October 2005

FCLB ex‑pres. slams high‑volume practices

Although most chiropractors say their goal is to help as many people as possible, Richard E. Vincent, DC, past president of the Federation of Chiropractic Licensing Boards, recently spoke out against high‑volume practices where hundreds of patients are cared for each week.

"High volume practices that report treating up to 700 to 2000 patients per week cannot provide the patient with the quality of care associated with excellence, and they may be a hazard to the public health," he stated in the August 2005 issue of ACA News.

Such criticism is at odds with the actual experience of numerous medical and chiropractic doctors who have combined high volume with high standards of care. In fact, it also runs counter to many medical research reports that have determined that hospitals and other facilities that provide high volume of services in specific areas offer more efficient and effective care.

For instance, a report in the July 2002 issue of Stroke: Journal of the American Heart Association, noted that "patients are more likely to survive a stroke caused by a burst blood vessel if they are admitted to a hospital that treats these strokes more often ... The correlation between mortality and treatment volume persisted even when the researchers examined multiple variables that might contribute to it." The researchers added that prior studies have shown better survival rates at higher volume facilities for patients with other complex medical needs, including coronary artery bypass surgery, carotid endarterectomy and HIV. ("Association Between Subarachnoid Hemorrhage Outcomes and Number of Cases Treated at California Hospitals," Naomi S. Bardach, et. al., Stroke, 2002;33:1851.)

Similarly, a retrospective analysis of 27,986 colon cancer patients aged 65 years and older undergoing surgery for colon cancer between 1991 and 1996, was published in the Journal of the American Medical Association, Dec. 20, 2000. Researchers noted, "Survival following high‑risk cancer surgery, such as pancreatectomy and esophagectomy, is superior at hospitals where high volumes of these procedures are performed." ("Influence of Hospital Procedure Volume on Outcomes Following Surgery for Colon Cancer, Deborah Schrag, MD; et. al., Journal of the American Medical Association, Vol. 284 No. 23.)

The medical research supports the observation that chiropractic offices that provide highly specialized subluxation‑corrective services can be more time efficient while providing high quality care. In addition, such practices usually reduce health care costs by avoiding additional charges for extraneous and often unnecessary quasi‑medical tests and procedures.

The criticism of high‑volume practices apparently stems from a misunderstanding about how such practices operate. Opponents often characterize these practices as "patient mills" where people are given generic care and where optimizing revenue is given priority over patient welfare.

"That is completely contrary to the reality of most high‑volume practices," stated Terry A. Rondberg, DC, president of the World Chiropractic Alliance (WCA). "No one will deny there are a few doctors whose only aim is to maximize income, with little regard for patient care. But that's an extremely small segment of the profession and it's absurd to condemn all high‑volume practices based on the conduct of these few unethical doctors. Most high‑volume offices I'm familiar with provide individualized care and maintain a high level of personal rapport with their patients. The only real difference is that they charge or bill for only one or two procedures rather than a laundry list of tests and therapies."

The WCA has an official position paper supporting high‑volume practices, stating, "Based on the clinical experience of numerous doctors of chiropractic, supported by these and other medical research studies, the World Chiropractic Alliance finds strong evidence that the adage 'practice makes perfect' may apply ‑‑ as it does to many other skills ‑‑ to chiropractic adjusting as well. Criticism of, or opposition to high‑volume chiropractic practices based solely on the number of patients who receive care, without regard to the outcomes of that care, is unfounded and unsupported by any valid research."

Other chiropractic leaders have similarly supported high‑volume practices. Thomas M. Klapp, DC, a past president of the Congress of Chiropractic State Associations and International Chiropractors Association Board member, taught doctors throughout the country how to ethically construct a high‑volume practice through his BOLT (Benefit‑Oriented, Long‑Term) Chiropractic Seminars. Two topics covered in the seminar were: "How a high‑volume practice is your only insurance against managed care and reduced third‑party payments," and "How to build your practice into a high‑volume powerhouse by changing short‑term thinking to long‑term thinking."

In an article for Dynamic Chiropractic, Stephen Perle, DC, conceded that although "The obvious cynical metaethical analysis of VSBC is that the only rationale for high‑volume practices and maintenance care is to make more money," one can make an equally compelling argument that "there is an altruistic motivation to remove vertebral subluxations from as many people as possible."

Robert Hoffman, DC, president of The Masters Circle reported in his 2002 president's address that the company's UCCFF (Universal Chiropractic Care at a Fixed Fee) program "contributes to transforming our profession away from the fee‑for‑service allopathic model and towards creating a high volume, low overhead, non‑insurance dependent, family and wellness practices. This is already revolutionizing how successful DCs are practicing as they return to the true doctor patient relationship and raise their standard in the process. It is allowing more and more patients to experience the miraculous results Chiropractic is famous for."

Drs. Ben Lerner and Greg Loman, authors of the best‑selling book "Body by God," proudly note that their Teaching the World coaches are "high volume, successful Chiropractors that truly care about their patients and changing their lives."

"For Dr. Vincent to label high‑volume practices as a hazard to public health, is to accuse a large portion of the chiropractic profession ‑‑ including many highly respected chiropractic leaders ‑‑ of malfeasance of the worst kind," Dr. Rondberg stated. "Such irresponsible statements serve only to further divide our profession and tarnish our reputation with the public."