Reinventing the ACA

A large segment of the chiropractic profession is struggling financially. Whether they are new graduates or well established in their practice, chiropractors are hurting. No one on the national level appears to be listening. The American Chiropractic Association (ACA) membership is very low because the average doctor thinks it would be a waste of money to join; and, as of the moment, they are right.

Why would those doctors be right? The ACA does not currently have enough resources (dues-paying members) to accomplish very much. The 55,000+ chiropractors who do not belong to the ACA see that the ACA is not accomplishing much and believe there is no real incentive for them to join. As a result, the entire profession is at an impasse, with insufficient resources to make any real progress on our most crucial issues.

The solution is to make every effort to reinvent the ACA. The way to do that is not to get doctors to quit the ACA; but rather, to join. The plan is simple. Convince at least 5% of the profession to join the ACA. Ask these 5% to join with many current ACA members who are dissatisfied with the inaction of the ACA and vote for leadership who will reinvent every part of the ACA’s operation until it is a lightening fast, aggressive organization with the focus of expanding the market share of chiropractic.

The commitment of those joining the ACA does not have to be long-term because it will not take long to unleash the huge potential of the ACA once its Board of Governors commits to change. Here are the steps to make it happen:

1. Join the ACA (and get a friend or two to join as well).

2. Call, write, or e-mail your delegate and tell them that you joined in order to reinvent the ACA.

3. Ask the delegate if he/she has read Reinventing the ACA: How to Fix the Managed Care - Medicare – Chiropractic Reimbursement Mess (they were mailed a copy).

4. Ask if he/she supports the thrust of the document.

5. If the delegate supports reinvention of the ACA, vote for them. If the delegate does not, support a candidate that is committed to fundamental changes at the ACA.

6. If the ACA begins to make the radical changes necessary to protect your future, continue your membership. If they do not – quit

This paper discusses the major problems in the profession and specific actions the ACA should be taking to resolve them. The plan is direct, challenging, and aggressive because that is what it will take to expand our market share in the face of increased competition from the physical therapy and medical professions. Our competitors are getting stronger and we need to meet their challenge.

(Scroll to the topic or click on the link)

Strategic Vision
Medicare Equality Initiative
Chiropractic Care to Federal Workers
Chiropractic Care for ERISA Plans
Managed Care
Educational Institutions
Coordination of Chiropractic Specialties
Advancing the Role of Non-DC Professionals
Advertising Code of Ethics
Public Relations/Communications
Chiropractic Research
Database Development
A National PAC with Impact
Re-inventing the ACA’s Lobbying Operations
Best Practices – Guidelines – Standards of Practice
Reinventing the ACA
Appendix A - Medicare Equality Initiative
Appendix B – ACA CCGPP Action Plan
Appendix C - Coordinating with the CCE
Appendix D - National Board of Chiropractic Examiners
Appendix E - National Database for Revocations and Suspensions

Downloadable Version • Reinventing the ACA.pdf

Strategic Vision

The chiropractic profession often expresses concern because of the amount of press coverage given to the views of the American Medical Association. On topics such as national health care, Medicare, managed care, or the everyday health care concerns of American citizens, the views of the American Chiropractic Association are not made known to the public. Is this bias on the part of the media – or a flaw in the ACA?

The media certainly has a bias, but health care is such a hot topic that it is likely the chiropractic profession would get more coverage of its views – if it had views to offer. The problem here is the ACA’s lack of a strategic vision. Without a strategic vision, it is difficult for the ACA to express a viewpoint on a given topic because it does not have a routine way of thinking through issues in advance. A strategic vision gives consistency and credibility to the views of an organization. Major news organizations want credibility in their stories. The ACA will get more coverage for the profession when they can react routinely to issues based on a consistent strategic vision.

The ACA needs to have a strategic vision (both short and long-term) which includes:

• Ensuring equity for chiropractic in Medicare
• Ensuring equity for chiropractic in managed care
• Ensuring equity for chiropractic in care for federal workers
• Ensuring equity for federal resources allocated to chiropractic research
• The chiropractic profession’s evolving role in health care
• Our collaboration with other health care providers
• Views on national health care initiatives
• Public safety issues
• An outcry against the abuses of medicine and cozy relationships between drug manufactures and prescribing doctors
• Proposals for ethical reforms or legislative changes to eliminate the exchange of money or perks for the use of certain drugs
• National safety standards for mattresses, back packs, lifting equipment etc
• Guidelines for the use of nutrition in chiropractic practices
• Summits with branches of the medical profession with national symposiums on topics of mutual interest

The ACA has tended to the day-to-day matters of the profession and, as a result, has attracted a small percentage of the profession to their membership ranks. When they develop a strategic vision and programs and policies to enact that vision, they will become a natural magnet for attracting members. Flashy slogans, exaggerated rhetoric, and personal attacks on people or groups that disagree with their views have not worked for the ACA. When they are consistently ahead of issues and effectively developing action plans to deal with those issues, they will add layer upon layer of credibility to their organization.

Medicare Equality Initiative

On Oct. 30, 1972 President Nixon signed into law the 1972 Social Security Amendments. The amendments expanded the definition of physicians under Medicare and Medicaid to include chiropractors. The amendment, which limited reimbursement to the chiropractic adjustment, required chiropractors to take X-rays and perform patient exams even though they were not, and are not, reimbursed by Medicare. The X-ray requirement was eliminated December 31, 1999 after action by a consortium of chiropractic organizations.

In 1972, the federal government spent approximately $28 billion dollars on Medicare. In the 35 years since, the medical profession has seen an explosion of coverage for cancer and heart disease, prescription drugs and rehabilitation. From $28 billion in 1972, spending on Medicare has increased to over $650 billion in 2006 . And yet, chiropractic is still only reimbursed for the adjustment.

The outrage continues…...

The Medicare prescription drug benefit that was passed in late 2003 is now estimated to have a price tag of $1.2 trillion in the coming decade . What did the chiropractic profession get? Under a two-year demonstration project beginning April 1, 2005, chiropractors are allowed to bill Medicare carriers for medical, radiology, clinical lab, and therapy services in the entire states of Maine and New Mexico, 17 central counties in Virginia, and the metropolitan area of Chicago. A demonstration project is an important stepping stone; however, there is no guarantee that the report which Congress mandated on this project will ensure its expansion.

