March 2006

Pre‑payment plans: Good for you and your patients

by Dr. Terry A. Rondberg

We've all become used to radical ‑‑ and often acrimonious ‑‑ differences of opinion within our profession. But few issues have elicited such diametrically opposed viewpoints as has the question of whether it is legal and ethical for chiropractors to offer "pre‑paid" service arrangements to patients.

On the one hand, many top chiropractic leaders say such arrangements are not only perfectly legal but of great benefit to patients wishing to make a commitment to wellness care. They point to many other health care professionals, such as orthodontists, acupuncturists, and even obstetricians who offer pre‑payment plans. They all deal with patients who aren't interested in short‑term, temporary fixes but want lowered prices on routine maintenance care.

On the other hand, some people say such arrangements are illegal because they are a form of insurance. Michael Schroeder, who serves on the Council on Chiropractic Guidelines & Practice Parameters (CCGPP) as the representative of the National Chiropractic Council malpractice insurance company, stated unequivocally that such plans are illegal. In an article for Dynamic Chiropractic, he said, "Chiropractic doctors who are operating unlicensed prepay plans should immediately stop doing so."

To support his contention, he noted: "The National Association of Insurance Commissioner's Bulletin has determined that prepay plans are illegal." (Incidentally, he wrote an almost identical article for Acupuncture Today, telling them, too, that "Acupuncturists operating unlicensed prepay plans should immediately stop doing so.")

I think Robert Graham, DC, of Grandville, Miss. was right in calling Mr. Schroeder on this statement. In a letter to the editor, Dr. Graham asked, "How does a group (whose) authority is supposed to be confined to relegating the insurance industry all of a sudden pass legislation? Can you or they cite the law in each of 50 states that says specifically that pre‑pay plans are in fact illegal? Or is this just another scare tactic generated by a group that sees that there is in fact some competition for health care dollars?"

Dr. Graham went on to say, "I suggest that if an individual wishes to contract with another individual with full knowledge of that contract, then there should be no interference from a usually self‑serving third party, period! If I recall, there is a document called the Constitution of the United States that guarantees that very thing."

Adding to his arguments are the many made by reputable and respected chiropractic leaders, who not only support a doctor's right to offer such plans, but often urge them to do so for the health of the patient and the practice.

Dr. David Singer, founder and CEO of David Singer Enterprises, wrote a detailed review of the issue for The Chiropractic Journal in which he noted that "The value of pre‑paid treatment plans can be enormous. They allow the doctor and patient to get the finances taken care of up front, effectively removing money as a barrier to the patient completing their full treatment program, thus getting the most benefits out of their care." (www.worldchiropracticalliance.org/tcj/1997/oct/oct1997singer.htm).

Likewise, many state organizations are standing up for the right of their doctors to offer these plans. Writing in the Ohio State Chiropractic Association's newsletter, OSCA ethics chairperson Dr. Greg Goffe and OSCA general counsel Rob Sherman stated: "We feel comfortable advising our doctors that prepaid plans are acceptable if they offer patients a specific number of visits and then give a discount for prepayment."

Obviously, there is a wide gulf in opinion between these positions and Mr. Schroeder's. Figuring out who was correct was a task undertaken in recent months by the World Chiropractic Alliance. We reviewed board findings, insurance laws, court cases and judicial opinions. We had the matter looked into by chiropractors and lawyers. Ultimately, we came to the conclusion that, if structured properly, pre‑payment arrangements are perfectly legal and, as Dr. Singer mentioned, of enormous value to patients.

Based on all this research and deliberation, the WCA issued an official position paper on "Pre‑Payment of Chiropractic Services." Be sure to see the article in this issue of The Chiropractic Journal for more information about this paper or go online to the WCA website (www.worldchiropracticalliance.org).

In short, the WCA not only concluded that such payment plans are legal but urged all regulatory boards to "consider such practices to be in compliance with the laws, rules, and regulations of the jurisdiction where the chiropractor practices." We deliberately put that provision in the paper because of recent reports ‑‑ increasing in frequency ‑‑ that some state chiropractic boards are going after doctors who offer pre‑paid services.

The WCA thinks those attacks are unjustified and must stop!

The fact is, why would anyone have a problem with offering such plans? Dr. Graham suggested one possibility: insurance companies that make money from our profession's reliance on third‑party payers.

