

But the reimbursement that D.C.s receive will not be adversely affected by the change. In fact, according to Barry Pineles, Regulatory Counsel, the House Committee on Small Business, "Since the term 'subluxation' is a term of art under the new chiropractic definition, one would have to be paid to diagnose the subluxation. That is the essence of the profession."

I realize that the ACA has spent a great deal of time, money and energy promoting the use of the term "physician" to apply to doctors of chiropractic. The reason appears to be that they feel it is more prestigious than mere "chiropractor," and can result in more reimbursement for various physician services.

The ACA worked hard to get chiropractors lumped in with medical doctors under the "physician" category with Medicare. It has done the same thing in various states.

For instance, while president of the ACA, Daryl D. Wills, D.C., also served as chair of the Nebraska Chiropractic Board. He spent four years in his state working to change the law so that D.C.s could call themselves "physicians." In an article in ACA Today, he explained that the issue "came about because of a district judge's ruling that doctors of chiropractic were not protected by a physician's lien since they were not physicians." So, in order to qualify for a physician's lien, the Board made sure D.C.s could be called "physician."

Of course, that wasn't his only goal. He noted, "As we work to carve out a niche for the chiropractor/chiropractic physician, our success will depend on our ability to integrate the unique chiropractic service we provide and to represent doctors of chiropractic as specialists for neuromusculoskeletal conditions."

Particularly telling was his comment: "Credibility opens the door to access and access leads to parity." In his opinion ‑‑ one shared by many ACA leaders and members ‑‑ the name "physician" apparently adds credibility to chiropractic.

In my opinion ‑‑ one shared by many WCA leaders and members ‑‑ calling chiropractors "physicians" confuses the public and the legislature about the real purpose of chiropractic, and threatens the unique character of our profession.

A quick look at the way the word "physician" is used will make this clear.

In the ACA's 1998 lawsuit against Donna Shalala, Secretary of the Department of Health and Human Services, Mr. Daly and George McAndrews noted (in reference to an exhibit) that "The 'physicians' referred to are medical physicians, not doctors of chiropractic who are extensively trained to diagnose subluxations."

That same document includes a quote from Senator Tom Daschle of South Dakota that "for certain diagnoses, chiropractors often provide high quality care at a lower cost than physicians." (September 24, Congressional Record, reported at 139 Cong. Rec. S12251‑05 (1993)).

Obviously, he doesn't see physicians as being the same as chiropractors. Normally, the word "physician" is used ‑‑ even by the ACA ‑‑ to refer to medical doctors. This has caused an avalanche of problems, particularly with Medicare.

If chiropractors can be considered "physicians" (even though they do not have the education, experience or exposure to make full‑body diagnoses), why can't physical therapists and other health care providers?

In 1998, Nancy‑Ann Min DeParle, administrator, Health Care Financing Administration, wrote to the ACA and explained: "The manual manipulation of the spine to correct a subluxation revealed by x‑ray is expressly referenced as a covered physician service. For purposes of providing the services only, the statute also states that a chiropractor is included in the definition of 'physician.' It does not follow, however, that this service cannot be provided by others who meet the definition of physician for all purposes, such as osteopaths."

In other words, if chiropractic care is a "physician" service, then all providers included in the physician category can legitimately offer that service, and be reimbursed for it.

HR 2560 would change that.

It would create a category of "doctor of chiropractic" ‑‑ a separate but equal category that makes chiropractic services exclusive to the chiropractic profession.

This is, in essence, what the ACA's "Save our Subluxation" campaign is supposed to be about. Chiropractors are not physicians and, frankly, I'm proud of that fact.

We are doctors of chiropractic ‑‑ the ONLY health care professionals trained and competent to detect and correct subluxations. That doesn't mean none of us provides other services, including treatment of neuromusculoskeletal conditions.

But it does mean that chiropractors are the ONLY ones who can be reimbursed for subluxation correction. Not medical doctors, not osteopaths, and not physical therapists.

