January 2007

The best of times?

by Dr. Jeffrey Shay

It was both the best of times and the worst of times for Charles Dickens. And while for Styx fans these are the best of times, for chiropractic, they're not the best, but hopefully not the worst. Chiropractic has lived through some of both. The present, if not the worst of times, certainly ranks among the most difficult ‑‑ even if some of our organizations won't admit it.

I've been around chiropractic all of my life, practicing or just observing. Every decade has had professional challenges, but the present time has many of them: managed care, lack of health insurance, high co‑pays, audits, HIPAA...issues I'll be talking about in future columns.

What drew my attention to this issue was a series of phone calls from other doctors. I've never had as many calls from other doctors about practice problems, and most of them I've known for years. Some are worried about their cash flow, some about HIPAA fines. One became so frustrated with the insurance companies that he closed his doors. Yet, most chiropractic publications act like these are boom times.

Historically, chiropractors have been jailed for their efforts, as well as shunned socially and economically. The Great Depression was hard on both the profession and the nation, as business dried up everywhere. The chiropractic colleges either closed or contracted. In his autobiography, David Palmer wrote about measures he took to keep the college afloat, including opening a public ice cream stand on the college grounds, as well as housing the Ringling Bros. Circus on campus.

I've seen a lot of history around our own clinic, although I don't like to think I've reached the stage where I spend my time yearning for the "good old days."

I lived in Davenport's West End when my dad was going to chiropractic college. We stayed in an upstairs apartment with no air conditioning, car, or television. In 1953, he bought an existing practice in nearby Muscatine for $100.00, which came complete with a Zenith side posture table and a dental x‑ray unit which, if tweaked enough, could take upper cervical pictures.

Muscatine is certainly not the garden spot of the Midwest, and will never be mistaken for Las Vegas, but the town has made us a pretty good living for 52 years. The lesson here is that mundane places can be a better location for a practice than some of the glitter spots of the world.

Dad's office was originally located on the third floor of a bank that had failed during the Depression. It came complete with an ancient cleaning woman and a bottle of rye whiskey on the dark room shelf. Over time, the two apparently got together, as the fluid level kept dropping every Friday night.

While adjustments were only $2.00, things worked out pretty well. In just six years the family had a new house, and my dad had a new Oldsmobile every three years (yes, they really were my father's Oldsmobiles). We also started taking vacations, although far too many of them involved fishing shacks, mosquitoes and dead carp. Others included a tow truck and a hook.

While ours could be an isolated success story, many other chiropractors have told me similar ones. Those were days when many young DCs did well in spite of the prejudice and lack of insurance. By the time I started in 1978, we had just begun seeing a number of insured patients. Insurance cases increased, and things were good until the last decade. Then, the special interests took over health care.

In the 1960s, the practice relocated across from a Baptist church. The building next door, unfortunately, was evolving into a flop house, and occasionally one of the reprobates would stumble through the front door looking for a place to dry out. My dad changed to full spine work, including Logan Basic and SOT. We had a Fisher 200/100 x‑ray unit with a Dial‑x collimator. At the time it seemed like the cutting edge of technology. Later, we learned that the Dial‑x emitted enough scatter radiation to sterilize a horse. Another x‑ray unit appeared years later, after an aborted effort to x‑ray a 300‑lb. biker fried the tube.

The practice had limited parking in front, which became more limited after the local medical society became concerned about the number of people seeing chiropractors. One morning, the city took away all of our parking and painted the curbs yellow. Our patients were forced to sneak their cars into a nearby supermarket's parking lot. It didn't hurt business too much, but we got the message. My dad built a new clinic, but not until we won a legal battle. The local hospital tried to block construction of our building, stating that the area was zoned for health clinics, and that they did not recognize chiropractors.

I've always felt that some of the ACA's policies were based on the concept that we can "get along" with the medical world, with all of us gathered around a table in a scene reminiscent of the Last Supper. In my experience, I've seen things improve, but the discrimination has never stopped. Any real cooperation will probably only come after a lot of us disappear from the scene. My memory's too good. I'll always be waiting for their next trick.

Our office has always been a family business. My mom worked as our receptionist for 37 years, and knew every patient by his or her first name, and most of them became old friends. This is the norm in a town like this, where everyone knows everyone else's business, as well as the real parentage of most of the kids in town.

When my mom passed away, we brought in a family friend and my wife, so it's still a small staff. The new receptionist used to work for the orthopedist up the street. She says we're seeing the same patients he was, just on different days. More and more this town seems like Mayberry.

In the chiropractic magazines there are a lot of photo spreads showing offices with four doctors, five assistants, a huge reception room, computers, and a partridge in a pear tree. The small one has a doctor and an assistant (usually a relative) and a computer (sometimes a typewriter). The big office has a receptionist, an x‑ray technician, and several billing and insurance specialists. The small one has two people who fight over taking the garbage out to the curb on Wednesdays.

I prefer the latter, because chiropractic has always been about people and relationships. And in spite of all the modern hassles, it always will be.

Those of you with long memories probably recall the battle over whether or not veterans needed a referral to receive chiropractic care. The WCA wanted direct access. The ACA (Brand X) wanted a gatekeeper system, where the patient had to have a referral. Don't ask me why the ACA took this stand. I don't know what they were smoking. Anyway, the ACA claimed that the referral system would make chiropractic care readily available for all veterans. As they say, now for the rest of the story.

I treated a patient last January who needed care for his low back and I filed a request for treatment at that time. Over the next six months, his referral was blocked by an MD on the staff who stated "nobody needs chiropractic."

However, my patient was nothing if not determined. In July, I finally received permission for 12 visits. I copied my referral sheet and other paperwork and sent in a claim form, which was promptly trashed. A second claim form received the same treatment. After several phone calls, I was informed that "just because you have permission to treat the patient does not mean you have the right to send a claim." Finally, I received my first check. It only took 10 months and several phone calls by me and my patient.

Which brings to mind a thought that perhaps my treatment might not be unusual. It would be interesting to know how most requests for chiropractic treatment are being handled. But, don't ask the ACA, as they're probably too busy working on an explanation that will pin the blame on someone else.

(Dr. Jeffrey Shay, a graduate of Palmer College of Chiropractic and the WCA's 1996 "Chiropractor of the Year," is the World Chiropractic Alliance Director of Insurance Relations. He welcomes comments or questions regarding any insurance‑related subject appearing in this column. Dr. Shay is available to speak to your state or local organization. Contact him at 1501 Mulberry Ave., Muscatine, IA 52761, or the WCA offices, FAX 480‑732‑9313.)