The Missouri Chiropractor - June 2007

President's Report

by Edward A. Hengel, DC,  MSCA President

Do You Have Vision

Some of the things I considered before moving to St. Louis to embark on the next stage of my education in 1984 involved some planning on my part. Encompassing as many variables into the equation as possible, I weighed:

Distance from home as a financial factor.
Curriculum (quarters, trimesters, etc.).
Accreditation.
Faculty (more PhDs from varying backgrounds vs. majority of instructors being alumni graduates).
Tuition.

After graduation, the next step was even more burdensome as starting private practice also involved enough foresight to make a positive beginning with a plan to get out from under the gravity of student loans. Some of the things that I considered were:

Location (and what will it be in 10-15 years).
Hours (what schedule would blend into that of my future patients).
What type of practice was I most comfortable in using to the benefit of my clientele.
How much of an investment for equipment was I willing to put forth or afford.
What type of diversity was most beneficial when it came to cash versus insurance.
Whether to buy, build, or rent office space.
Which insurance groups did I associate with as a provider and which panels were even open.

Most likely, the majority of you have been fraught with similar decisions over the course of your professional careers. While our daily decision making may now center around treatment plans and when will we be able to take a vacation, we need to continue to have foresight regarding our profession and the benefits of the MSCA. If we neglect the history of legislation and insurance issues, this short-sighted approach will surely take chiropractic health care stumbling backwards once again. Chiropractic has made numerous gains on the healthcare landscape. The old adage that there is strength in numbers is definitely true with regards to legislation, solving insurance issues and moving forward consistently as a profession. Please join the MSCA and get involved so that our vision is the vision of our entire state.

Your comments or questions are welcome at edhengeldc@aol.com

Executive Directors Report

by Kathleen Wilcoxson, MPA

Many improvements and changes are transpiring at the Missouri State Chiropractors Association. We have redesigned the MSCA website, added a new partnership, hired new staff, and made building improvements at our facility in Jefferson City, just to name a few.

Probably the most noticeable improvement would be the facelift given to the MSCA website. In March, we hired an outside web-management company to give our site a more professional look and feel. A work in progress, the site will continue to develop as we add more user-friendly options and member-specific information.

I welcome you to visit the MSCA website at www.mscainfo.com and watch as the new pages develop. Feel free to offer your opinion and make suggestions as we continue to improve the site (see page 30).

If you are one of the many doctors who pay your MSCA dues early each year, and contribute your 10 percent discount back to the association’s Building Fund, “Thank You!” Your contributions, along with a generous donation from the MSCA Auxiliary, made it possible for the MSCA to undertake many long over-due repairs at our headquarters in Jefferson City. Over the past year, the building has received a new roof, carpeting, tile, and much-needed bathroom sinks and toilets.

Two other major repairs, made possible by your donations to the building fund, include the replacement of two outdated furnaces when they developed internal cracks and became a fire and carbon-monoxide hazard; and the replacement of our sewer lines between the building and the city sewer line when the pipes collapsed. This repair entailed digging up and resurfacing a long section of the MSCA’s asphalt driveway.

If you take advantage of the MSCA’s many partnerships, Federal Check Recovery, the Quit For Life Smoking Cessation Program, ChiroCode Deskbook, Bank of America credit card program, and I.C. Systems, to name a few, you might enjoy checking out our newest partner, TPK. This company offers the TPK Back Saver Wallet.

TPK offers a front-pocket wallet that folds thin and flat and eliminates the need to carry a bulky wallet in your back pocket which is known to cause a muscle imbalance leading to Wallet Sciatica, a medical diagnosis recognized by the Centers for Disease Control. A bulky wallet acts like a wedge, raising one side of the pelvis forcing the spine to compensate for the resulting pelvic imbalance which can lead to painful sciatica.

For more information on TPK, visit their website at www.tpkleather.com/chiro.html.

Remember, when you take advantage of the MSCA partnership programs, the programs make contributions back to your state association. It’s a win-win situation.

The most recent change at the MSCA came as an addition to association staff. Dawn Jackson started April 16 as the new Office Manager in the Jefferson City office. Dawn comes to us with many years of experience ranging from service in the United States Air Force to employment with the State of Missouri’s Office of Administration. Be sure to introduce yourself the next time you call.

Thank You To The Key Company

Sometimes it is easy to take for granted the many blessings we
receive in our lifetime
……. personally and professionally.

Thank you Wanda Munson, Ted Wenzlick and The Key Company for your support of the MSCA.

You made Legislative Day possible.

Governmental Affairs Report

by Mo McCullough, Government Affairs Director

Once again, we had a very successful Legislative Day at the Capitol.

Special thanks goes to Wanda Munson and the Key Company for providing a fantastic lunch. Not only did they feed all the docs in attendance, they also fed all the legislators, their staffs and the Capitol employees. It boggles my mind how Wanda does it; but with the help of some volunteer docs and members of the auxiliary, she pulled it off in fine fashion.

