Congress overrides Bush's Medicare veto scheduled to take effect Tuesday, July 1, 2008 and cut 10.6% in Medicare payments to physicians. The US Congress canceled the reduction in Medicare payments to doctors treating elderly patients. Within hours of President Bush’s Veto Representatives voted 383-41 to override it. The Senate followed suit soon after, by a vote of 70-26.

Alarm Rings in Lousiana—Time for the Profession to Wake Up An Open Letter to Chiropractic From FCER President, Charles Herring, DC With the closing of the Louisiana legislative session it became even more apparent to me that the external influences on the chiropractic profession (and healthcare in general) are moving—in a very organized fashion—to use the literature (or the lack thereof) to make decisions regarding payment policies of the insurance industry (both health and workers’ compensation insurance). During the recent Louisiana legislative session it was learned that the National Insurance Commissioners Association has written a model piece of legislation. A major part of this legislation addresses the issue of denying care based on evidence or the lack of evidence. This model legislation is occurring because state legislatures have passed “Medical Necessity Review Organization laws” that limit the ability of the insurance companies to deny care on the basis of medical necessity. To combat these limits, the proposed bill would legally permit the insurance companies to stop denying care because it is not medically necessary and begin denying care on the basis that it is “observational and investigational.” They are attempting to change the rules of the game and will now deny claims because there is no evidence to support the effectiveness of a particular treatment. Methods to The Madness • For quite some time, health insurance has talked about “evidence-based practice,” but they have not actually done much to create standards and enforce the concepts of “Best Practices.” Medical necessity is routinely based on the demonstrated needs of the patient and the documented demonstration of a condition and the response to the treatment being rendered. The treatment rendered and the need for future care was then addressed by a consultant at the point of pre-certification. United Healthcare and ACN have typically used standards that they created from what they perceive to be the evidence-based treatment protocols in the literature. • The “length of care” determination has been arbitrary at best and is predominantly determined by the use of data comparisons with other chiropractors in the network. They have also used other outcome measures which may not address the specific problems of the patient that you are treating. • Until recently, the insurance companies deny payment for recently developed therapies—such as VAX-D and Low Level Laser—by making the determination that these new therapies are considered “observation and investigational.” The result is that all new technologies are being measured by the evidence that is available. In making these determinations, the required level of evidence has been high quality randomized controlled trials. • Many private insurance companies will not pay for cervical disc replacement with the new disc that allows movement of the motion unit. While a study of the disc approved by the FDA resulted in the approval of the device, the insurance companies have refused payment because the patients were not randomized, the treatment was not blinded, and the study did not compare the new treatment to a placebo. • Learning from their success with not paying for new therapies, health insurance companies are now creating policy language to limit payment for various long-standing, well-established treatments in chiropractic such as massage and various electrical modalities. Aetna now has a “clinical policy bulletin” that specifically addresses chiropractic care. This policy bulletin states that they will not pay for the treatment of scoliosis except during early adolescence. There are also a number of techniques that are not covered. This is all being denied because there is no evidence that the treatment is effective and therefore the treatment is considered “observational and investigational.” • Workers’ compensation insurance and business interests are now pushing very hard to pass legislation that will require the use of treatment guidelines in the treatment of injured workers. The Workers Compensation Research Institute (WCRI) has been providing data analysis reports of workers’ compensation costs in numerous states. Their reports have targeted medical cost and have suggested that certain treatments are major cost drivers—with chiropractic care being list at or near the top of the list. The insurance industry and business groups have also heard about the implementation of the American College of Occupational and Environmental Medicine (ACOEM) guidelines in California. They have been told that medical costs have significantly decreased since ACOEM guidelines were mandated by law in California. Guidelines only use the highest level of evidence—RCTs or systematic reviews that are based on RCTs. These two situations are creating and will continue to create great difficulties for the chiropractic clinician. • Our first problem is our lack of evidence. While there is a body of evidence that supports the major conditions that chiropractors treat, most of the evidence is not rated at the highest quality because it is difficult to blind the patient or the doctor and it is difficult to do a treatment comparison with a placebo or sham treatment. This affects the quality of the RCTs that have been done and thus weakens our argument that spinal manipulation is effective. • Other treatments, such as therapeutic modalities, have been tested and have been found to be ineffective within the standard RCT model of research. For example, electrical stimulation has been tested alone, in conjunction with spinal manipulation, and spinal manipulation alone in a single study. This study found that there were no prolonged treatment effects of electrical stimulation when performed alone or in conjunction with spinal manipulation at 30 days, 90 days, 6 months, and 12 months. Spinal manipulation was just as effective with and without electrical stimulation. I think we would all agree that there are no long-term therapeutic benefits to the administration of electrical stimulation. The research design prohibits a successful outcome because electrical stimulation was never intended to have long-term effectiveness. The effects on pain and spasm have shorter-term therapeutic benefits, but the studies do not measure the effectiveness with the context of how it is used in clinical practice thus the studies report that it is ineffective. Now the insurance industry says... “There are no studies to support the effectiveness of this treatment.” • Finally there is increasing competition between the chiropractic profession and the physical therapists. They have established doctoral programs and are doing a significant amount of research in universities. There is even talk in Washington that chiropractic should be considered a subset of physical therapy since PTs are more integrated into the education system and the medical treatment model. We are currently in a race to have cultural authority over manipulation, but when it comes to research to support this authoritative position we are losing the race. Meeting the Challenges Ahead What must our profession do? 1. We MUST fund research like our livelihoods depend on it—because they do. New studies are needed to demonstrate the benefits of chiropractic care with the public, government, and payers of healthcare services. Our lack of evidence is going to allow the insurance industry to continue to deny more and more treatments provided by the chiropractic profession. FCER is setting up practice-based research programs to create clinical data that can then be leveraged into Federal grants to do major research projects through our colleges and other institutions. FCER will need to fund small studies that can be used to obtain Federal grants. State associations will need to step up and support this effort and individual DCs will be needed to participate in these studies. 2. DCs MUST learn how to find, read, interpret, and apply evidence in their practices. We can no longer afford to do things just because BJ said it. We must be able to use evidence to guide our decisions with regard to the treatment of our patients. Society is now demanding that doctors practice in an evidence-based manner. The chiropractic profession must embrace this approach to providing care if we hope to participate in future government programs, insurance programs, workers’ compensation, as well as developing closer working relationships with the medical profession. Even public acceptance hangs in the balance. 3. We MUST fund programs that have the potential for developing more evidence and for training the profession to use evidence in practice. FCER must be funded at the level necessary to meet the professions needs both now and in the future. We do not have the benefit of outsiders who will foot the bill for us. We must look to ourselves for the major financial assistance that is needed. The time for us to act is NOW. We cannot wait any longer. Further delays will only result in our profession falling farther and farther behind in the evidence-based world. Please support FCER today and give on a continuing basis. Research evidence is the foundation for inclusion of chiropractic care in all programs. The responsibility for our profession falls on you as it falls on me; we can not rely on “them.” As the chiropractic profession’s oldest not-for-profit foundation, serving the profession since 1944, FCER is charged solely with providing the chiropractic profession with the research tools to battle exactly these challenges—and the Foundation is funded entirely by those within the chiropractic profession. FCER, based in Norwalk, Iowa, has as its mission to “Translate Research into Practice” by granting funds for research and producing practitioner and patient education materials including teleconferences, CDs, books and pamphlets. FCER is developing the profession’s only Evidence-Based Resource Center at www.DCConsult.com. More information on FCER, membership, and subscriptions to DCConsult can be found at www.fcer.org or by calling 515-981-9888.