While Congress ignored the budget busting implication of the Medicare drug benefit, it is likely that the cost of an expansion in chiropractic benefits will have to be offset with other revenue or budget cuts. According to past ACA President James Edwards, DC, Medicare an expanded chiropractic benefit is likely to cost at least $800 million that may have to be offset.

The ACA has an incredible opportunity to provide leadership on this important issue. By coordinating a national grassroots effort that would require Medicare to pay for all of the services allowed by a chiropractor under their respective state laws, the ACA can significantly improve access to chiropractic services and assist DCs in the development of their practices.

Appendix A of this report contains a complete step by step action plan to achieve this goal.

Chiropractic Care to Federal Workers

The ACA should develop an initiative to allow federal workers injured on the job (primarily postal workers) to receive chiropractic services without going through antiquated procedures that are designed to prevent reimbursement for services. The action steps for this initiative are

• Meet with the appropriate federal agencies to determine
o The process for obtaining reimbursement
o The individuals responsible for revising the policy or policies
o The policies under which chiropractic treatment is reimbursed
o The documentation requirements for services

• Communicate with the states and ACA members to inform them of the initial meetings and the action plan to resolve the problem.

• Solicit examples from all 50 states to substantiate the archaic nature of the reimbursement practices.

• Prepare a memo outlining the policy deficiencies with recommendations for modernizing reimbursement practices. Since a major problem is the requirement for X-rays, the new Medicare X-ray policy should be included along with the rationale for the new X-ray policy and the savings that has resulted from the policy change.

• Meet with the appropriate officials to present information and recommendations.

• Communicate with the states and ACA members to inform them of the outcome of these meetings and the revisions, if necessary, to the action plan.

• Involve the states, if necessary, to assist with grassroots lobbying and to provide examples of denied reimbursement.

Chiropractic Care for ERISA Plans

States across the country generally have good to excellent insurance equality or anti-discrimination laws. Unfortunately, these laws are useless when the patient is covered under an insurance plan governed by federal ERISA laws. Fighting a “not medically necessary” decision issued by a plan covered under ERISA is next to impossible for most chiropractors because of the wide latitude given to these plans in defining their benefits and the requirement that lawsuits be filed in federal court. This last fact alone makes it cost prohibitive for a patient or their chiropractor to battle the insurer.

The fact that ERISA plans are not required to cover chiropractic services presents a real opportunity for the ACA. By working with the states and Fortune 1000 corporations, the ACA can expand chiropractic’s market share and increase the value of the chiropractic benefit for those corporations who offer it as a benefit.

Here are the steps to accomplish this goal:

• Produce a master chiropractic benefits plan that would include reasonable methods the corporation could use to review utilization and quality assurance.

• Solicit information from the Fortune 1000 corporations related to their chiropractic benefit and the location of their U.S. based employees.

• Prepare a spreadsheet for each of these corporations detailing such items as the plans, deductible, co-payment, co-insurance, pre-authorization requirements, and treatment or payments caps. If the plans differ by state, each state should be listed separately.

• Modify the spreadsheet, if necessary, to reflect the insurance options the corporation makes available to its employees. Pay particular attention to differences between union and white collar plans.

• Review each corporation’s plan against each state’s insurance equality or anti-discrimination laws. Prepare a summary to 1) reflect differences between the plan’s benefits and what would be required if the corporation fell under state law, and 2) the deficiencies when compared to the ACA’s master plan.

• Produce a master analysis of each deficiency explaining how the corporation could benefit if they followed state law or the master plan. These benefits would focus on the improved health of the work force, improved employee satisfaction with the overall health benefits, and the financial benefits/savings by allowing more access to chiropractic care.

• Provide all of this data to the states to coordinate the next phase of the plan.

• In coordination with each state, publicize Fortune 1000 compaines’ ERISA plans that have a chiropractic benefit that match what is required under state law or the ACA’s master plan.

• Coordinate with the states to expand the number of corporate ERISA plans offering chiropractic benefits that match what is required under state law or the ACA’s master plan. This effort would involve

o Making presentations at the local level to request more chiropractic benefits
o Leveraging the local presentations prior to making a presentation at the corporate headquarters to the senior benefits managers
o Involving communities to request more chiropractic benefits through e-mails, letters, or petitions

Projects like this will give the ACA access to the decision makers that control the growth of the profession. During the course of these interactions, the ACA will be exposed to the prejudices that exist about the profession and, having been exposed to these perceptions, will be able to provide leadership in resolving these systemic problems.

Managed Care

Much is written about the insidious nature of “managed care.” In this contentious arena, chiropractors share a great deal with medical doctors. Both health disciplines require rigorous training and education. Generally, only individuals with well above average intelligence are capable of entering either profession. Upon graduation, society has always placed doctors in a special category where their skills have earned them deference and respect. When the insurance industry developed the concept of “managed care,” it often meant that non-doctors were making clinical decisions. To DCs and MDs that had gone through rigorous training, this was not only unacceptable, it was an insult. Doctors are not used to administrators dictating care, and always want the right to make the final decision about treatment.

Managed care greatly reduces the opportunity for independent decision-making and places constrains on a doctor’s freedom to manage the business aspects of their practice. When it comes to developing standards/ guidelines/best practices, the concerns of the medical profession are similar to those of the chiropractic profession, although the medical profession is further along in accepting clinical protocols.

Regarding the business aspects of managed care, the chiropractic profession is well behind its medical counterparts. There are three primary reasons for this.

1. By whatever name they are known, the lack of practice protocols affects a chiropractor’s ability to negotiate managed care reimbursement. Managed care organizations systematically intimidate chiropractors into reducing the number of services received by patients. They get away with this because many chiropractors desperately need the income provide by managed care and may be influenced to assume that the utilization controls are clinically appropriate and not merely a means to enable the managed care organization to enhance their profitability.

Some type of generally accepted practice protocols would create “a level playing field.” This is particularly true if the profession would focus on “minimum” treatment protocols so that chiropractors are required to:

o Use evaluation management coding appropriate to the patient’s condition
o Take X-rays when dictated by the patient’s condition
o Provide adjustments on a schedule appropriate to the severity of the patient’s condition until, at a minimum, the patient’s symptoms have been resolved

In today’s environment, some chiropractors will arbitrarily terminate treatment when the patient reaches the artificial limit imposed by the managed care organization. On a short-term basis, this may serve the chiropractor’s economic interests; however, the practice should scare the death out of the ACA and the profession as a whole. When patients are shortchanged in their treatment, they become dissatisfied. They assume “chiropractic does not work.” The next time they have a problem, the profession may lose the patient to a non-chiropractic health care provider. The more frequently chiropractors make this “bargain with the devil,” the more quickly the profession loses market share. When minimum treatment protocols are adopted, chiropractors will be able to compete on a financial basis without compromising the quality of patient care.