We had a good turnout; but next year we need more. Those in attendance let their voices be heard; but we need more. We raised some money for the MSCA PAC; but we need more. Legislative Day is an extremely important day for our legislative efforts; and the bigger the numbers, the better. Also, it is one of MSCA PAC’s major fundraisers of the year. This is more important now than ever before because the limits on the amount an individual or association can donate to a candidate or party committee were dropped this year. So, if we hope to compete against the insurance industry, with their unlimited funds and numerous lobbyists, we need to build our political action committee to more than double its current size. Lest I repeat myself – WE NEED MORE!

On the legislative front, by the time this journal hits the streets, we should know how our bills faired. The practice act, HB 233, looks, at this time, to have a good chance of success. However, so many things can happen the last week of session, You never know until the final bell. Pass or fail, I want to thank all of you who responded to my alerts and called your representative and senator on this issue. I am reminded on a daily basis how important grassroots efforts are to the legislative process.

I’ll provide a full report on the 2007 legislative session in the next journal along with a preview of 2008. In the mean time, make a commitment to your future and the future of this great profession – join or re-new your membership to the MSCA; donate to the MSCA PAC; get active in your district and make plans to attend this years MSCA Summer Convention and next years Legislative Day at the Capitol.

PAC Report

by Phillip Prater, DC
PAC President

First of all, many, many, many thanks to Wanda Munson and the Key Company for the great luncheon served for Legislative Day.

Thanks to the doctors who purchased lumbar supports and for taking the time to attend Legislative Day.

Our gross receipts were down considerably from previous Legislative Days, which is our second largest fund raiser for PAC. We are now preparing for our largest fund raiser, which is the sale of Raffle Tickets. They are now available from all PAC Trustees and others involved with PAC. You may find who your PAC Trustee is by reading the next column. Let's call the Trustees and prepare for the largest fund raiser of the year.

Last, but not least, thanks to Mo and Sam for their efforts on House Bill 233, and for the doctors who took the time to call their representatives for their support of HB 233. As many of you are aware, we have a strong voice in Jefferson City.

Committee Reports

by Margaret Freihaut, DC
Insurance Committee Chair

Do you have an email address? If you do have one, please get it to the MSCA. We send out insurance questions and alerts regularly, but they only go to the email addresses that the MSCA has in their database.

MEDICARE
NPI numbers will be mandatory for use May 23, 2007. You can use NPI and your current ID, or just your current ID numbers, until the May 23 deadline. This new form has necessitated a redesigned CMS 1500 form. The new form, 08-05, will replace the 12-90 this year. For Medicare, you could start using these new forms as of 1-1-2007. Contact all payers and Medicare carriers to confirm when they will accept the revised version of the form 08-05 and make sure to have your NPI numbers.

After May 23, 2007, claims will be rejected if the NPI number is not entered on form 08-05 in items 24J (replaces 24K), 17B (replacing item 17 or 17A), 32a (replacing item 32) and 33a (replacing item 33). Medicare has extended the deadline for the new forms to June 1, 2007. You still must be using the NPI numbers as of May 23, 2007. Claims from October-December 2005 must be filed by December 31, 2007. Penalties for late filing of claims is 10 percent on assigned claims, and up to $2,000 on non-assigned claims. Deductibles for 2007 are $131. Medicare Part A covers hospital services. Medicare Part B is outpatient fee for service. Medicare Part C is Medicare managed care. Medicare Part D includes drug benefit plans administered by various health plans. Just a reminder that beneficiaries can access the new drug plan either by subscribing to Part D or by joining Part C. Subscribing to part D plan will not affect access to chiropractic care. However, joining Part C, which restructures the administration of Medicare-covered services, could affect access to chiropractic care. It is important to know that there are many varieties of Part C plans which could have in-network and out-of-network benefits. It is important that you call to verify benefits because, even though you are out-of-network, if there are out-of-network benefits, you are still obligated by the Medicare rule of mandatory filing and limiting charges. If there are no out-of-network benefits, or you cannot get a referral, then these Medicare rules do not apply.

I attended the ACA annual CAC (Carrier Advisory Committee) in Washington, D.C. on March 23. Some statistics were provided that I would like to share with you, and they are divided by carriers. Eastern Missouri has 542,208 Medicare enrollees. There are 201,128 allowed services for chiropractic: 50,639 are for 98940, 126,561 are for 98941 and 23,928 are for 98942. There is an 11 percent denial rate for 98940, and seven percent denial rate for 98941 and 98942. There is a total of $6,441,646 in allowed charges. Eastern Missouri had 370 charges per 1,000 enrollees and $11,880 in charges per 1,000 enrollees.. In Kansas City and Northwestern Missouri, there are 191,404 enrollees. There were 92,685 allowed services: 24,802 for 98940, 56,239 for 98941 and 11,644 for 98942. The denial rates were seven percent, six percent and seven percent, respectively, for each of the three manipulation codes. A total of $2,979,061 was the allowed charges. There were 485 services allowed per 1,000 enrollees and $15,564 in charges per 1,000 enrollees. There was a special presentation at the CAC meeting on the new bill that President Bush signed into effect in December, 2006, that would allow a bonus for providers meeting certain quality measures. Chiropractic is eligilible for this quality measure; however, we are not in a position to be included this year in July when it begins. According to the information provided at this meeting, many of the professions are scrambling to get quality measures through the proper channels to get included in the future. Some professions are already included and have quality measures approved. You will be seeing much more about this subject in the future.