INSIDE THIS REPORT: 1. NBCE Redesigns Web site 2. 2008 Annual Meeting Results 3. NBCE Updates Part IV Eligibility Policy 4. Part I and Acupuncture Test Committees Meet 5. Part IV Test Committee Gathers 6. NBCE International Update 7. NBCE Calendar 1. NBCE Redesigns Web site The NBCE launched its redesigned Web site in June. Please visit www.nbce.org to see the changes. The site has been reorganized to include information that was previously available only through printed materials. For example, examinees may now find test plans, test schedules and lists of reference texts for the written examinations online. Popular features such as online applications and online score reporting will continue to be available. The redesigned site is organized into two sections: one for examinees and one for professionals. The information for examinees includes written, practical and post-licensure examination information. The professionals section includes information about the NBCE Board of Directors, as well as the NBCE reports and publications, and links to other chiropractic organizations. The redesigned site features expandable menus for navigation between pages. In the coming months, we plan to add more features to the site, including RSS feeds and streaming video. The NBCE Web site is always the first and best place to seek information about this organization and we hope you will visit it often. 2. 2008 Annual Meeting Results It was gratifying to see so many of you at the meeting in Atlanta. On behalf of the NBCE Board, we are grateful for your confidence in the direction and leadership of the NBCE. A total of 39 voting delegates and alternates attended the NBCE business meeting. We truly believe that the voice of the delegate body is most effective when it is the voice of many! Dr. Ted Scott (Utah) was re-elected by acclamation to his second term as District IV Director. Additionally, the Executive Committee was returned with President Dr. Vernon Temple, Vice President Dr. Ed Weathersby (Arizona), Secretary Dr. Mary-Ellen Rada (New Jersey), and Treasurer Dr. Ted Scott. Proposed NBCE Bylaws Revisions The main purpose for all corporate and non-profit bylaws is to provide a blueprint for the operation of an organization. The existence of bylaws frees directors and management to manage and govern in a transparent and accountable manner—to concentrate on the true mission of the organization. The delegates and alternates therefore continue to fulfill their responsibility to provide input to the NBCE, not just for a year or two but into the 21st century. We sincerely appreciate that the delegates and alternates put so much thought and effort into re-examining the NBCE bylaws. Proposal 1 passed, amending the NBCE’s mission to clarify that our activities must be in the best interests of the Corporation (NBCE) and chiropractic testing. Proposal 2 passed, creating term limits for directors, reclarifying eligibility requirements and terms of service for district directors and FCLB-appointed directors. Proposal 4 passed, thereby eliminating the position of chairman of the board with the president serving as the presiding officer over meetings of the Executive Committee and Board. Proposal 5 passed, clarified that bylaws amendments will become effective at the adjournment of the Annual Meeting of Delegates, and that meetings will be governed by the Robert’s Rules of Order Newly Revised. The proposal also detailed the process for possible removal of an officer and the requirement that two-thirds of the entire board must vote to do so. Proposal 3 failed; it suggested a process for enacting change in the bylaws. FCLB Funding This past year, the National Board concentrated on revitalizing our relationship with the FCLB, especially to ensure their future financial stability and ability to support state licensing boards. The NBCE’s efforts have been directed towards the development of a funding plan to allow both organizations to accomplish their independent missions and yet to ensure financial stability. We are moving forward with an agreement that will provide funding for the FCLB for the year 2009 and beyond. We look forward to providing more details in the near future. Please visit www.nbce.org to view the 2008 NBCE Annual Meeting pictures, revised bylaws and press releases. 3. NBCE Updates Part IV Eligibility Policy Notices have recently been mailed to all state licensing boards that the eligibility requirements for the Part IV Practical Examination will change effective with the May 2009 administration. The new requirements will be: • The successful completion of all subjects in Part I • A graduation date falling within six months of the Part IV administration • Sign-off by the college registrar indicating the student is academically prepared to take Part IV Modifications to the current requirement will better accommodate the great diversity of course sequencing in the chiropractic curricula, as well as the wide range of graduation dates existing among chiropractic programs in the United States and Canada. 4. Part I and Acupuncture Test Committees Meet The Part I and Acupuncture test committees were held on April 18-19, 2008, at the headquarters of the National Board of Chiropractic Examiners (NBCE) in Greeley. NBCE District I Director Dr. Robin Lecy attended the test committee meeting and expressed his gratitude for the test committee members’ hard work. “Thank you for taking some of your valuable time and coming here today,” he said. “Your expertise and knowledge is appreciated by the Board. Your dedication to the test committee process is an integral part of our exam development; in fact we couldn’t do it without you.” During the two-day meeting, the test committees selected items that they felt would best assess an examinee’s knowledge. To ensure the fairness of the examinations, the test committees are composed of college instructors, subject matter experts and state licensing board members. These individuals are selected based on their expert knowledge of the subject matter. The NBCE examinations are offered twice yearly at chiropractic colleges across the United States and in several foreign countries. The Part I Examination is part of a battery of tests that candidates must pass prior to becoming licensed doctors of chiropractic. Part I consists of 110 standard multiple-choice questions in each of the six basic science areas: general anatomy, spinal anatomy, physiology, chemistry, pathology, as well as microbiology and public health. NBCE written examinations are accepted for initial licensure in all 50 states and the District of Columbia. Acupuncture is an elective exam for individuals who have received acupuncture instruction while in chiropractic college or those who have already graduated from chiropractic college, have complete 100 hours of acupuncture instruction and want to demonstrate their knowledge of the subject matter. This exam consists of 200 multiple-choice questions. Part I attendees were: General Anatomy: • Chad Maola, D.C., NBCE Staff Chiropractic Specialist and Moderator • Sheldon P. Clayton, Ph.D., Sherman College of Straight Chiropractic • Steve W. Kirk, D.D.S., Parker College of Chiropractic • Kim L. Swineheart, D.C., Northwestern Health Sciences University Spinal Anatomy: • Heather Kauffman, D.C., NBCE Moderator • James R. Carollo, M.S., Western States Chiropractic College • Christopher Coulis, D.C., University of Bridgeport, College of Chiropractic • John H. Romfh, Ph.D., Life University College of Chiropractic Physiology: • Kathleen Jones, Ph.D., NBCE Moderator • Kashif A. Ahmad, Ph.D., Northwestern Health Sciences University • Louis J. Freedman, D.C., Palmer College of Chiropractic, Davenport • Christopher A. Meseke, Ph.D., Palmer College of Chiropractic, Florida Campus Chemistry: • Jim Schreck, Ph.D., NBCE Moderator • John Gutweiler, Ph.D., Logan College of Chiropractic • Marc P. McRae, D.C., National University of Health Sciences • Bert Silverman, Ph.D., Life University, College of Chiropractic • Verena Van Fleet, Ph.D., Northwestern Health Sciences University Pathology: • Greg Crawford, D.C., NBCE Moderator • Samir Ayad, M.D., Southern California University of Health Sciences • Cynthia B. Gibbon, D.C., Sherman College of Straight Chiropractic Microbiology and Public Health: • Michelle Clark, D.C., NBCE Moderator • Shahla Abghari, Ph.D., Life University, College of Chiropractic • Sameh A. Awad, M.D., Southern California University of Health Sciences • Kim B. Khauv, D.C., Life Chiropractic College West Acupuncture attendees were: • Martin Kollasch, D.C., NBCE Staff Chiropractic Specialist and Moderator • Bruce Shotts, D.C., NBCE Moderator • David Dresner, D.C., Florida Practitioner • Manual A. Duarte, D.C., National University of Health Sciences • Michael D. Jacklitch, D.C., North Dakota Practitioner • Mary M. Jennings, D.C., National University of Health Sciences • Peter D. Lichtenstein, D.C., Northwestern Health Sciences University • Teresa Marshall, D.C., Minnesota Board of Chiropractic Examiners • Denise C. Natale, D.C., Vermont Board of Chiropractic • Gary Rosquist, D.C., Utah Practitioner 5. Part IV Test Committee Gathers Part IV test committee members gathered on June 20-21, 2008, at the National Board headquarters in Greeley, Colo. NBCE Executive Vice President Horace Elliott welcomed the test committee members and I addressed the group to express the Board’s appreciation for their efforts on this project. Sixteen participants from across the United States, who were chosen to review patient case scenarios and select case-related questions for the Part IV Practical Examination to be administered in November 2008 and May 2009. Part IV assesses clinical skills in diagnostic imaging, chiropractic technique and case management for applicants seeking state licensure. The NBCE Part IV Examination was administered for the first time in January 1996 and has been administered twice yearly to a total over 39,000 doctors. Part IV is presently accepted by 48 states and the District of Columbia for initial licensure in chiropractic. Part IV test committee members were: • Dr. David Allen, Mississippi • Dr. Mark Bledsoe, South Dakota • Dr. John Calisesi, Iowa • Dr. Gary Carver, Missouri • Dr. Marc Cohen, Pennsylvania • Dr. Frank Corner, North Dakota • Dr. Shannon Gaertner-Ewing, Idaho • Dr. Scott Hansing, Montana • Dr. Scott Kilmer, New York • Dr. Richard Lacey, South Carolina • Dr. Paul Morin, Maine • Dr. Harold Rasmussen, Washington • Dr. Duane Sadula, Maryland • Dr. Albert Stabile, New Jersey • Dr. Richard Tollefson, Minnesota • Dr. Rosemary Zimmerman, Alaska 6. NBCE International Update National Board of Chiropractic Examiner’s (NBCE) Director of International Operations, Dr. Martin Kollasch, visited Han Seo University in Korea during the month of June. At Han Seo University, students who study nursing, chiropractic, dentistry and other health sciences receive all their basic sciences as a group. Currently, 20 students plan to follow their bachelor degree program with entry into the chiropractic program, which is equivalent to a two-year master’s degree. In the second year, students transfer to the University of Bridgeport, College of Chiropractic, to complete their chiropractic education and receive their doctor of chiropractic degree. There is no legislation in place that protects the chiropractors of Korea. Chiropractors can be fined and imprisoned. Han Seo University is therefore seeking accreditation of a doctor of chiropractic program from the Council on Chiropractic Education Australasia (CCEA). With CCEA accreditation, Han Seo University is committed to encouraging legislation to officially recognize the profession, and to recognize licensed chiropractors as those who have graduated from an accredited program and who have completed the NBCE examinations. Also, in support of the chiropractic profession in Korea, Dr. Kollasch attended the World Federation of Chiropractic (WFC) council meeting. He was able to visit the WFC’s meeting as an observer during the same time as the Han Seo visit. In other NBCE international news, Italy passed chiropractic legislation in December 2007. In pursuit of establishing independence from the medical profession, the Italian Chiropractic Association (ICC), which is now recognized by the World Federation of Chiropractic (WFC), has asked for assistance from the National Board of Chiropractic Examiners to develop formalized protocals for recognition of chiropractors in Italy. The ICC requested examples of examinations similar to those that U.S. students must successfully complete for the NBCE. 6. NBCE Calendar Fall National Written Exams Administration- September 12-14 Part IV Practical Exam Administration- November 14-16 National Board of Chiropractic Examiners 901 54th Avenue Greeley, Colorado 80634 970-356-9100 To view the full report in Portable Document Format ( PDF ), click on the link below:

The U.S. Food and Drug Administration (FDA) has notified manufacturers of fluoroquinolone antimicrobial drugs that a Boxed Warning in the product labeling concerning the increased risk of tendinitis and tendon rupture is necessary. Through its new authority under the Food and Drug Administration Amendments Act of 2007 (FDAAA), the agency also determined that it is necessary for manufacturers of the drugs to provide a Medication Guide to patients about possible side effects. The FDA has notified the manufacturers of these drugs that a Risk Evaluation and Mitigation Strategy (REMS) is necessary to ensure that the benefits of the drug outweigh the risks. The Medication Guide will be considered to be an element of the REMS. The new Boxed Warning and Medication Guide would strengthen warning information already included in product labeling for the fluoroquinolone class of systemic antimicrobial drugs. Fluoroquinolones are drugs approved for the treatment or prevention of certain bacterial infections. Like other antibacterial drugs, fluoroquinolones do not treat viral infections such as colds or flu. "Fluoroquinolones are effective in treating certain bacterial infections, but health care professionals and patients need to be aware of the increased risk associated with the use of these drugs of developing tendinitis and tendon rupture, particularly for certain patient populations," said Edward Cox, M.D., director, Office of Antimicrobial Products, Center for Drug Evaluation and Research. "The FDA believes it is important to highlight and strengthen information regarding possible side effects of fluoroquinolones because it may affect decisions about the relative risks and benefits associated with these products." The FDA has conducted a new analysis of the available literature and post-marketing adverse event reports. This new analysisreconfirmsthat use of fluoroquinolones is associated with an increased risk of tendon rupture. It alsodemonstrates that despite the current warning of tendon rupture in the labeling for the fluoroquinolones, large numbers of tendon-related adverse events continue to be reported. The FDA considers this new analysis to be "new safety information" as defined in FDAAA. The FDA also issued Information for Health Care Professionals today to alert health care professionals to the increased risk of tendinitis and tendon rupture in patients taking these drugs and to highlight new information concerning who may be at higher risk for this side effect. The risk of developing fluoroquinolone-associated tendinitis and tendon rupture is further increased in people older than 60, in those taking corticosteroid drugs, and in kidney, heart, and lung transplant recipients. Patients experiencing pain, swelling, inflammation of a tendon or tendon rupture should be advised to stop taking their fluoroquinolone medication and to contact their health care professional promptly about changing their antimicrobial therapy. Patients should also avoid exercise and using the affected area at the first sign of tendon pain, swelling, or inflammation. Manufacturers are being notified of the need to change labeling so that all of the drugs in the class carry uniform updated warning language. These warnings would apply to fluoroquinolones for systemic use (e.g., pills, tablets, capsules and injectable formulations). The warnings would not apply to fluoroquinolones for topical ophthalmic or otic use (e.g., eye and ear drops). Fluoroquinolone manufacturers are required to submit the safety labeling changes, including the strengthened warnings and the Medication Guide, to the FDA within 30 days, or to provide a reason why they do not believe such labeling changes are necessary. If they do not submit new language, or the FDA disagrees with the new language the company proposes, FDAAA provides strict timelines for resolving the labeling changes and allows the agency to issue an order directing the labeling change as deemed appropriate to address the new safety information. In addition, in accordance with FDAAA, sponsors will be required to assess whether their REMS are achieving the goal of informing patients of the risk of tendon-rupture. These assessments may include a survey of patients' and prescribers' understanding of the risks of tendon-rupture and whether the Medication Guide is being distributed and dispensed with the drug. Health care professionals should consider the potential benefits and risks for each patient. While most patients tolerate these medicines well, occasionally some will develop other serious adverse reactions that may include convulsions, hallucinations, depression, abnormalities in heart rhythm, or severe diarrhea. The medications involved in this action are: Cipro and generic ciprofloxacin, Cipro XR and Proquin XR (ciprofloxacin extended release), Factive (gemifloxacin), Levaquin (levofloxacin), Avelox (moxifloxacin), Noroxin (norfloxacin), and Floxin and generic ofloxacin. Information for Healthcare Professionals on Fluoroquinolone Antimicrobial Drugs:

The American Chiropractic Association (ACA) today announced it has mailed copies of a report issued by the Task Force on Neck Pain and its Associated Disorders to more than 16,600 neurologists across the country. The seven-year, international, multidisciplinary study was published in the journal Spine and is designed to help health professionals apply the best available evidence to prevent, diagnose and manage neck pain. In the cover letter accompanying the study, ACA President Glenn Manceaux, DC, noted that ACA encourages evidence-based clinical practice and interprofessional cooperation in patient care. “There is growth in the referral of patients between chiropractors and neurologists and therefore, it is important that all practioners be on the same page regarding the most current research in treating this pervasive condition,” Dr. Manceaux said. In distributing the study findings, ACA worked closely with NCMIC, the nation’s leading provider of chiropractic malpractice insurance for doctors of chiropractic. The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders considered almost 32,000 citations and performed critical appraisals of more than 1,000 studies in developing its 236-page report. The Task Force is an independent research group recognized by the United Nations and the World Health Organization. Task Force researchers found that some alternative therapies such as acupuncture, neck manipulation and massage are better choices for managing most common neck pain than many current practices. Also included in the short-list of best options for relief are exercises, education, neck mobilization, low-level laser therapy and pain relievers. In addition to its comprehensive review of the existing body of research on neck pain, the Task Force also initiated a new population-based, case-control and case-crossover study into the association between chiropractic care and vertebrobasilar artery (VBA) stroke. This Canadian study investigated associations between chiropractic visits and vertebrobasilar artery stroke and compared this with visits to primary care physicians and the occurrence of VBA stroke. The study — which analyzed a total of 818 cases of VBA stroke admitted to Ontario hospitals over a 9-year period (more than 100 million patient-years of observation) — concluded that VBA stroke is a very rare event and that the risk of VBA stroke associated with a visit to a chiropractor’s office appears to be no different from the risk of VBA stroke following a visit to a family physician’s office. To access the “Best Evidence Synthesis on Neck Pain: Findings” from The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders, click here .