2. Medical doctors have an advantage when it comes to negotiating managed care agreements because they practice in larger groups. More doctors mean that they can openly discuss reimbursement strategies without violating anti-trust laws, and they can afford expert financial management to assist in developing reimbursement strategies and negotiating agreements.

3. An additional advantage of the larger clinics, typical of the medical profession, is that they benefit from “economies of scale.” Their systems, staffs, and costs are spread over a larger base of patients making it more economical to practice, which allows them more flexibility when negotiating a managed care agreement.

The ACA can play a pivotal role in gradually improving the impact of managed care on chiropractic practices by providing leadership in all of these areas.

Practice protocols...As discussed later in this paper, the ACA needs to provide leadership in the development of practice protocols. As it relates to managed care, the ACA should insist on “minimum” practice standards to protect patients from chiropractors who would trade their health for the economic benefits of a managed care agreement.

Clearinghouse...The ACA should establish a clearinghouse for reporting abuse or intimidation by managed care organizations. To ensure specificity, objectivity, and honesty, this web based reporting system would prompt the chiropractor or patient to report specific details of the abuse by managed care organizations. Examples of the types of abuse are:

• Intimidation against providing care
• Imposing artificial limitations on adjustments, x-rays, exams or PT modalities
• False representation about benefits
• The attempt to intimidate a DC to down-code
• Variations in DC vs. MD cost containment

Annual Report...The ACA should publish an annual report on the most abusive managed care organizations from the perspective of the chiropractic profession. This report would get wide spread publicity and would help employers and patients steer away from selecting abusive organizations to provide their health care benefits.

Educational Institutions

When it comes to maximizing the long-term potential of chiropractic, the profession has a dilemma. If the chiropractic profession wants to be perceived by the public in the same manner as engineers, geologists, physicists, biochemists, or medical doctors, it must attract the same type of individual to the profession as they do to theirs.

Government agencies and high school guidance counselors provide information about a career in chiropractic. Students interested in becoming a chiropractor may now compare the potential of a career in chiropractic alongside alternative careers for high-achieving students. While the chiropractic profession has attracted some of the brightest and most gifted, the typical student entering chiropractic today has changed along with the business opportunity.

The ACA needs to be concerned with the type of student being admitted to chiropractic colleges/universities. When students are unprepared to deliver the quality of health care demanded by consumers, or to handle the competitive business challenges in an era dominated by managed care, the profession suffers greatly.

You can see indications of these problems in

• The deteriorating quality of advertising in which unsubstantiated claims of quality and/or superiority are made

• An increasing proportion of chiropractors who use gimmicks such as “free services” or vastly reduced fees for the patient’s first visit in order to attract patients to their practices

• Chiropractors who under treat patients because of intimidation or constraints imposed by managed care or insurers

• Chiropractors who over treat patients worker’s compensation and/or personal injury patients to make up for the low reimbursement

The chiropractic profession’s educational community is not meeting the challenge of attracting enough top tier students. Overall, its entrance requirements are less than the requirements of medicine, dentistry, veterinary medicine, engineering, MBA programs, or the legal profession.

Incoming students do not understand that while they may be paying as much for their postgraduate education as students in other fields, their prospects upon graduation may be vastly different.

The chart in Appendix E provides examples of how chiropractic colleges/universities attract prospective students to their schools.

The reality is that, upon graduation, engineers, geologists, physicists, biochemists, or medical doctors do not generally have difficulties in finding a job or earning a living commensurate with the investment they have made in their education. Not so with chiropractors.

The Wisconsin Chiropractic Association conducts an annual compensation survey in which more than 50% of the chiropractors in Wisconsin participate. In 2006, the mean income for male chiropractors with less than 3 years experience was $31,714. The mean income for female chiropractors with less than 3 years experience was $30,833. According to the National Association of Colleges and Employers, the average starting salary for a liberal arts graduate in 2006 was $30,958. A chiropractic graduate spends an additional $100,000 - $125,000 only to find out that their salaries are comparable to a 4-year liberal arts graduate, instead of the much higher paying careers in engineering, geology, physics, biochemistry, or the medical profession.

Those incomes are for those chiropractors who “succeed.” The chiropractic profession, unfortunately, has failures – and a much higher percentage than other health care professions.

The U.S. Department of Health and Human Services maintains a website that details the number and amount of defaulted HEAL loans (see chart). As of May 2007, defaults by chiropractic

students represent 45% of all defaulted loans. That statistic, in itself, is an incredible blow to the credibility of the career prospects in chiropractic. However, when you consider that the number of students enrolled in chiropractic colleges/universities is a small percentage of the total number of students in all health care professions, the default rate of chiropractors is staggering.

The data in the chart strongly suggests that the market for chiropractic services is not large enough to sustain the number of graduating students and/or that these graduates are not trained to meet the challenges upon graduation.

The ACA would likely claim that they are not responsible for the marketing of chiropractic colleges/universities, the irresponsibility of graduates regarding the repayment of their HEAL loans, or inequities in the supply/demand ratio. But that would be missing the point. A national trade association that seeks to provide real leadership would be meeting with the educational community on a regular basis to address a broad range of issues including:

• Raising the academic standards for incoming students to more favorably compare with the academic standards of the medical, engineering, and financial professions.

• Creating a clearinghouse for legitimacy of techniques so that the public can develop a greater trust in the “product” offered by chiropractors.

• Supporting the development of minimum standards of care to be provided to all patients, regardless of the amount of managed care reimbursement.

• Promoting the requirement for training in the practical application of managing a health care practice in an ethical manner.

• Encouraging the development of database systems that can track the success or failure of students so that colleges/universities can react more quickly to the changing needs of the marketplace.

Regular communication between the chiropractic educational community and the ACA is essential. Without this communication, the schools may not understand the need to continuously improve the quality of their graduates. Since much of their endowment funds come from practicing chiropractors, it is important that they understand the current and long term needs of the marketplace for new chiropractors. If a college/university were not willing to participate in these meetings, the ACA would be able to throw a spotlight on the deficiencies in their institution.