I'm not the only one who sees this as the crux of the ACA's rejection of HR 2560. Mr. Pinella, who is one of the brightest and most politically savvy men on the Hill (and who understands the intricacies of chiropractic as well as he does the complexities of politics) put it this way: "What apparently is going on here is that ACA wants to be called physicians and WCA does not ... The philosophical gap will not be bridged by a discussion of how the relative values for the codes are developed because that is fundamentally a mechanical process that can be easily dictated by legislation or report language."

The fact that the changes made through HR 2560 might require separate chiropractic codes should be a plus. "Would you rather have codes solely developed for chiropractors or ones that are developed for chiropractors and physicians?

It would seem to me that by simply limiting the data to chiropractors, you would get more accurate data and potentially lower relative value units, i.e., chiropractic services would be cheaper and more readily used by Medicare patients," Mr. Pinella pointed out.

It comes down to one thing.

In order to achieve the true goal of chiropractic (which is ‑‑ or should be ‑‑ to secure a firm foothold in the health care system) we need to establish an identity distinct from the medical profession.

We need to make sure we are recognized as an independent category, with exclusive "turf." We need to let the medical doctors and osteopaths continue using the term "physician" while we use "chiropractor" ‑‑ a word that has an even greater meaning!

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From Dr. Edwards

After reading your response, I must say I am very concerned.

It appears that, for the sake of philosophical purity, the WCA believes "physician" status should be abandoned without regard to the financial ramifications of your member doctors. That "all or nothing" philosophical purity position, the same one the WCA used in opposing H.R. 1588 that would accelerate DoD implementation, is not what the ACA (an organization whose leaders are elected to represent the interests of its members) can support.

And even more incredibly the WCA seems to be implying that doctors of chiropractic are being paid too much under RBRVS and are in fact overcharging the system.

Once the WCA membership becomes fully aware of what you are proposing and the harmful ramifications that will result, I suspect they will not be very happy.

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From Dr. Rondberg

Philosophical purity has little to do with this (although I don't think a bit of philosophical purity would hurt the profession right about now). It has to do with economics.

This whole problem started back in 1996, when the ACA teamed up with the AMA to produce "generic" CPT codes. I looked back at a report published in The Chiropractic Journal and found that on June 12, 1996, Garrett F. Cuneo, D.C., ACA executive vice president, sent a memo to all state association executive directors noting that, "Throughout our discussion regarding the CPT proposal, there has been a concern expressed by some that the codes were chiropractic specific.

"When the ACA initially submitted its coding proposal to the AMA's CPT Health Care Professional's Advisory Committee (HCPAC), it was for the purpose of obtaining generic manipulative treatment codes. ... Although we believe we have addressed the legal concerns regarding these codes, it remains the goal of the ACA to work toward generic codes within the next year" (emphasis added).

Dr. Cuneo referred to the AMA workgroup meeting in the memo, saying it "has the potential of being a first important step towards realizing the goal of generic codes for spinal manipulation."

At the time, I argued that "Chiropractic is not generic. Adjustments are not generic. We are a separate and distinct profession and we need to have unique codes to distinguish us from the spinal manipulative therapies used in the osteopathic and medical professions."

The ICA opposed the ACA‑AMA code plan as well. "It is obvious that while some believe the road to survival is to blend in," ICA President Robert Braile, D.C. told The Chiropractic Journal, "the ICA has always stood for separate and distinct."

Creating a "generic" code and lumping D.C.s in with M.D.s and osteopaths had precisely the disastrous result we predicted. In fact, it led directly to the ACA having to spend $5 million on lawsuits against Medicare and Trigon. In explaining the reason why the ACA was battling Trigon, Dr. Cuneo stated: "It should be obvious that any portion of the 40 percent savings extracted from chiropractors is available for higher payments to medical physicians."

Of course it was! If you lump D.C.s in with M.D.s, osteopaths and other "physicians," using a generic CPT code ‑‑ as though there were no difference between any of them ‑‑ it is inevitable that the medical physicians will get the lion's share of the money, and a good part of the chiropractor's share as well.

Why? Because, as "physicians" we are in direct competition with medical doctors and other providers. We're not offering anything they can't offer. A few very broad‑based "chiropractic physicians" will try to duplicate medical services and milk the system for as much as they can, while the vast majority of chiropractors end up with fewer patients and reduced payments.