UNITED HEALTHCARE
Starting January 1, 2007, United Healthcare no longer reimbursed hot and cold packs separate from the CMT. Unattended electric stimulation was required to be reported under the HCPCS code GO283 rather than the CPT code 97014. I have had many calls about denied 97014 as not separately reimbursable. These denials will have to be recoded and resubmitted. Please let me know if there are any problems with resubmitting these services.

There have been significant problems with UHC/ACN administration of benefits reported on a national and a state level. Doctors report that ACN is behind upon processing their notifications; and when the doctors file the claims, they are denied for not having proper ACN notification because their claims get in before ACN gets the notification processed. ACN has a system to catch these denied claims, but it can take an additional 30 days to reprocess the claims. It is recommended that you do your ACN notifications on-line for a quicker turnaround time and/or hold up your claims until notification is received. ACN sent out a recent newsletter explaining the changes and reason for the difficulties in processing. They do have a new notification form that should be used. ACN put out a memo recently stating that many of the companies that have not required ACN notification in the past will now need notification as of March 1, 2007.

Make sure to check the ACN website, or call to see if previously excluded group numbers will now need notification. Information obtained from the ACA stated that ACN has introduced a national policy called “Pay The Enrollees Program,” which went into effect February 1, 2007. This policy dictates that when a beneficiary visits an out-ot-network provider, payment for services will be sent directly to the patient. This policy is regardless of any assignment of benefits. Ironically, out-of-network providers who signed up for direct deposit will continue to pay directly. Many Missouri DCs have reported that they no longer receive EOBs and checks have been sent to the patients for some time now on many of the plans. We have also observed difficulty getting claims paid after errors are found on the EOBs. The problem continues even after contacting customer service with the proof.

Please let the MSCA know if you have any problems, and make sure to file complaints with the Division of Insurance, especially if the issue remains unresolved.

ANTHEM BLUE CROSS AND BLUE SHIELD
The MSCA has received dozens of calls concerning the changes with Anthem Blue Cross and Blue Shield. Since many of the policies have renewed bearing the Anthem name, we’ve heard complaints of higher co-pays, deductibles, improperly processed claims, and a change in the definition of an office visit (meaning that an office visit used to mean an E&M code and now it is the place of service). The MSCA has had three meetings with Anthem since they lowered reimbursement last April. They claim lowering reimbursements was done to keep them competitive in the marketplace, but also because they saw what other companies were paying; and, if we took less from those other companies, why should they pay more. We pointed out some practices that appear discriminatory such as having a lower multiplier for the RVUs for our profession than for other professions and having out-of-network benefits for other professions but not chiropractic. After much discussion, none of these issues have changed.

I have had many complaints about improperly processed claims. If you have received improperly processed claims, send me examples so I can send them to our contacts at Anthem to try to get the problems resolved. I also have had many calls about claims still unpaid from 2006. If you have any unpaid claims from 2006, you can contact Ms Ruth Myer-Hollenbeck at Anthem. Effective July 1, 2007, there is a new fee schedule, sent out in early April by Anthem Blue Cross and Blue Shield, which raises our manipulation reimbursements and lowers many of our therapy and examination codes. Ms Hollenback told me that they determined that approximately 55 percent of the Missouri Anthem chiropractic practitioners would be affected either in a neutral or positive direction.


MISCELLANEOUS COMMENTS
The mistakes that I am seeing on claims, and experiencing in my office, are very time consuming and frustrating. It is hard to understand why these billion- dollar corporations, with thousands of employees, cannot get our claims processed properly. I am recommending that you meet with your staff about making sure to document all that goes on and on how to file complaints with the Division of Insurance (making sure to send MSCA a copy). Documentation would include reference numbers, who you speak to, the date, the time and, of course, what was said, as well as how many calls were made, when it was filed and refiled, etc. I know this takes away from productive time in the office, but it is important when complaints are filed, or lawsuits are filed, to be able to back up what is said and done.

The MSCA LEGAL ACTION FUND is going well and needs to continue to go well and continue to grow so we can act on the issues as they arise. If you are a member, thanks. If you are not a member, please join. If your membership lapsed, rejoin. Strength comes in numbers.

Committe Report

by Michael Finley, DC, Membership Committee Chair

The Red Dye

Many chiropractors may use the “Red Dye” analogy when talking about what’s needed for the chiropractic profession. It explains how the dental profession work-ed together and issued millions of red dye tablets to school children. Kids chewed on the tablets, and they would leave a red stain on their teeth and gums. This would show the areas most susceptible to plaque, bacteria and the infamous gingivitis. Then, with a through brushing and floss, you could remove all the dye. Probably one of the greatest teaching tools ever. Within a decade, everyone understood the importance of dental care and preventive maintenance for you teeth.