The ACA should also develop materials that can be sent to guidance counselors in every high school in America. These materials should compare and contrast chiropractic colleges/universities so that students are given complete and accurate information about the profession. Jawboning the educational community into raising their academic standards will not be easy or have immediate results; however, the profession will benefit long-term from this much needed reform.

Council on Chiropractic Education (CCE)
National Board of Chiropractic (NBCE)
Federation of Chiropractic Licensing Boards (FCLB)

The Council on Chiropractic Education (CCE), the National Board of Chiropractic (NBCE), and the Federation of Chiropractic Licensing Boards (FCLB) each has an extremely important role in the chiropractic profession. They are responsible for establishing and maintaining the credibility of chiropractic education and licensing.

While they are all independent organizations, the ACA should have an important role in monitoring their activities and encouraging them to make improvements vital to the long-term integrity of the profession. A rudimentary analysis of their operations indicates potential weaknesses that need to be addressed. Please see Appendices C, D, E for a discussion of the ACA’s role with these organizations.

Coordination of Chiropractic Specialties

Over the years, there has been a proliferation of chiropractic subspecialties. From a gradual increase in diplomate programs to an explosive increase in “certificate” programs, both chiropractic colleges/universities and unaffiliated educational groups are addressing the desire of chiropractors to enhance their credentials in some way.

The problem is that consumers are increasingly sophisticated. All of the following undermine the credibility of chiropractic:

• Pretending that an individual or group without standing in any chiropractic postgraduate organization can issue a credential that will have clinical credibility with policy makers, third-party payers, or consumers.

• Pretending that a consumer can have confidence in the “specialization” of a chiropractor who attends a 48 hr. program that does not have a testing requirement. Or, pretending that a program that has a testing requirement is credible when the test is not prepared or administered in a generally acceptable manner.

• Pretending that all chiropractic diplomate programs provide the same relative level of clinical training.

• Pretending that it is not important to standardize curriculums to improve consumer confidence.

• Pretending that a course instructor is an “expert” in a field when the only qualification is their self-affirmation.

• Pretending that the completion of a particular course of study will give a chiropractor a competitive advantage without providing a credible basis for the assertion.

If chiropractic continuing education is to have the credibility it often deserves, the ACA should coordinate

• The definition of a credential
• The organizations entitled to award credentials
• The requirements to attain a particular credential

The ACA must serve as a clearinghouse between CCE and the chiropractic colleges/universities. All parties must realize that if there is no credibility behind a credential, there is no need for chiropractors to attend the “education.” Establishing a hierarchy of credentials gives meaning to each level of attainment and is an effective way of educating the public about the unique credentials of an individual chiropractor.

Advancing the Role of Non-DC Professionals

Chiropractors are truly fortunate to have incredibly dedicated individuals that assist them in the administration of their practices and the care of their patients. Historically, these individuals have been known as “chiropractic assistants (CA).” More recently, the term “chiropractic technician” (CT) has evolved as both chiropractic and community colleges have developed more formalized training programs.

Unfortunately, the chiropractic profession is behind other health care providers in its use of non-doctors to provide patient services. In the dental profession, for example, dental hygienists have had their scope expanded so that they can administer anesthetic to patients. In the medical realm, the nursing profession has evolved a wide variety of credentials for nurses to fit the needs of different clinical situations, as well as the shortage of medical doctors in certain communities.

Those health care professions that are able to develop multiple levels of non-doctor caregivers have an economic advantage over the chiropractic profession because the non-doctor providers can provide services more cost effectively which allows the doctors to focus on their particular area of expertise and/or to focus on expanding their practice.

Working with the colleges/universities, the ACA should develop model legislation that would allow for varying levels of credentialed CTs. These tiers would be divided into varying levels of responsibility, dependent on education and training, and include:

• Patient history
• Patient exam
• X-rays
• Physical therapy modalities
• Nutrition
• Rehabilitation
• Exercise

Under no circumstances should the model legislation provide for a CT to perform chiropractic diagnoses, adjustments/manipulations, or to prepare a treatment plan as these services define the uniqueness of a chiropractor and are dependent on the training and education at a chiropractic college/university.

The model legislation should be fully documented with comparisons to other health care providers so that it has instantaneous credibility with state legislatures. In adopting this model legislation, chiropractic organizations can actually save the profession money. This will occur as technical colleges develop programs to meet the demand for these credentials and high school graduates seek out the education at their own expense - just as those in the nursing profession are responsible for the costs of their education.

Advertising Code of Ethics

The chiropractic profession suffers because it has an image problem. Two factors contributing to that are, 1) the perception that the lack of standards/guidelines/best practices results in the over treatment of patients (this subject is discussed later in this paper), and 2) unprofessional chiropractic advertising.

Chiropractors do not receive marketing training while in chiropractic college/university. Without the knowledge on how to properly develop their practices, new doctors fall prey to directory sales people who make outrageous claims about the effectiveness of unethical advertising approaches, newspaper sales people who do not understand that consumers look for a different type of marketing from doctors than they do from a hardware store, and practice management companies who will gladly sacrifice the long term reputation of a chiropractor in a community if they can implement a scheme to induce a person to receive care - whether they need it or not.

Neither a state nor national association can terminate the membership of a chiropractor because the chiropractor violated an advertising standard. To do so would be a violation of federal anti-trust laws. However, the ACA could do much in this area to provide guidance and leadership to the profession by providing “best practices” that would distance the profession from chiropractic advertising that includes:

• Ambulance chasing
• Claim of superiority
• Phony testimonials
• Fake “free” services
• Inflated credentials
• Claiming non-existent superiority

All of the traditional forms of advertising should be addressed as well as telemarketing, mass e-mails, web pages, and mail coupon distribution.

There are those who would say that our trade associations should never say anything negative about the profession or those who immediately claim that chiropractic is no worse than other professions with its advertising. While both of these viewpoints have arguments in their favor, they are shortsighted – especially if they are adopted by the organization that is supposed to provide leadership on a national level.

If the market share of chiropractic is to grow, consumers must have access to accurate information as to who we are and what we do. Advertising is a key source for this type of information. However, when that information is misleading, it does not create new patients. Rather, it turns them away as the public loses confidence in the profession’s willingness to police itself. To alleviate this problem, the ACA should develop a “consumer guide” to unprofessional chiropractic advertising that explains each of the above “pitches,” and the misleading nature of each approach, and offers tips to selecting an ethical chiropractor.