The neglect or failure of a carrier or self–insured employer to pay awards for medical bills in a timely manner has a significant impact on the ability of all injured workers to obtain effective and immediate treatment, as it discourages health care providers from seeking or retaining authorization to treat workers' compensation claimants. Additionally, it may result in the health care provider seeking direct payment from the claimant, despite the statutory prohibition against direct payments. A claimant's ability to obtain proper medical treatment expeditiously not only benefits the claimant, but also results in lower medical costs for employers. Claimants who receive prompt and proper attention are more likely to be able to return to work swiftly and less likely to have long term disabling conditions. The integrity of the workers' compensation system is compromised when carriers and self–insured employers do not meet their legal obligations to pay awards. The Board has received an increasing number of complaints by health care providers that bills rendered for the treatment and care of workers' compensation claimants are not being paid in a timely manner. In particular, providers are concerned that bills are not paid in many instances even after issuance of an administrative and/or arbitration award by the Board. Further, concern has been expressed that some bills are automatically rejected by the carrier due solely to a carrier's policy against paying bills for certain specific coded procedures, regardless of the apparent medical necessity for such treatments. It is the Board's intent that health care provider bills be paid in a timely manner after the carrier or self–insured employer has had a full and fair opportunity to contest the compensability or value of the bills if it elects to do so. Further, effective March 13, 2007, the Workers' Compensation Law, § 54–b was amended to authorize the Chair (or the Chair's designee) to issue a consent to file judgment when a carrier, self–insured employer or the State Insurance Fund fails to pay indemnity or medical benefits to a claimant or medical provider. Failure or neglect to pay awards for medical bills will be subject to judgment collection. In any case where the insurance carrier or self–insured employer has failed to make timely payments after an administrative or arbitration award and all appeals have been exhausted or no timely appeal has been taken, the health care provider may also seek to enter judgment for payment, pursuant to Workers' Compensation Law § 54–b. Workers' Compensation Law § 54–b specifically provides that in the event an employer or insurance carrier defaults in the payment of an award and/or an award of benefits made by the Board, any party to an award may, with the Chair's consent, file for judgment against the employer with the county clerk for the county in which the injury occurred or the county in which the employer has its principal place of business. Workers' Compensation Board authorized providers seeking payment of administrative and/or arbitration awards made on or after March 13, 2007 are asked to submit Form HP-J1, Provider's Request for Judgment of Award and to enclose a copy of the original award(s) issued. In order to allow for billing cycle payments, please allow 60 days after issuance of the administrative and/or arbitration award prior to requesting judgment. Send requests to: Workers' Compensation Board Bureau of Health Management Office of Health Provider Administration 100 Broadway – Menands Albany, NY 12241 The continued viability of the workers' compensation system is substantially dependent upon voluntary compliance of all parties with the Workers' Compensation Law, rules and regulations of the Board, and legal responsibilities imposed upon the parties. The Board remains committed to reducing adjudicatory delay and costs to all participants in the system. Self–insured employers and workers' compensation insurance carriers can contribute significantly to adjudication reform measures instituted by the Governor, the Legislature and the Board by meeting its obligations without the need to resort to extraordinary enforcement measures. If you have any questions, please contact the Office of Health Provider Administration at 1-800-781-2362. Zachary S. Weiss Chair