What’s our red dye? I can think of several. But the importance of the Red Dye is not the “Red Dye.” It was the tool. The fact that the dental profession worked together is the real story. The dentist worked in unity to get the message out. How’s the dental profession today? In some markets dentist have income levels that exceed the medical doctors.

My thought. Quit waiting for the “Red Dye!” Focus on working together. You have heard many times quotes such as, “Together we stand and divide we fall,” or something similar. Well it’s true.

Join the MSCA. Get involved. It’s amazing what can happen when we work together in unity.

District Reports


District 1

District 1 has it’s monthly meeting at Logan college in room 156B every fourth Monday at 7:30 pm. Everyone is welcome, members and non-members. Attend to learn what is going on with legislation, legal/lawsuits and insurance. If you have questions about any of these issues, or others, come and have them answered.

If you have any questions, you can always contact any of our District 1 representatives who are listed on page three of this journal.

Also,check out mscainfo.com for a list of district meetings, continuing education classes, fund raisers, political events and much more.

District 2

This month, District 2, representing chiropractic physicians in the nine Missouri counties of Benton, Cass, Clay, Henry, Jackson, Johnson, Lafayette, Platte, and Ray, reports on District 2 seminars and Legislative Day.

Just a reminder that we are going to have a 36-hour Continuing Education Seminar December 6-9, 2007, and a 36-hour Continuing Education Seminar February 7-10, 2008, at the Holiday Inn Northeast (same location as the last seminars). A Dinner Banquet is being planned for Thursday, December 6, 2007. Please put these dates on your calendar and plan to attend. If you have suggestions for improvements to any of our events, please direct those to our President, Dr. Ron Manfredi, who can be reached at 816-358-0035. Your support and participation is important to our organization. We hope more of our colleagues will plan to attend the 2007 Christmas Banquet.

Legislative Day at Jefferson City took place on March 6, 2007. Dr. Linda Buckmiller and Dr. Jim Gray did an excellent job of coordinating the bus and kept us supplied with donuts and juices. This was an opportunity for us to meet legislators, face to face, and to impart important legislative goals that protect our profession. Your profession needs your participation. If you were unable to attend this year, please plan to join us next year.

The next District 2 meeting will be Thursday, September 6, 2007. District 2 will not meet in the months of June, July or August. Hope to see you at the Summer Convention at Tan-Tar-A in July.

If you wish to attend one of our monthly meetings, they are held on the first Thursday of the month at 7:30 pm in the Truman Room on the first floor of the Ararat Shrine Building located at exit 65 (I-435 and Eastwood Traffic-way). Go east to 5100 Ararat Drive, Kansas City, Missouri. Visitors are welcome.

Gerald W. Witt, D.C.
District 2 Secretary

District 5

Although cold, damp and dreary, with looming tornado and thunderstorm warnings, District 5 pushed on and was finally able to conclude its seminar efforts that began in January. The district provided all 12 mandatory hours on Saturday, March 31, at the Holiday Inn North, with approximately 78 doctors in attendance.

A brief meeting was held over lunch discussing membership, auxillary, by-laws and recent legislature. Dr. Richard Behrend, from Lamar, was elected District 5 treasurer. The meeting concluded with Dr. Charles Maurer making a valiant effort to sell $100 raffle tickets for the Summer Convention. Many doctors expressed their appreciation that District 5 was becoming more active and showed interest in becoming more involved.

Our next meeting is scheduled for Saturday June 2 at the Holiday Inn North in Springfield.
Jeremy Thornton, DC, DABCI

District 7

District 7 met the first week of March with Dr. Paul Foster presenting information regarding the Centennial. Our next scheduled meeting is May 3, 2007. Beth Sankpill, wife of Dr. Stephen Sankpill, of this district will be presenting "The Care and Treatment of Lymphadema." Beth is a Certified Therapist at Hannibal Regional Hospital. Discussion of topics presented at the April 21 board meeting are also on the agenda.

Front Desk Organization & Patient Retention

by Susan Hoy

DOES YOUR OFFICE APPEAL TO YOUR PATIENTS’ SENSES

What would your patient sense upon entering your office. What does your office smell like? Has your CA just eaten tuna sandwich at the front desk. Worse yet, is your front desk CA eating a tuna sandwich when the patient arrives. VERY UNPROFESSIONAL! What’s wrong with a tuna sandwich, you ask? Well...it smells like fish! Maybe someone hates the smell of fish, therefore, creating a unfavorable first impression. Don’t laugh...it matters! Eating should be done away from patient’s sight and sense of smell (unless you’re baking chocolate chip cookies). If you want to be treated like a professional, then act like a professional. What does your office feel like when your patients arrive? Can they feel stress and tension from your staff or you? Do they feel welcome or is your CA too busy to acknowledge them? Worse yet, is anyone there to greet them when they arrive? Our front desk is never left unattended. I know this is difficult for some offices but entering an office and being greeted by a real person feels good. What does your office sound like? Are you playing your music for your staff or your patients. I believe that music should be soothing and for relaxation purposes. You want your patients to be as relaxed as possible. Are you playing the radio or nicely presented CDs? Back Talk Systems have several choices of CDs for your office. Does your office staff shout comments and commands to each other instead of using the intercom button on the phone or speaking quietly?