There will be voices within the ACA that will argue that the profession should do nothing because other professions have similar problems with advertising. Those who fear the enmity of those doing the unprofessional advertising typically adopt this shortsighted approach. Perhaps they fear that these individuals will quit the ACA if their advertising methods are exposed. If the ACA is truly interested in becoming the most professional health care organization in the world, the answer is not difficult. The profession cannot condone any form of advertising that misleads the consumer, and if a doctor does not agree with this ethical approach to marketing, the ACA is better off without this individual as a member.

Public Relations/Communications

Many in the profession believe that the way to increase market share is through greater advertising. The premise that more people would go to chiropractors if they only knew more about the profession is being tested by those chiropractors and organizations involved in the marketing campaign being conducted by the Foundation for Chiropractic Progress (FCP). Whatever the impact of the FCP project, the ACA’s focus should be on larger public relations/communication projects that confer credibility and esteem on the profession – and generate significant opportunities for media coverage.

The following ideas can be launched with much fanfare and relatively little cost. Coverage of any of them by the national media will, in a single day, eclipse the FCP’s marketing efforts:

• National contest to develop edible nutritious school lunches
• National award for chiropractic research
• National award for innovation in the chiropractic profession
• National award for practice integration

By coordinating their efforts with the states, the ACA can gain access to thousands of media outlets with compelling stories that have national interest. By adopting high profile campaigns to solve a significant societal issue, the ACA immediately achieves the stature of the national groups who provide free trigger guards for guns or who hand out bicycle helmets for kids.

In addition, there are “everyday” public relations efforts that should be accelerated by the ACA. These include

• Disseminating articles and stories on a national and statewide basis. The stories and articles should be tailored so, by working with state associations, a chiropractor in a specified city can be used to give the story a local angle.

• Developing relationships so that the ACA has representatives serving as advisors to the major national health care publications.

• Establishing relationships with the health editors at all of the major national newspapers. These contacts must be based on more than just press releases so that the profession is not blindsided by negative articles.

• Developing a program to train spokespersons in as many major cities as possible to provide reactions to television and radio when a controversial issue affecting the chiropractic profession is aired.

• Providing advance notification to states of all upcoming stories or features on the profession.

• Providing advance notice of all press releases and suggested stories that the ACA intends to send to all media sources. This will allow state organizations to coordinate their efforts with those of the ACA.

Public relations plans often fail because they attempt to influence various groups on a grand scale. If the plans are viewed as communications programs, instead of public relations programs, the focus will shift to influencing individuals and groups on a less grand, but more practical basis. It is more important to hit singles and doubles in this game, rather than to wait for the occasional, but all too rare, grand slam home run.

Chiropractic Research

Research into the effectiveness of chiropractic is done by

• Chiropractic colleges
• General health care research groups
• Federal government agencies
• Foreign governments
• Individual chiropractors
• Biochemists
• Clinical chemists
• Biostatisticians
• Epidemiologists
• Other health care providers and scientists

The oldest chiropractic research-funding institution is the Federation of Chiropractic Education and Research (FCER). In its 56 years of existence, FCER has funded $11 million of research grants, fellowships, and residencies. 56 years - $11 million. The federal government awards more than twice that amount in health care research in one day.

This lack of research has greatly impeded the growth and development of chiropractic. If the chiropractic profession had received its prorata share of government and private research money, the profession would not have the controversies that exist over practice protocols. The market share of chiropractic would be exponentially greater because corporations would have a clear understanding of the cost/benefit of offering chiropractic benefits. It is even possible that researchers would have identified the biological basis supporting wellness and preventative care.

Research is very costly, not only because of the time necessary to design the research protocol to the highest standard; but also because of the time involved in studying vast amounts of clinical documentation and in treating patients as part of a study. Because the chiropractic profession does not have a highly developed research capacity, we are subject to abnormally long delays in the investigative stages, as research is secondary to the primary work of the clinic or provider.

The ACA can have a major impact in creating an atmosphere conducive to broader participation in the funding for research. Much of the work required to obtain research money is political and, as explained in another section of this paper, establishing the proper lobbying relationships can yield enormous results. However, the ACA also needs to spend more resources explaining how research benefits the profession.

The resistance to research on the part of some in the profession rests with their belief that research into chiropractic’s effectiveness is not necessary. The vast majority of chiropractors, however, can be educated to understand that research is one of the primary tools used to gain greater access to patients.

Since insurance is the vehicle by which most people purchase their health care, and employers make benefit decisions on their perceptions of what is effective, the case for chiropractic must be made using the language understood by business. Every time a piece of research confirms the effectiveness of chiropractic, a business gets closer to understanding that it is in their best interest to allow their employees access to chiropractors or to expand the chiropractic benefits already available.

The ACA must work more closely with FCER to encourage chiropractors and their patients to more aggressively support chiropractic research. Within the chiropractic community, the goal should be to have FCER literature on the front desk of every chiropractic office in the country. After all, much like the medical profession, chiropractic has patients who have had life changing experiences because of the work of their chiropractor. Undoubtedly, a percentage of these patients would like to express their gratitude. The medical profession does an outstanding job at directing contributions to the American Cancer Society or the Diabetes Foundation; the chiropractic profession must emulate them to achieve similar success with FCER.

Either working with or independent of FCER, the ACA should

• Solicit contributions that would fund the hiring of experts to write grant proposals
• Develop the expertise necessary to make effective grant presentations
• Communicate the success of the profession in raising research funds through the efforts of chiropractors and their patients
• Report on the successful results of research as results are published

Because the battles between health care professionals will continue to be waged for decades to come, research is the secret weapon of chiropractic. While most other professions have already had their treatment methods validated, the chiropractic profession has much of its story yet to tell. If funding for research can be accelerated, the profession will more quickly achieve its goal of a much higher share of the health care market.

Database Development

Those who have been involved with the chiropractic profession intuitively know that there are millions more chiropractic adjustments provided today than there were ten years ago. General knowledge also exists that chiropractic is an appropriate health care choice for men, women, and children of all ages. Unfortunately, the ACA does not provide regular updates on the data that is so important for everyone involved with policy development, publicity, treatment, and education.