Palmer College of Chiropractic officials have announced the positive outcome of the lawsuit filed against the former Palmer alumni association and the members of its executive committee. This defamation of character lawsuit was based on untrue statements and character attacks made in 2004 against members of the Palmer Board of Trustees, the College and the administration. On Thursday, June 26, an agreement was reached with the seven members of the former alumni association. The settlement agreement allowed the College to dismiss its defamation of character lawsuit against those individuals. “All we’ve ever asked is that these individuals issue an apology to members of the Palmer Board of Trustees as well as the College administration, and we would dismiss the lawsuit,” said Palmer Board of Trustees Chairman Trevor Ireland, D.C. “The Board’s intention in filing the lawsuit was to have the record set straight. As a Board, we held fast on our position that we would dismiss the lawsuit as soon as these individuals issued a public apology and admitted that their comments pertaining to the Palmer Board of Trustees, its members and the College administration were not true. We are very pleased with this outcome.” On June 26, the alumni—John Willis, D.C., David Reopelle, D.C., Ted Conger, D.C., Kirk Lee, D.C., Marc Leuenberg, D.C., Frank Bemis, D.C., and Scott Harris, D.C.—issued a collective public apology to the Board, the College and the administration. The Board accepted the apology and retraction, and the lawsuit was then dismissed. The apology and retraction from the named alumni is as follows: “We acknowledge that this situation has developed into something entirely different from anything we desire. We certainly do not now, nor have ever, wanted to harm Vickie Palmer or Palmer College or impugn their reputation in any manner. We apologize for any comments or actions which Vickie Palmer or Palmer College may have deemed offensive to them. We acknowledge that Vickie Anne Palmer has received nothing from Palmer College except for expense reimbursements in connection with her services as a trustee and chairperson of the board of trustees. In addition, we fully understand the governing structure of Palmer College of Chiropractic. The board of trustees makes and has always made the substantive policy decisions. Such decisions are not made by administrative personnel. We believed we exercised our First Amendment Rights. If we exceeded our Constitutional rights, we apologize. We apologize for the inconvenience and injured feelings Ms. Palmer and the trustees may have undergone.” “I am very pleased that Palmer was able to dismiss the lawsuit against these individuals,” said Palmer Chancellor Larry Patten. “I am extremely proud of the Palmer Board of Trustees for its firm position relating to those who may choose to wrongfully denounce our people and our purpose. We appreciate the public apology. We are happy to have this matter behind us so that we can devote all of our energies and attention to moving the College forward.”

Given the failed efforts by Congress to avoid the looming cuts to the Medicare Physician Fee Schedule slated to take effect Tuesday, July 1, 2008, the Department of Health and Human Services (HHS) has intervened. The Agency announced that they would essentially freeze the Fee Schedule at its current levels for a period of ten days. That allows Congress three days to address the matter once they return from recess for the July 4th Holiday. Thank you to all of the ACA members who contacted your Members of Congress to request action. We will continue to keep you updated on any future action on legislation to address these draconian cuts.

Despite the aggressive efforts by ACA and its members, after multiple attempts by Congress, no agreement could be reached on legislation to avoid the looming cuts to the Medicare Physician Fee Schedule. The 10.6% across-the-board cut will go into effect on Tuesday, July 1, 2008. Doctors of chiropractic are urged to contact their local Medicare contractor or visit their carrier’s website for the most up to date information. Although the House of Representatives overwhelmingly passed legislation (355-59) earlier this week that would continue the Fee Schedule at its current levels through the end of the year, supporters in the Senate fell one vote short of overcoming a Republican filibuster. Leadership in the Senate has promised that they will revisit the issue when they return from next week’s recess for the Fourth of July Holiday. It is believed that any fix to be implemented would be retroactive to restore payments and compensate for the cuts. Some providers may wish to hold their claims until Congress acts to readjust the fee schedule. Thank you to all of the ACA members who contacted your Members of Congress to request action. We will continue to keep you updated on any future action on legislation to address these draconian cuts.

US Senate fails to pass a bill that would cancel the 10 percent cut scheduled to occur on Tuesday July 1, 2008. The bill would increase Medicare payments to doctors by 1.1 percent in January and cancel the 10 percent cut scheduled to occur on Tuesday. The President threatened to veto the bill, because it would reduce federal payments to private insurance plans, like UnitedHealth, Humana and Blue Cross and Blue Shield companies that offer Medicare Advantage plans.