What about your paperwork? Look at your sign-in sheet right now. Is it a mess? Has it been copied over and over again? Is it straight or crooked? Do you realize what your paperwork says about you? Is every form your patient sees copied from an original or actually printed from your printer? Are your counter top displays arranged neatly? Are your handouts neat, easy to read and understand?

How about your state of readiness? Is your CA ready for patients when they arrive. Are the new patient files made up and individualized as much as possible? Are the new patient forms ready on a clip board with the name of the new patient and time of arrival?

Remember, your office and your staff are an extension of you. Your patients will judge you through them. A well organized, professional, stress free office means a well organized and professional chiropractor who will be professional and organized when treating patients. Unfortunately, we get so used to looking at our office we don’t see things as others see them. Take the time today to get an idea of what kind of patients you are attracting and make the changes accordingly. Finally, the more organized and stress free you are, the more patients you will be able to care for. So, get organized and make way for the crowds!Œ

PATIENT FLOW EFFICIENCY

I have indicated many times, there are three components to having an extraordinary practice. The first is creating good feelings within your patient. That means making all of your patients feel special. It means that when they think of your office, the thought triggers warm feelings about you and your practice. The second component is creating good experiences. Good experiences are directly related to your ability to serve your patient efficiently and expediently. Finally, the third is the component of positive energy and enthusiasm. You and your staff must be enthusiastic and excited about chiropractic and the difference you can make!

While all three of these components must exist, I want to focus on the second component, creating good experiences. Good experiences are the result of good procedures, good systems, and your ability to serve your patients in a timely manner so that they perceive quality care and quality service. How long the doctor spends with the patient is not as important as the patient perceiving quality care from all staff members.

Patient satisfaction and experience is the result of proper patient flow procedures. All of your patient procedures must be systemized and each staff member must know his/her responsibility as well as all other staff members’ responsibility also. That means besides being systemized, you must also be able to carry out those procedures efficiently. Every system must be planned out and practiced routinely.

Following are some time management tips for better patient experiences.

Schedule Realistically: Make sure you are scheduling according to the doctor’s treatment time. Nothing gives a patient a bad experience more than waiting too long. Additionally, remember you are not just writing names into your schedule, you are serving your patients. Know your patients and their needs and schedule accordingly. In other words, know your speed bumps and your speed demons and schedule them at the proper times, making sure you are giving personalized care as much as possible.

Be Proactive: Start your day with a huddle and solve your scheduling problems before they happen. Additionally, do your best to address the needs of your patients in advance.

Be Ready: Make sure your travel cards or files are pulled and in proper order. New patient files are made up as much as possible and Report of Findings reports and x-rays are arranged. In other words, do everything that can be done in advance.

All Hands on Deck: During peak patient times, every staff member must be focused on patient service. When patients are in your office, be sure you are focusing on them and not your paperwork!

Be Efficient: Know your patient flow procedures. Set timers so that no patients have to wait unnecessarily. Utilize color-coded flag systems and clipboards to help with staff communication. Have hot seat area so the doctor is not waiting for the patient. Remember, seconds count.

Communication: Have a method of communication so that you are not interrupting each other. During busy patient times, there should be very little staff communication. Communication procedures should be done by means of routing slip check marks, circles, and practiced patient flow queues and signals.

Reception Area: Have separate check-in and check-out areas at your reception desk so you are not creating a bottleneck situation. Also, create an efficient work area so that everything you need is within easy reach.

Time Study: If you are not sure about your patient flow system, figure it out. Know the optimal time patients should spend in your office and then do a time study to ascertain if you are being efficient. Write down the time the patient arrives, their appointment time, and the time your patient actually leaves your office. Determine where the inefficiency lies and take steps to correct the problem.

If you are not working efficiently, then you are losing patients. No one likes to wait. Additionally, you are creating the perception that you are either too busy or not very organized. When that happens, your patients stop referring others. The bottom line is your practice must be working at peak performance in order to create good experiences not just for the patients but for the staff also.

Susan Hoy has managed a busy chiropractic office since 1989. www.beefitup.net

Diabetic Patient In A Chiropractic Office

Documentation of the Diabetic Patient in a Chiropractic Office

by Michael S. Butler, DC

Since the beginning of the discovery of chiropractic by D.D. Palmer in 1895, in Davenport, Iowa, the practice of chiropractic has been along the major theme of allowing a greater expression of the body’s natural and innate wisdom using the pathways of the nerves. Other approaches to chiropractic included the nutritional approach and the holistic-energy approach; while others involved a biomechanics approach to health, as well as other schools of thought. Due to the many approaches to chiropractic health, different schools and colleges were created. This created disunity in the profession.