But there are others, as well, including those who don't think it's in the best interest of patients to visit chiropractors as part of a routine wellness care program. These individuals (and they include some chiropractors!) think chiropractic should be a short‑term therapy to relieve symptoms and address acute problems. The idea of offering a patient a long‑term program of regular maintenance care is alien to them.

They would no doubt agree with Mr. David Chapman‑Smith, secretary general of the World Federation of Chiropractic, who said the public has the perception that chiropractic treatment is "endless," a perception, he claimed, that is "fueled by and is consistent with some practices and practice management schemes that boast lifetime care, promote unreasonable frequency of care, and press patients for large advance payments for future treatments."

What does Mr. Chapman‑Smith consider "unreasonable frequency of care?" Is it 6.7 visits (at $26/visit to treat lower back pain cases) that is being circulated as the new "acceptable" level of care? Is it the maximum of eight visits per year recommended by the ACN (formerly the American Chiropractic Network. According to Dr. Dave Elton, ACN's Vice President of Clinical Programs, quoted in the St Louis Post‑Dispatch, August 6, 2005. The newspaper reported that "ACN wants chiropractors to average eight visits per patient a year. It says 85 percent of patients recover from injury or illness with that amount of care, based on claims and patient outcomes data from its national network of more than 20,000 chiropractors treating more than 500,000 patients a year."

Frankly, I think the perception of endless chiropractic care isn't a bad thing at all. We all know that we're going to be going regularly to the eye doctor and the dentist for as long as we live. We're told we need to go for regular medical checkups ‑‑ including everything from pap smears to blood glucose tests. The doctors performing these tests revise our eyeglass prescriptions, fill our cavities, and prescribe medication and even surgery on the basis of these ongoing visits.

Yet, people are being told NOT to go to a chiropractor unless there is something wrong with them that their medical doctors couldn't handle. They're told ‑‑ by people who are supposed to be representing this profession ‑‑ that a DC who suggests regular visits for spinal evaluation and maintenance adjustments (when needed) are being "unreasonable" and unethical.

It's obvious to me that the real concern isn't the legality of pre‑plans, but the fact that they might promote the "wrong" idea about chiropractic, namely that it's more than a quick fix for back pain. The concern is that people might choose to go to chiropractors for a true alternative to medicine rather than to chiropractic physicians for another type of medicine.

Matthew McCoy, DC, editor of the Journal of Vertebral Subluxation Research and vice‑president of the Council on Chiropractic Practice, put it in his typical forthright manner when he said that attacks on pre‑pay plans were ultimately "another way to 'get' subluxation‑centered chiropractors."

As the chair of the World Chiropractic Alliance Chiropractic Advocacy Council, he's helped defend several doctors who have been brought before their boards for offering pre‑pay arrangements to their patients. He's also received reports of similar cases in the UK, Australia and Canada. Inevitably, the doctors offering the pre‑pay plans are those interested in long‑term wellness care based on the detection and correction of vertebral subluxation.

This large and growing group of doctors also offers care to children and asymptomatic patients. They are adamant that vertebral subluxation is an appropriate primary diagnosis in and of itself because it is a detriment to the fullest expression of life. They also tend to have larger volume practices, since they don't spend time performing non‑chiropractic examinations and treatments. In their advertisements, newsletters and patient education talks, they emphasize the need for wellness care, and explain that their role is to correct nerve interference caused by subluxations, and not to "treat" symptoms.

Not surprisingly, each of these practices has been the subject of criticism and the justification for licensing board actions against doctors. Good doctors have been hauled before their boards because they give adjustments based on the presence of subluxations rather than symptoms. They have been slapped with fines and even suspension for teaching about chiropractic wellness care.

In response, the World Chiropractic Alliance has issued strong position papers in support of chiropractic for children and asymptomatic patients, high‑volume practices, subluxation as a rationale for care, and, now, on pre‑payment plans. These position papers aren't just high‑sounding rhetoric. They are useful tools in protecting your rights as doctors of chiropractic. They can be entered into court as evidence, used in defense of board complaints, and referred to in patient education material.

The battle over pre‑payment plans isn't simply a legal debate removed from the realities of practice. It's one more way to control how you practice chiropractic. Read the World Chiropractic Alliance position paper, follow its advice, and don't be afraid to do what's best for your patients and your practice. And join the WCA so together we can continue supporting and promoting the rights of all chiropractors to realize their fullest potential as true wellness providers.