At the minimum, the profession needs regular updates on all of the following data:

• Utilization rate of chiropractic by state, gender, age, income, general occupation categories

• Conditions for which patients seek chiropractic care, again broken down by the above regional and demographic groupings

• Penetration of chiropractic as an insurance benefit by size of company and industry

• The effect on utilization rates once chiropractic has been added as a benefit (and the decrease in corresponding medical costs)

• Chiropractic incomes by region, age, specialization, and years in practice

• The value of chiropractic practices on a geographic basis

Some of this data is available from third parties. However, because these third parties have a broad range of potentially conflicting relationships, this data should come from the ACA. When a survey is released, it should be accompanied by a complete explanation as to the source(s) of the data and means used to compile it.

As the chiropractic profession continues to develop, transparency becomes increasingly important for everyone concerned with policy development. This is particularly challenging because of the plethora of means that states use to control and manage the chiropractic profession. States vary widely in their statutes, rules, administrative procedures, opinions, guidance, and “common knowledge,” and there is a critical need for a database that the profession can trust as a resource for policy development.

At a minimum, the database should provide the actual text of all statutes, rules, opinions, and guidance in a comparison table for all states on the following topics:

• Scope of practice
• Prohibited techniques or practices
• Treatment and/or documentation standards, guidelines, or best practices
• Insurance equality
• Anti-discrimination

• Chiropractic assistant delegation rights and responsibilities
• Chiropractic and chiropractic assistant CE requirements
• Standards of conduct or ethical rules
• Recommendation and/or sale of nutritional supplements, vitamins, or herbs
• Injectible nutrients

• NSAID prescription
• Primary care provider
• Hospital privileges
• Joint ownership of service corporations with other health care providers
• Worker’s compensation

• Timely payments
• Claim processing requirements
• Independent medical exam requirements
• Claim review options
• Any willing provider

• UCR requirements
• Adjusting under anesthesia
• Preceptorship requirements
• Nomenclature (Chiropractic Physician, Doctor of Chiropractic)
• Licensing requirements including temporary permits

The benefits of these databases go beyond meeting the needs of policy makers. Because much of the American population relocates several times during their lifetime, they need access to accurate information about the differences in chiropractic services that can be provided to them, if they relocate to another state. Wide variations in the chiropractic scope of practice can negatively affect the consumer perception of the profession, especially when the patient moves from a state that has less restriction to a state where chiropractic is more heavily regulated.

There is an additional issue for patients who live near the border of their state. Imagine their confusion if they work in one state, but live in another, and decide to switch to a chiropractor across the border. The patient faces a possible disruption in their treatment plan that could be avoided if more information were available.

Because the growth of chiropractic relies on consumer confidence, the ACA needs to promote uniformity among the laws that govern the profession. While a state should always be free to develop rules and regulations that meet the needs of their citizens, the ACA can be of great assistance in helping states to build on the work already completed and successfully implemented elsewhere in the country.

By serving as an additional resource, beyond what is available through the FCLB, the ACA can help lessen the opportunities for unethical doctors to skip around the country looking for the easiest areas to exploit consumers.

A National PAC with Impact

Money has been and always will be a major part of politics. Because the chiropractic profession does not yet have the “standing” of other health care organizations, the profession has to do more. The goal of the ACA should not only be to win the access necessary to discuss its legislative agenda; but also to position the profession so that it receives its pro rata share of research and grant money. To achieve these long-term objectives, the ACA must adopt guiding principles for its political fund raising.

Ethical conduct...The law provides for plenty of ways to influence legislators with financial contributions to their campaigns. The ACA should adopt formal procedures to ensure that they are always operating above the law and never “in the gray.” Staff, committee members, or leadership who violate these procedures should be terminated from their position and/or their membership.

Transparency...The law already provides that much political activity must be disclosed. The ACA should have a policy that its members may have access to records detailing any financial contribution made to a candidate and the rationale behind that contribution. This transparency will be resisted on the part of some who are part of the PAC leadership because they will not want to relinquish the power or perks that accrue to those who make financial decisions. However, to tap into the vast fund raising potential of the profession, the ACA must have the reputation that its campaign contributions are always made in the best long-term interests of the profession and not for short-term reasons unrelated to the profession’s goals.

Adopting successful fund raising strategies...Some states have had remarkable success in getting large percentages of their members to contribute to PACs and conduits. Well over 50% of Wisconsin Chiropractic Association (WCA) members, for example, contribute to the Chiropractic Health Information and Education Fund (CHIEF), raising hundreds of thousands of dollars annually. Other states with smaller numbers of doctors are incredibly successful in the average size of each contributing members’ contributions. Still others have evolved very successful events that raise awareness and substantial amounts of money to be used for politicians in their state.

The ACA needs to tap into these resources to understand what works, why it works, and how they can adopt the successful strategies nationally. Too often, a chiropractor believes that a contribution to a PAC or conduit is nothing more than a charitable contribution. When the ACA is successful in educating doctors that their organization exists to protect their future and that the money that is donated to political contributions is just another form of insurance that needs to be paid, they will transform the political part of their organization into a national powerhouse.

Re-inventing the ACA’s Lobbying Operations

The ACA needs to accomplish these goals:

• Complete chiropractic inclusion in health care at the state and federal level
• Reform of discriminatory practices against chiropractic in ERISA plans
• Full reimbursement for Medicare and Medicaid services
• Implementation of a managed care bill of rights
• Full equity in government research and grants
• Appropriate inclusion in all government agencies, councils, and work groups

To accomplish these goals, the ACA needs more than a couple of lobbyists and a support staff. The government affairs part of the organization must be set up to service the permanent needs of the membership and the profession. Health care issues will dominate the national agenda for at least the next generation and the ACA must make the commitment to develop this part of the organization to meet the challenge.

By recognizing this need, the ACA’s government affairs process must be organized to acknowledge the following needs:

1. A policy development group which anticipates the statutory needs of the profession and sets goals for their implementation.
2. The resources to enable the ACA to communicate personally with every Senator and Representative over a period of seven working days.
3. An accurate knowledge of the amount of support the profession has on a given issue, from each Senator and Representative.
4. A priority system, based on the resources of the ACA PAC, to financially support those legislators and prospective legislators who support the chiropractic profession.
5. An ongoing communications program to educate the members and states on the progress of each of the ACA’s legislative goals.
6. A continuous dialogue with each state to incorporate the state’s knowledge and resources into the ACA’s goals and objectives.

The ACA is not currently organized to accomplish much, if any, of the above needs. To get from where it is today, to where it needs to be in the future, takes people. These ACA staff people need to be assigned to work with a designated group of legislators to coordinate communication as well as grassroots efforts on the ACA legislative agenda.