The one unifying theme of the profession of chiropractic is the importance of nerve function from the brain to the rest of the body. By restoring strong nerve flow, through motor and sensory and autonomic function, the body is able to respond to environmental stimuli and show innate powers of healing.

A diabetic patient will form a unique challenge to the
practitioner. The patient with uncontrolled blood sugar will have a higher risk of cellular damage. Due to a higher risk of cellular damage, they will be more prone to neural pressure palsies; and most all nerves could be in danger of neuropathic issues. Typically, these diabetic neuropathies and pressure palsies occur in the lower extremity before they occur in the upper extremities. The sensory nerves will be impacted before the motor nerves.

Peripheral nerve damage in diabetic patients occurs distally, symmetrically, and are sensorimotor neuropathies. Then, occurrence is in the hands. This is due to an axonal damage which causes denervation of the longest nerves first. This is a typical stocking and glove syndrome. Sensory nerves are more fragile than motor nerves, and the patient will experience numbness and burning prior to muscle weakness. Unlike traumatic nerve injuries, diabetic neuropathies occur slowly. The longest axons will be the first to denervate and die back. This die back phenomenon of the axons, also known as Wallerian degeneration, can occur in three to nine days. Denervation of the axons is then followed by reinnervation in the growth of the new axons sprouts. The chiropractor trained in electro diagnostics will be able to identify motor and sensory nerve decreases and amplitude and slowed speed along the course of the nerves tested. If these are uncontainable, it is unlikely that it will be possible for the electrodiagnosticians to record other lower limb sensory nerve functions, and the reduction in amplitude of upper limb responses would be expected. This is the beginning of the stocking and glove sensation of the diabetic patient. At this time, the patient will be experiencing numbness or burning of the feet, and possibly difficulty in heel and toe walking examinations.

Two other methods of sensory testing have been applied to the examination of patients with diabetic neuropathy in an effort both to characterize the clinical deficit and to quantitate peripheral nerve dysfunction. One of these tests is the cold limb study for our temperature differences in the lower limbs as well as a perception of vibration deficits. Nerve conduction studies and EMG are also used to assess the pattern of damage due to axonal polyneuropathies, and is of great interest to the chiropractor treating the entrapment in the spine. The diabetic patient will have bilateral symptoms; and it is very rare for them to have unilateral signs and symptoms. Asymmetry and foot pain, or hand pain, is distinctly unusual and implies a mononeuropathy multiplex pattern, or a superimposed entrapment process or radiculopathy. That is because nerves are very fragile and cannot take pressure such as the type of pressure imposed by altered biomechanics of the spine in a subluxation complex.

Subluxated patients will have altered nerve flow. This fragility may make them more risky candidates for having axonal damage and schwann cell damage. Patients who have diabetic neuropathy are more susceptible to mononeuropathy at typical entrapment sites. In the upper extremity, median neuropathy at the wrist and ulnar neuropathy at the elbow are common. In the lower extremity, entrapment sites include the medial malleolus for the tibial nerve, and patients will feel numbness of the foot. Electrodiagnostic studies document a lower amplitude and lower conduction velocity in the nerves. More exciting research from our colleges is underway and is necessary.

The study of proper nerve flow in the patient with diabetic neuropathy should be considered for every diabetic patient of electrodiagnostic studies to confirm the presence of diabetic neuropathy from other pressure polyneuropathies. They determine the severity, the pattern and the location of the neuropathy. They determine if it is motor, sensory, or if both fibers are involved. They determine if the deficient pathway is axon loss or loss of myelin sheath. The correlations with lab work to accurately determine the type of lesion is important.

The common denominator in unifying the practice of chiropractic and achieving the best practice is allowing the patient to have improved health from an improved nerve supply. Through the use of electrodiagnostic tools for the diabetic patient, proper documentation is achieved.

Author:
Michael S. Butler D. C. is a 1983 graduate of Life Chiropractic College. He has certification in insurance claims review, chiropractic sports physician, and acupuncture and meridian therapy. He recently completed the Carrick Institute electrodiagnostic certification program and is an assistant professor in electrodiagnosis and is board eligible.

ACA Report

by Jack Kessinger, DC DABCI, Missouri Delegate

I just returned from the ACA’s National Chiropractic Legislative Conference (NCLC). It was combined with the House of Delegates (HOD) meeting and was very effective and informative in its lobbying intent. In addition to the elected ACA Delegates visiting “The Hill” and educating their congressional leaders about chiropractic, over three hundred Student American Chiropractic Association (SACA) members also attended, helping deliver important chiropractic messages to congress.

