Chiropractic integration into the hospital setting is accelerating. Some recent happenings demonstrate the impending changes. The emergency department (ED) director of a busy New York City hospital called me recently to help her set up an on-call chiropractic program. This physician had been a member of the emergency department where I currently work. Only two weeks after her appointment to her position at her new hospital, she decided she needed to establish a chiropractic department. Her phone call did not surprise me. This physician had previously declared that adding chiropractors to the ED was the best change she had witnessed in all her years as an ED physician.
The New York State Chiropractic Association (NYSCA) - led by Mike Bernstein, DC, president of the Nassau County chapter and chairman of the hospital committee, with Lou Lupinacci, DC, co-director of the hospital program - has initiated a two-pronged strategy to promote wide-scale chiropractic inclusion in New York state hospitals. Their first step is to educate their members through a hospital protocols seminar, planned tentatively for early 2007. NYSCA's second step is to approach hospitals as an organization rather than as individuals. Having gained support from the American Academy of Hospital Chiropractors (AAHC), the NYSCA appears to be well on its way to making the dream of hospital chiropractic a reality in the state of New York.
AAHC President Joseph D. Salamone, DC, has been having discussions with a major New York City hospital chain. Dr. Salamone reports that influential administrators have voiced significant interest in promoting chiropractic inclusion in their member hospitals. Dr. Salamone and the AAHC soon will be making a formal presentation to the hospital administrators.
With the promise of a quantum leap in hospital inclusion comes an equally large increased fear. As the number of chiropractors entering hospital practice grows, it becomes increasingly difficult to monitor their actions to ensure we all are working toward the same goals.
In our hospital, with only four on-call chiropractors, it is relatively easy to stay aware that everyone is performing within ethical practice parameters. With an increasing number of, "hospital privileged" chiropractors, it becomes crucial that everyone involved become dedicated to the adherence of ethical standards. My personal fear is that those motivated by quick financial gain will try to take advantage of hospital practice without concern for the future of our profession.
Stephen R. Covey, author of The 7 Habits of Highly Effective People, writes about the need to develop character rather than to rely merely on learned "success and marketing" techniques. An example would be a desire to get your patient well as a foundation upon which to formulate treatment recommendations, rather than composing a great-sounding report of findings; thereby encouraging acceptance of the number of treatments you would like to deliver and maximizing income.
Another relatively recent change in chiropractic practice is the performance of manipulation under anesthesia (MUA). Some hospital administrators are anxious to invite chiropractors to perform MUA in their hospitals. Others are less enthusiastic to add a procedure with which they are unfamiliar. It has been my experience that MUA is a procedure that can reflect well upon the chiropractic profession as long as ethical considerations rule over monetary ones.
While performing medical director reviews for an insurance review organization, I noticed a disturbing trend demonstrated by a few chiropractors requesting pre-certification of MUA. A small number of chiropractors are adding MUA of the shoulder and hip on all patients being considered for MUA of the spine. The letters of medical necessity most often eloquently detail the reasoning for hip and shoulder procedures. Unfortunately, most often, the office notes and independent examination reports fail to document any hip or shoulder complaints. The appearance is that these few chiropractors are basing their requests on a desire to maximize income by expanding one of the few "big-ticket" chiropractic procedures. It is only natural that the insurance company representatives will take progressively more aggressive action to eliminate the practice of MUA altogether.
Most of us have experienced the "anti-chiropractic-appearing" reviews. When I perform the medical director reviews for MUA pre-certification, I feel I am working in a pro-chiropractic fashion. By scrutinizing and forcing our colleagues to maintain high documentation standards that clearly demonstrate ethical considerations over monetary considerations, I am contributing to the longevity of the very valuable MUA procedure, so chiropractic patients can continue to benefit when other conservative measures have failed. Any chiropractor who has read my medical director review will attest to the fact that the review was based upon specific details, rather than being an attack upon the MUA procedure itself. Any chiropractor who has received a denial, based upon my review, has the opportunity to provide additional information that answers the specific objections to have the review overturned. It is only when the request has not been properly documented, or there is a lack of facts that would contribute to proper documentation, that an appeal will not be effective.
I look forward to working with chiropractors entering into hospital practice, as well as the insurance companies and insurance review companies, to set up review procedures for hospital chiropractors. Hospital chiropractic cannot be practiced with a money-maximizing attitude. Some insurance companies and insurance review organizations already have reviewed and approved of the benefits of hospital chiropractic. Many others are in the process of reviewing the need to reimburse for hospital chiropractic services. It is imperative that chiropractors involving themselves in hospital practice place ethics above monetary concerns. They should enter hospitals with the attitude of providing the very best care, with reimbursement being a welcome side effect of their altruistic actions.
Organizations like the NYSCA need to consider establishing policies concerning hospital practice. While the AAHC continues to work on national practice guidelines, state policies need to be established, as chiropractic practice is regulated differently in each state. An example is the Medication Reconciliation Form mandated in New Jersey hospitals. The need to complete this form affects the manner in which doctors of chiropractic can participate in patient discharge from the ED. Different states have different rules regarding a chiropractor ordering physical therapy or certain types of diagnostic tests.
The dream of widespread chiropractic participation in hospitals appears to be closer to becoming a reality. Through adherence to ethical practice standards and well-researched state regulations, hospital chiropractic will indeed become a permanent reality.
Many relevant diagnostic signs are not performed deliberately by the examiner or by the patient at the examiner’s direction. They are observed as the patient reacts to their condition. Fortin’s finger sign, Minor’s sign, and Vanzetti’s sign are three examples of this principle.
On Feb. 1, 2024, two more legislators – John R. Carter (R-Texas) and Robert “Bob” Good (R-Va.) – co-sponsored the Chiropractic Medicare Coverage Modernization Act of 2023, bringing the co-sponsor total to 155, two more than the total achieved over the entire two-year congressional cycle in which identical legislation last appeared (2021-22).
While working at the Lovelace Medical Center in Albuquerque, N.M., one of the primary care physicians stated that imaging every patient prior to receiving chiropractic was not medically necessary. It was at that point I reconsidered the need for the imaging of every patient to avoid malpractice.