AUBURN - Auburn University researchers have found that wearing thong-style flip-flops can result in sore feet, ankles and legs. The research team, led by biomechanics doctoral student Justin Shroyer, presented its findings at the recent annual meeting of the American College of Sports Medicine in Indianapolis. “We found that when people walk in flip-flops, they alter their gait, which can result in problems and pain from the foot up into the hips and lower back,” Shroyer said. “Variations like this at the foot can result in changes up the kinetic chain, which in this case can extend upward in the wearer’s body.” The researchers, in the AU College of Education’s Department of Kinesiology, recruited 39 college-age men and women for the study. Participants, wearing thong-style flip-flops and then traditional athletic shoes, walked a platform that measured vertical force as the walkers’ feet hit the ground. In addition, a video camcorder measured stride length and limb angles. Shroyer’s team, under the direction of Dr. Wendi Weimar, associate professor of biomechanics and director of the department’s Biomechanics Laboratory, found that flip-flop wearers took shorter steps and that their heels hit the ground with less vertical force than when the same walkers wore athletic shoes. When wearing flip-flops, the study participants did not bring their toes up as much during the leg’s swing phase, resulting in a larger ankle angle and shorter stride length, possibly because they tended to grip the flip-flops with their toes. Shroyer, who owns two pairs of flip-flops himself, said the research does not suggest that people should never wear flip-flops. They can be worn to provide short-term benefits such as helping beach-goers avoid sandy shoes or giving athletes post-game relief from their athletic shoes, but are not designed to properly support the foot and ankle during all-day wear, and, like athletics shoes, should be replaced every three to four months. “Flip-flops are a mainstay for students on college campuses but they’re just not designed for that kind of use,” he said. The study included thong-style flip-flops from well-known retailers and manufacturers and ranged in price from $5 to $50. Athletic shoes included in the study also ranged in price and style. Shroyer’s interest in flip-flops has other footwear applications, as well as applications in other areas of biomechanics research. He will apply conclusions from the flip-flop study to his dissertation research on specialty athletics shoes and how they support the foot and aid in biomechanic performance.

The New York State Chiropractic Association is proud to announce the May 2008 election results. The individuals below are elected to the Board of Directors: Lloyd M. Angel, DC – NYSCA District 6 Steven Breines, DC* – NYSCA District 5 Robert Brown, DC – NYSCA District 16 David L. Heffer, DC* – NYSCA District 15 James Hildebrand, DC* – NYSCA District 15 Janusz R. Richards, DC – NYSCA District 8 (* serving for a 2nd term) The new Directors will assume their elected office on June 1, 2008. NYSCA thanks all the candidates that participated in this year’s election and congratulation to the winners.

37,000 Small Businesses in New York Will Receive Payments Refund Points to Need for Insurance Law Reform Governor David A. Paterson and New York State Insurance Department Superintendent Eric Dinallo today announced that Oxford Health Insurance, Inc. has agreed to refund $50 million to approximately 37,000 small businesses in New York City, Long Island and the northern suburbs for overcharging on health insurance policies in 2006. The refund highlights the need for legislation to reinstate the Insurance Department’s authority to approve rate increases before they go into effect, something the Insurance Department is pursuing this legislative session. Prior to 1996, the New York State Insurance Department had the authority to pre-approve rate increases for health insurance, a process that helped keep rates relatively stable for decades. Since the law was changed to eliminate the Insurance Department’s prior approval authority, the Department has only been able to look at the rate increases a year after they take effect. For more than a decade the only consequence for excessive rate charges has been repayment in subsequent years. “We must make New York a good place to do business by keeping costs competitive. We know that small businesses are the engine of growth in this State and the rising cost of health insurance is one of their major complaints,” said Governor Paterson. “If it can help protect business and keep premium rates down for New Yorkers, we should update the laws to give the Insurance Department more oversight.” Superintendent Dinallo said: “I am pleased that the Department was able to get these refunds for small businesses. But an after-the-fact settlement in 2008 does nothing for those businesses that may have had to drop coverage in 2006 because they could not afford a larger than necessary premium increase. These refunds would be unnecessary if the NYS Insurance Department had the authority to pre-approve rate increases for health insurance premiums. Requiring health plans to get approval from the Department before increasing rates would help keep New Yorkers insured. Lawmakers should restore to the Department the tools to better monitor and manage the marketplace for health insurance rates.” The $50 million settlement will be paid to 36,746 small business policyholders with approximately 300,000 employees and family members. The refund will vary depending on the number of covered individuals. It amounts to an average of $1,360 per business, which is about 5.5 percent of the total average annual premium in 2006. The Insurance Department initiated a review after Oxford reported to the Department that Oxford’s loss ratio for small group policies in 2006 was below the 75 percent minimum. Oxford paid benefits equal to 70.58 percent of its overall premiums in 2006. The vast majority of health insurers, like Oxford in this case, raise premium rates without first getting approval from the Insurance Department by utilizing a “file and use” procedure. If a health insurer using this method does not pay benefits equal to at least 75 percent of overall premiums in a calendar year, the insurer must refund the excess premium to policyholders in the form of cash payments or credits against future premiums. Superintendent Dinallo also said: “Oxford did the right thing in working with the Insurance Department to make sure consumers got their money back. But it is unfortunate the Department lacks the legal authority to pre-approve health insurance premium rate increases and prevent premiums that turn out to be larger than the law allows.” Elisabeth Benjamin, Director of Healthcare Restructuring Initiatives at the Community Service Society of New York, said: “This case just proves the old adage that ‘an ounce of prevention is worth a pound of cure. New York needs to revoke the insurance industry’s ‘E-ZPass’ on their ever-increasing rate increases. And the only way to do that is to restore the Insurance Department’s ability to approve rate increases in advance, and with public input.” The settlement affects policyholders of Oxford’s small group Freedom Plan Direct, Freedom Plan Metro and Freedom Plan EPO products. It does not affect Oxford’s small group and direct pay HMO and “point of service” (HMO/POS) policyholders. This case was handled for the Insurance Department by Deputy Superintendent and General Counsel Robert Easton, Deputy Superintendent for Health Troy Oechsner, Assistant Deputy Superintendent for Health John Powell, Deputy Bureau Chief Lou Felice, Chief Actuary Michel Laverdiere, Supervising Insurance Examiner Jim Carroll and Assistant Deputy Superintendent and Counsel Jon Rothblatt.