Staff Requirements

To begin, the ACA must assess the number of individuals necessary for their Congressional liaison team. If the goal is to have the resources to meet with each member of Congress over a maximum of seven working days and each meeting takes 30 - 45 minutes, with 15 minutes travel time between meetings, you would need a staff of 7-8 highly motivated individuals.

These staff people would each be assigned to a group of 1 to 8 states, with the number varying based upon the size of a state’s Congressional delegation. Their responsibilities would be:

• To meet personally, on a regular basis, with the members of Congress and their staff.

• To solicit the support of the members of Congress, at appropriate times, for chiropractic legislative initiatives.

• To provide the latest reference information on the profession and explain its significance, in person, to each member of Congress and their staff.

• To offer members of Congress and their staffs the professional resources to answer questions from their constituents on chiropractic or chiropractic involvement with a particular insurer or managed care entity.

• To act as a liaison with the state organizations assigned to them to:

o Coordinate state political activities with the members of Congress
o Provide current, up-to-date information on legislative initiatives
o Verify the expressed support for chiropractic on any given issue
o Identify potential chiropractic supporters among candidates for Congressional seats
o Coordinate state legislative efforts with national legislative goals
o Coordinate the above activities with other members of the Congressional liaison team
o Coordinate in-district “listening-sessions” and town hall meetings
o Attend fundraisers when appropriate and in the interest of the profession

With this structure, states and ACA members would have a great deal of confidence that the profession was proactive on any issue that potentially affected the profession. Senators and Representatives would know that the chiropractic profession was ready to react instantly if an initiative was undertaken that threatened its interests. There would be no guessing on a legislator’s support, or lack thereof, for the profession on a given issue.

There are innumerable benefits for coordinating national legislative activity with state organizations. So often, a position a Congressman takes in Washington is far different from what is communicated back in the district, and vice-versa. Having the two groups constantly talking and coordinating their activities alerts them to potential problems before it is too late.

Because some states have very effective political organizations, it is possible that their relationship with a legislator or candidate is, and always will be, better than the relationship the ACA can develop in Washington. In cases like this, it is to the advantage of the ACA to coordinate its lobbying efforts through the appropriate individual at the state level. This structure also allows a state to receive information on a continuous basis from their ACA counterpart. Because the information will be of much higher quality than that received in the past, the confidence in the ACA will grow exponentially.

Today, the support for the ACA’s political operations is based on hope and potential. That type of support is tenuous at best. When hope is replaced by the tangible knowledge that the ACA is in the trenches on a daily basis, that tenuous support will solidify into a true commitment for the organization.

Clearly, this structure is more expensive than the structure currently being used. However, imagine the excitement when ACA members and potential members are told about the real work the ACA is doing, with real accountability and real information being distributed to the membership and the states. The increase in membership dues will far outpace the increased cost of the lobbying operation.

Best Practices – Guidelines – Standards of Practice

Transparency and data. These two words are likely to dominate discussions on how to control the cost of health care over the next decade. As applied to the chiropractic profession, data will become increasingly critical to validate treatment methodologies advocated by different segments of the profession. Much of this data will undoubtedly come from a variety of outcome measures or, more likely, a straight-line analysis of insurer or managed care statistics. Transparency will be integral to the success or failure of the profession to develop best practices, guidelines, or standards.

To the majority of the profession, the distinction between these best practices, guidelines or standards is meaningless. If there is a document developed that tells them how to treat a patient or allows an insurer or managed care entity to dictate treatment, it will be very controversial unless the final document is the product of a profession-wide consensus.

Since the ACA, over the last decade, was unwilling or unable to provide leadership in this area, the Congress of Chiropractic State Associations (COCSA) has assumed the leadership role.

While COCSA performed admirably in its management of the discussion of the first draft of the “Best Practices” document, COCSA is not well suited for the long-term management role this type of process requires.

• COCSA has no permanent staff outside of a part-time administrator.

• COCSA has very limited resources that do not allow it to underwrite the costs for the number of meetings it would require to manage their role in the creation of this document or the response of the profession to various drafts of the document.

• Based on the lack of resources, the leadership of COCSA is primarily restricted to telephone meetings that do not allow for the type of interaction necessary to manage their role in the creation of this document or the response of the profession to various drafts of the document.

• COCSA has recognized the need for a single organization to run the trade interests of the profession and is on record in support of disbanding, subject to the merger of the ACA and the ICA.

It is unknown as to why the ACA abdicated its responsibility in this area. It may have been a fear of having to take a position on a controversial topic or the fact that members of its leadership have been criticized for perceived conflicts of interest.

Regardless of the reason, the ACA must recognize that:

• The state or Federal goverment will act to provide health insurance to more individuals even if those plans do not include “national” healthcare.

• The expansion of heath care benefits will result in considerable increases in cost and the resulting pressure of funding these initiatives.

• Business entities will make a strong case for a “basic” benefits package with chiropractic available only as a consumer paid option.

• The rationale for the exclusion of chiropractic will be based on anecdotal “evidence” of unnecessary chiropractic care or the profession’s inability to control itself through standards, guidelines, or best practices.

• The result of these proposals will be massive political fights on both the state and federal levels.

• These national political fights will be managed by the ACA (even if COCSA retains control of this issue).

• The cost arguments will be so overwhelming, that the ACA will lose the fight unless they can defeat the opposition’s arguments.

This brings us full circle to the fact that the argument will only be won by competing in the same manner as the other health care professions with transparent best practices, guidelines, or standards.

If the ACA accepts the responsibility, the profession has a real opportunity to gain all of the advantages of the expansion of health benefits to the uninsured. If they reject the responsibility, it is very likely the profession will not develop the transparency needed and will lose the political argument and the opportunity for expansion.

How to get it done

There is a difference between the legal relationship between COCSA and CCGPP, and the practical reality of gaining a national consensus around future drafts of the “Best Practices” document. In the near-term, the ACA should meet with the leadership of COCSA to request the opportunity to jointly manage the next discussion of the next draft of the “Best Practices” document. If COCSA refuses to yield, the ACA should implement the action plan contained in Appendix B of this report.

Reinventing the ACA

The chiropractic profession must have an aggressive, well respected national trade association. If we do not, the profession will lose market share as chiropractors are left out as major changes are made to health care across the country. The ACA is not an aggressive organization and it needs to be reinvented. It needs to be reinvented because it has no relevance to the average doctor because it does not do anything of substance for the average doctor. That has got to change or the profession is in big trouble.