Some of the talking points included:
CORRECTING ERISA BY ENACTING A PATIENTS BILL OF RIGHTS (PBR) TO PROTECT CONSUMERS FROM INSURANCE AND MANAGED CARE ABUSES. All states have enacted statutory protection at the state level designed to insure consumers and patients accessing health care insurance are treated fairly, and not denied care in which they are entitled. Unfortunately, these state laws do not protect millions of Americans who receive their health care through Employment Retirement Income Security Act (ERISA), because these plans are not subjected to state-mandated consumer protections. Earlier this year (2007) the late Rep. Charlie Norwood (R-Ga.) introduced House Bill 979 to correct this problem. Those doctors and students visiting “the hill” urged House members to support this legislation. Senators were encouraged to work toward a passage of a companion bill to HR 979 on the Senate side.

MEMBERS OF THE SENATE AND HOUSE OF REPRESENTATIVES WERE ENCOURAGED TO OPPOSE ASSOCIATED HEALTH PLANS (SIMILIAR TO SB 1995 THAT WAS ATTEMPTED LAST YEAR). If passed, this legislation would, in effect, eliminate the important consumer and patient protections enacted at the individual state levels. If such a law were passed, it would most likely make insurance unaffordable for many, including those with any pre-existing conditions, and would not cover basic and preventive services.

MEDICARE BENEFICIARIES DESERVE EXPANDED ACCESS TO CHIROPRACTIC CARE. Under the current Medicare system, beneficiaries are denied the freedom to select a doctor of chiropractic as their provider of choice, except for a single service, manual manipulation of the spine to correct a subluxation. This restriction is unfair to patients and anti-competitive. Under Medicare, doctors of chiropractic are not reimbursed to the range (broad scope) of existing benefits their license allows in most states. The practical impact of this current restriction discourages chiropractic as a treatment option — even though chiropractic treatment typically costs the Medicare program significantly less than patients who do not access chiropractic.

At the urging of the ACA, Congress included a provision allowing doctors of chiropractic in select areas (Maine, New Mexico, Northern Illinois, Scott county in Iowa, and 17 counties in Western Virginia) to furnish the full range of Medicare covered benefits they are entitled to provide under the respective state scope of practice laws. The outcome of this study will likely determine whether or not Congress will — at some future date — enact permanent legislation expanding access to chiropractic services for all beneficiaries in the Medicare program. The demonstration, which began in April, 2005, will end March 31, 2007. After the program has ended, CMS will analyze and submit data to Congress.

Members of Congress were asked to support appropriate access to chiropractic care in the Medicare program and remain in close contact with the ACA as the Medicare Chiropractic Demonstration project is concluded and studied. The ultimate goal of the ACA is to enact permanent legislation to all barriers to chiropractic care. For additional information concerning the Demonstration Project see Federal Register, CMS-5037-N, ½8/05, p.4130.

SUPPORT EXPANSION OF CHIROPRACTIC SERVICES AT ALL MAJOR MILITARY TREATMENT FACILITIES. According to a report by the U.S. Government Accountability Office (GAO), the Department of Defense (DoD) is not complying with current law and has failed to fully implement its own plan to provide chiropractic health care services at all active duty military facilities. In fact, it has only implemented chiropractic health benefits at only 42 of the 238 military treatment facilities worldwide, with no plans for any additional benefits to which all 1.8 million active duty
military are entitled.

Key Congressional members include Rep. Ike Skeleton (D-MO), Chairman, House Armed Services Committee; Rep. Duncan Hunter (R-CA), Ranking Member, House Armed Services Committee; Sen. Carl Levin (D-MI), Chairman, Senate Armed Services Committee; and Sen. John Warner (R-VA), Ranking Member, Armed Armed Services Committee. Unfortunately, we could not get an appointment with Senator Skeleton during the NCLC.

The Long Range Planning Committee (LRPC) reported on their October 27 - 28, 2006, Face-to-Face Strategic Planning Committee Meeting, detailing recommendations for the future growth of chiropractic. The report begins with the ACA Vision Statement.

“The ACA and its members seek to transform health care from a focus on disease to a focus on wellness. This transformation results in positive outcomes for public health, including reduced morbidity, increased functional capacity, increased longevity of the U.S. population, and a significant reductions in health care costs. In this new health care environment, doctors of chiropractic are full partners in health care decision making, are highly respected and widely used, for their unique conservative approach, primary care knowledge, hands-on expertise, and effective patient communication skills. Healthcare in 2015 will be patient-oriented, outcomes driven and value based, including open areas for all Americans to benefit from comprehensive chiropractic health care.”

The HOD pledged $150,000 over the next six months to insure chiropractic representation in the upcoming health care market place. At this time, the profession has a window of opportunity to become seriously involved in the planning in the current health care revolution.

The Long Range Planning Committee proposal coincides with the Council on Chiropractic Education (CCE) definition of what is a doctor of chiropractic — “the doctor of chiropractic’s responsibilities as a primary care physician (emphasis ours) includes wellness promotion, health assessment, diagnosis, and the chiropractic management of the patients health care needs.”

Today, there is a revolution in heath care. This revolution will provide opportunities that can help level the playing field for health care providers. Congress will soon be reevaluating health care, and there will be winners and losers. All health care providers will be competing for the same dollar; and when one group wins, another has to lose. The ACA remains very active promoting the fact that the services provided by chiropractic deserves equal pay to the other mainstream health care providers.