Dr. Cuneo wrote an article in The Chiropractic Journal back in January 1998, in which he said: "you will never escape our (the ACA's) presence because every time you bill Medicare for a CMT code and receive a higher reimbursement for your services than you would with the old A2000 code, you will be forced to think of ACA."

Well, the fact is doctors have often been reminded of the ACA's work ‑‑ but not because they're getting higher reimbursements. It's because they get fewer patients, less revenue, and more problems under the ACA/AMA devised system.

Under HR 2560, doctors of chiropractic will have to "sacrifice" the label physician under Medicare (although they will still be free to use that title if their states allow it). In return, they will have a distinct and separate category just for chiropractic care ‑‑ services that M.D.s, physical therapists and other providers will NOT be able to provide or be reimbursed for. There will be less opportunity for super medical D.C.s to abuse the system, but far more opportunity for the majority of doctors to have a larger piece of the future 60‑million‑patient Medicare pie!

HR 2560 will open the floodgates of patients who will have two clear choices: medical physicians for medical care, or chiropractic doctors for chiropractic care. We won't ever have to worry again about losing patients to physical therapists or osteopaths or M.D.s, because none of these providers will have the right to provide chiropractic care. At the same time, since chiropractors and medical physicians will not be duplicating each others' services, HR 2560 could significantly reduce overall health care costs for the Medicare system ‑‑ an end result that will benefit all American taxpayers.

The categorization of D.C.s as physicians has NOT helped the profession, and we feel it's time to try something else.

By the way, you're wrong about the reaction of the WCA membership to HR 2560. The fact is, we keep no secrets from our members. We regularly inform them of all our efforts ‑‑ and even make sure they have a chance to read important pieces of correspondence. So far, the reaction to the information covered in our discussion has been very positive.

Here are a just a few of the comments I received yesterday:

"When will some of our colleagues realize we will never be equal status with medical doctors or 'physicians' in the eyes of the government and on the court of public opinion? All I know is Medicare reimbursement has been cut this year ($4.00 per visit in NY) and they are rejecting more claims than ever, even if you follow the recommended step diagnosis process. We need to have separation in order to survive. I am sick of playing the medical game. I am a chiropractor, a healer, not an insurance pimp!"

"I stated years ago as President of the Chiro Assoc of Ohio that if we would DROP the degree DOCTOR of Chiropractic and go to a degree of M.C.(Master of Chiropractic) that a good % of these 'birds' will NOT even go to Chiro college to get a "Dr"(status) title. Then we would have people who would be going to be SERVANTS (humility) to helping people get well."

"I perceive that many DCs cling to 'physician' not because it make their patients better, but because of fear, and it makes it easier for insurance re‑imbursement. Nothing to do with care. It is a gut check for those who want to break with the status quo and forge a new future. It takes cahones to make a change."

"ACA's goal, I believe, is to keep 'physician' more to expand scope than get reimbursement. I think that they feel the reimbursement will come with expanded scope, and their bizarre, dysfunctional fantasy that 'we'll show'em who's better at treating conditions,' and the medical community will give them a rousing ovation."

Actually, I don't think it's the WCA that has to worry about losing members when the true impact of HR 2560 is understood.

Jim, although I think this discussion has been extremely helpful to us personally and to all the doctors who will read it, the bottom line is that I don't think HR 2560 requires defending. The statements from Rep. Don Manzullo, Adam Magary, Barry Pineles and so many other supporters of the bill explain the benefits of the bill far better than I can, and I have to start focusing my time and energy on making sure the legislation passes.

Clearly, we have different views on the relative merits of HR 2560 and the ACA's chiropractic demonstration project provision in S1. I respect those differences and although the WCA and the other Coalition members do not think the demonstration project will be of lasting benefit to chiropractic, we have done nothing to interfere with your efforts to get it passed. But, whether or not it is cut from the final version of the Medicare Bill now being debated in Congress, we continue to be committed to supporting and promoting HR 2560 for the good of the entire profession, and for all patients.