Late yesterday, the U.S. House of Representatives passed H.R. 5658, (Sec. 704. Chiropractic health care for members on active duty) the National Defense Authorization Act for FY2009, which includes language declaring chiropractic care a standard benefit for all active-duty military personnel. The bill—supported by the American Chiropractic Association (ACA) and Association of Chiropractic Colleges (ACC)—also contains language allowing for chiropractic demonstration projects at overseas military locations and clarifies that chiropractic care at U.S. military facilities is to be performed only by a doctor of chiropractic. According to ACA’s department of government relations, this most recent legislation strengthens current law and, if enacted, will increase access to chiropractic care at more facilities worldwide. To date, there is a doctor of chiropractic at 49 military bases around the United States; however, servicemen and women serving overseas do not have access to the chiropractic benefit.

Cleveland Chiropractic College will host an open house on June 11 from 4 to 6 p.m. to celebrate the official opening of its Overland Park Health Center. A ribbon-cutting ceremony for the Health Center, part of the college’s new 34-acre campus at 10850 Lowell Ave., will take place at 5 p.m. Dr. Carl S. Cleveland III, president, will be joined at the celebration by dignitaries from around the metro area, including Overland Park Mayor Carl Gerlach. In the college’s state-of-the-art health care facility, interns, under the supervision of licensed doctors of chiropractic, provide chiropractic care and other services to the public. Cleveland also maintains a health center in the Brookside area of Kansas City, Mo., which received more than 40,000 patient visits last year. The ribbon-cutting ceremony for the entire campus will take place in October in conjunction with the college’s annual homecoming festivities. For more information on these events, call 913-234-0600.

Abstract Background Back problems are often recurring or chronic. It is therefore not surprising that chiropractors wish to prevent their return or reduce their impact. This is often attempted with a long-term treatment strategy, commonly called maintenance care. However, some aspects of maintenance care are considered controversial. It is therefore relevant to investigate the scientific evidence forming the basis for its use. Objectives: A review of the literature was performed in order to obtain answers to the following questions: What is the exact definition of maintenance care, what are its indications for use, and how is it practised? How common is it that chiropractors support the concept of maintenance care, and how well accepted is it by patients? How frequently is maintenance care used, and what factors are associated with its use? Is maintenance care a clinically valid method of approach, and is it cost-effective for the patient? Results Thirteen original studies were found, in which maintenance care was investigated. The relative paucity of studies, the obvious bias in many of these, the lack of exhaustive information, and the diversity of findings made it impossible to answer any of the questions. Conclusion There is no evidence-based definition of maintenance care and the indications for and nature of its use remain to be clearly stated. It is likely that many chiropractors believe in the usefulness of maintenance care but it seems to be less well accepted by their patients. The prevalence with which maintenance care is used has not been established. Efficacy and cost-effectiveness of maintenance care for various types of conditions are unknown. Therefore, our conclusion is identical to that of a similar review published in 1996, namely that maintenance care is not well researched and that it needs to be investigated from several angles before the method is subjected to a multi-centre trial. Chiropractic & Osteopathy 2008, 16:3doi:10.1186/1746-1340-16-3

On the May 2nd WFAN 66AM Sports Radio Show, Boomer & Carton, hosted by Boomer Esiason and Craig Carton, the topic of discussion was the rib injury suffered by the Yankees pitcher, Phil Hughes. During the discussion, a caller, identifying himself as “Dr. Ron” and a chiropractor in Orange County, NY, attempted to give his explanation about the complexity of the injury and how it could affect his ability to play. However, before this doctor was able to offer an explanation regarding Hughes’ condition, Carton rudely interrupted the doctor and began a long-winded chiropractic bashing, replete with a quack attack that berated the profession and mocked chiropractic education. (To hear the replay go to and listen to the audio clips dated 5/2/08, entitled “ You SIR, are not a doctor ” and 5/9/08 entitled “ Harry Carson.”). After receiving numerous complaints from the NYSCA membership, a letter was crafted by NYSCA President, Dr. Mariangela Penna and Executive Director, Dr. Karl Kranz, chastising Carton for his insulting remarks. This letter was sent to WFAN’s program director and the NYSCA is eagerly awaiting his response. The swift action that the NYSCA took on this matter is just another example of how we are constantly protecting your right to practice chiropractic in this state. The ACA and the NY Chiropractic Council have also voiced their displeasure with Carton’s remarks and chiropractic organizations in adjacent states have been alerted of the talk show host’s potentially libelous remarks. We look forward to continuing to serve you and all of the chiropractors practicing in New York. To see a copy of this letter click on the link below:

Former Gov. Eliot Spitzer charged Insurance Dept. Supt. Eric Dinallo to create new medical treatment guidelines. Mr. Bruce Topman was selected as the Chairman of a Workers Compensation Task Force which made recommendations to then Governor Spitzer and Mr. Dinallo in December 2007. The NYSCA has reviewed the Task Force's recommendatiions and questions the headlong rush to adopt medical treatment guidelines. It is the NYSCA’s understanding that the Workers’ Compensation Board is in the process of reviewing the guideline drafts provided by the Department as the Board toils with promulgating the regulations needed to implement the guidelines necessary to meet former Governor Spitzer’s agenda. In anticipation of the forthcoming rules and regulations, the New York State Chiropractic Association (NYSCA) offers the following observations giving voice to the profession’s concerns. The New York Chiropractic Council concurs with the NYSCA analysis and its conclusions. To view the entire NYSCA WC Position Statement click on the link below:

The National Board of Chiropractic Examiners (NBCE) reports on the latest events at NBCE. The National Board of Chiropractic Examiners (NBCE) hosted a number of meetings including Practice Analysis Advisory Committee, Part IV Case Development Committee workshop, and Part IV Standardized Patient Trainers Workshop. To view the full report click on the link below.