A disturbing finding was reported at the ACA HOD meeting. Aetna has announced their new Mid-Atlantic policy, distributed by American Specialties Health Network, which indicates that both interferential current therapy (IFC) and the use of hand held spinal adjusting instruments are experimental and reimbursement will be refused beginning March 1, 2007. The Aetna Mid-Atlantic region includes: Pennsylvania, Delaware, Virginia, Maryland, New Jersey, and Washington DC. The ACA is actively addressing this issue for both the patients and doctors rights. IFC is a specialty form of EMS, and an integral and beneficial component of many treatment plans. The use of hand held manual manipulation is used by many, and is an integral part of manual manipulation. The ACA is actively working to right this latest salvo fired at chiropractic.

The MSCA is by far the strongest and most influential chiropractic association in Missouri, essential for advancing and protecting chiropractic in Missouri. The ACA is by far the strongest and most influential association in the world. A strong national association is equally essential to advance and protect chiropractic internationally.

It’s All About The Water

by Jenna Broeg Colgan, MA, RD

You have heard the recommendation for as long as you can remember - drink at least 64 ounces of water each day. Yet, how many of us hit or even come close to hitting that mark on a regular basis? According to the estimates – not many. A staggering 75% of Americans are not drinking enough water, with more than one third of the population believed to be chronically dehydrated. Mild dehydration can slow our metabolism by up to 3% and affect everything from digestion and nutrient transport to oxygenation of our cells and waste removal. It is also the number one trigger of daytime fatigue. Water is second only to oxygen in terms of being essential for life. So with warmer temperatures and days of greater sun exposure quickly approaching, it becomes even more important to consider water. Water intake is critical not only to prevent dehydration, but to optimize overall system functioning.

We have established that water is important, but its extensive involvement may surprise you. For starters, all of the body’s processes occur in a water medium. Therefore, if your water levels are below optimal, your entire system function will be compromised. From a nutrition standpoint, water is critical for digestion, transportation, and absorption of food and nutrients. Both oxygen and waste products are carried to and from cells by water. Water protects our organs and provides cushion and lubrication for our joints. It also acts as a shock absorber for the inside of the eyes, spinal cord and during pregnancy, the amniotic sac. In addition, adequate blood volume is maintained by water, deeming it essential to the integrity of the cardiovascular system.

Another important function of water, especially this time of year, is to regulate body temperature. Both physical exercise and heat stress affect the body’s water balance. As you exercise, the majority of the increase in your body’s metabolism is released as heat. Especially when conditions are hot, this can result in a significant amount of body water being lost through sweat, as your body works to dissipate this heat. People generally become dehydrated when exercising in the heat, despite attempts to consume water as they go along.

Once dehydrated, other factors complicate the situation. Thirst is not a good indicator as to the body water levels. It is estimated that by the time a person is thirsty, a deficit of approximately 2% body weight loss has already occurred. The thirst sensation also decreases with age. Dehydration reduces the rate at which ingested fluids are emptied from the stomach during exercise in heat. Since fluid emptying and thus availability is delayed, core body temperature increases, meaning your body has become less efficient at cooling itself. As a result, dehydration decreases an individual’s exercise performance and tolerance to heat, emphasizing the need to begin water replacement in the early stages of exercise and heat exposure.

Since water’s functions are critical and vast, it is not surprising that our bodies are 60-70% water. Unlike nutrients, which we can store, our bodies are largely unable to store water. Each day, we have to replenish the approximately 2.5 quarts of water we lose. Water loss occurs through urination, bowel movements, sweating, and normal breathing. Both heat and exercise clearly increase daily water requirements. If the body becomes dehydrated, water is redistributed based on priority. A study in dehydrated rats by Nose et al showed that 40% of the water loss was from muscle, 30% from skin, 14% from viscera, and 14% from bone. Neither the brain (75% water) nor the liver (96% water) showed significant water loss. In an effort to maintain blood volume, the water was largely redistributed from the muscle and skin. (This explains why increasing water intake may improve skin suppleness and appearance for those with suboptimal fluid levels.)

What can you do?? For starters, go drink a glass of water immediately! Begin drinking water shortly after rising and spread your intake throughout the day. Fruits and vegetables have a high water content; increasing consumption is a good way to improve fluid balance as well as overall health. Your primary beverage should be water. Other beverages that contain caffeine can actually cause you to lose fluid. If you are going to be in the heat or especially exercising in the heat, begin drinking water as soon as possible. Slowly increase your amounts until you reach the goal. Drinking more water is a simple change with extraordinary impact.

References:

1. HealthQuest. 2nd ed. CD-ROM. Fort Collins, 2004
2. Sawka, Michael N and Scott J Montain. “Fluid and electrolyte supplementation for exercise heat stress.” Am J Clin Nutr 2000;72(suppl):564S-72S
3. Whitney, Eleanor Noss and Sharon Rady Rolfes. Understanding Nutrition. St. Paul: West Publishing Company, 1993.

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