The solution is not to whine or complain – or worse to do nothing. The profession cannot afford to ignore the ACA; it must reinvent it. The way to do that is to is not to get doctors to quit; but rather, to join.

There are approximately 9,000 voting members of the American Chiropractic Association. They elect delegates who, in turn, elect a Board of Governors. To reinvent the ACA, you need enough ACA members who will vote for delegates who will then elect a Board of Governors committed to the ACA’s reinvention.

There are a lot of ACA members and delegates (and maybe even some on the Board of Governors) who would support the reinvention – but not enough to get it done. We need you and approximately 5% of the profession to join the ACA. These doctors, combined with current ACA members committed to change, would be able to vote out any delegate who does not support a radical makeover of the ACA.

The commitment to the ACA does not have to be long-term because it will not take long to unleash the huge potential of the ACA once its Board of Governors commits to change. Here are the steps to make it happen:

1. Join the ACA (and get a friend or two to join as well)
2. Call, write, or e-mail your delegate and tell them that you joined to reinvent the ACA.
3. Ask the delegate if he/she has read “Reinventing the ACA” (they were mailed a copy).
4. Ask if he/she supports the thrust of the document.
5. If they do, vote for them. If they don’t, support a candidate that does.
6. If the ACA begins to make the radical changes necessary to protect your future, continue your membership. If they do not – quit.

ACA DELEGATES - APRIL 2007

AK James D. Martin, DC, CCSP
400 N. Main St.
Wasilla, AK 99654
Phone: (907) 373-2022
Fax: (907) 373-2029
E-mail: jcmartin@mtaonline.net

AL Jonathan H. Griffiths, DC, FACO, DABCC, FICC
5290 Old Springville Rd., Ste. 106
Pinson, AL 35126
Phone: (205) 854-9988
Fax: (205) 854-9990
E-mail: chirogriff@aol.com

AR Karen K. Konarski-Hart, DC
422 N. Cedar St.
Little Rock, AR 72205
Phone: (501) 664-1477
Fax: (501) 666-2549
E-mail: hartwnkkk@aol.com

AZ James J. Badge, DC
5658 N. 19th Ave.
Phoenix, AZ 85015-2403
Phone: (602) 249-1555
Fax: (602) 331-8649
E-mail: jimbadgedc@aol.com

ID Henry G. West, DC, FICC
1355 E. Center St.
Pocatello, ID 83201
Phone: (208) 232-3216
Fax: (208) 232-9412
E-mail: drwest@thewestclinic.net

IL - North Frank E. Strehl, DC, DABCI
111 E. Cole Ave.
Wheaton, IL 60187
Phone: (630) 653-5755
Fax: (630) 653-8478
E-mail: DrStrehlOnCall@aol.com

IL - South James L. Rehberger, DC
1000 Zschokke St.
Highland, IL 62249
Phone: (618) 654-4451
Fax: (618) 654-5361
E-mail: drjlreh@hometel.com

IN Robert W. Tennant, DC
P.O. Box 470
Shirley, IN 47384
Phone: (765) 737-1117
Fax: (765) 737-1119
E-mail: doct@hrtc.net

KS Edward D. McKenzie, DC, FICC
928 W. 6th St.
Holton, KS 66436
Phone: (785) 364-4151
Fax: (785) 364-2774
E-mail: ks_delegate@earthlink.net

KY Mark G. Schweitzer, DC
20 N. Grand Ave., Ste. 6
Ft. Thomas, KY 41075
Phone: (859) 441-8800
Fax: (859) 441-8813
E-mail: sschweitzer2@insightbb.com

LA John E. Daigle, DC
345 Doucet Road, Ste. 104B
Lafayette, LA 70503
Phone: (337) 989-0800
Fax: (337) 989-0867
E-mail: chirojd1@bellsouth.net

MA Albert R. Kalter, DC
400 Washington St., Ste. 102
Braintree, MA 02184
Phone: (781) 848-8734
Fax: (781) 848-9941
E-mail: AKalterDC@aol.com

MD Audie G. Klingler, DC
203 Greene St.
Cumberland, MD 21502
Phone: (301) 777-0110
Fax: (301) 722-2982
E-mail: allchiro@mindspring.com

CA – North James E. Peterson, DC
1105 E. Foster Rd., Ste. F
Santa Maria, CA 93455
Phone: (805) 937-2009
Fax: (805) 934-5130
E-mail: DrPistolpe@aol.com

CA - South Bradley J. Sullivan, DC
4955 Van Nuys Blvd., Ste. 404
Sherman Oaks, CA 91403
Phone: (818) 990-1742
Fax: (818) 990-6379
E-mail: DRBJS@aol.com

CO Michael P. Simone, DC
P.O. Box 217
Dacono, CO 80514
Phone: (303) 833-2332
Fax: (206) 203-2303
E-mail: msimonedc@yahoo.com

CT Keith S. Overland, DC, CCSP, FICC
8 East Ave., Ste. 313
Norwalk, CT 06851
Phone: (203) 838-9795
Fax: (203) 853-2078
E-mail: doco57@aol.com

DC Bruce E. Nordstrom, DC
1600 K St., NW, Ste. 100
Washington, DC 20006
Phone: (202) 466-3803
Fax: (202) 429-9699
E-mail: dcchiropractor@yahoo.com

DE To be appointed

FL - North Craig A. Newman, DC
3305 W. Kennedy Blvd
Tampa, FL 33609
Phone: (813) 875-6569
Fax: (813) 874-2889
Email: canewmandc@aol.com

FL - South Thomas E. Hyde, DC, DACBSP
2240 NE 202nd St.
Miami, FL 33180
Phone: (305) 931-8311
Fax: (305) 933-5840
E-mail: thyde444@bellsouth.net

GA Richard J. Clark, DC
P.O. Box 1199
Dublin, GA 31040
Phone: (478) 272-1800
Fax: (478) 274-9137
E-mail: clinic_dr@bellsouth.net

HI Joseph G. Morelli, DC, FICC
94-050 Farrington Hwy, Ste. E1-1B
Waipahu, HI 96797
Phone: (808) 671-2685
Fax: (808) 671-9368
E-mail: crunch@aloha.net

IA Steven J. Kraus, DC
517 N. Main St.
Carroll, IA 51401
Phone: (712) 792-4000
Fax: (712) 792-3554
E-mail: sjk@familymedcenter.com