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CAM practitioners as primary care providers under the Affordable Care Act: Part 1

Section 2607 (42 U.S.C. Sec. 300gg-5) of the Affordable Care Act (the “ACA” or “Obamacare”) prevents “discrimination” against any health care provider acting within the scope of his or her state license. The provision, supported by the American Chiropractic Association and other CAM practitioners, was inserted, without a hearing, under the leadership of Sen. Tom Harkin. Sec. 2607 is of concern to advocates of science-based medicine due to the broad scope of practice granted chiropractors, naturopaths, homeopaths, acupuncturists and direct-entry midwives under state law, as well as their over-confident view of themselves and their abilities. As we have previously discussed, for example, both naturopaths and chiropractors fancy themselves as primary care physicians able to differentially diagnose any patient with any disease or condition and, in many cases, treat or “co-manage” these patients.

As might be expected, a brouhaha is brewing over just what Section 2607 means. And there is one attempt to repeal it outright.

In all cases of statutory interpretation, the proper starting point is the statutory language itself.

SEC. 2706. NON-DISCRIMINATION IN HEALTH CARE.

(a) PROVIDERS.—A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider’s license or certification under applicable State law. This section shall not require that a group health plan or health insurance issuer contract with any health care provider willing to abide by the terms and conditions for participation established by the plan or issuer. Nothing in this section shall be construed as preventing a group health plan, a health insurance issuer, or the Secretary [of Health and Human Services] from establishing varying reimbursement rates based on quality or performance measures.

In short, while broadly prohibiting discrimination, there are two important limitations. This is not an “any willing provider law” requiring an insurance company to contract with any provider agreeing to the insurer’s contract. And insurers can pay different rates to different providers as long as these rates are “based on quality or performance measures.”

Rep. Andy Harris (R-MD), a medical doctor, is sponsoring a bill (H.R. 2817) to repeal Section 2607 outright. Last month, seven medical specialty societies sent a letter to Rep. Harris in support of his efforts. In their view,

it would become illegal “discrimination” under federal law for private individual and group health plans, and state-based health insurers, to make qualification distinctions among varying groups of physicians and other health care professions . . . We are deeply concerned that for certain covered services in a number of states, [Section 2607] will be interpreted to provide that all health professional groups be considered as if their education, skills and training were equal even if the state-based medical and healthcare professional licenses or certifications are very different.

CAM tizzy

Short of actual repeal, a debate is developing about how Section 2607 will be interpreted and applied.

The three agencies charged with administering the ACA (the Departments of Health and Human Services, Labor and Treasury) issued what little guidance they are offering at the moment in a “FAQ” format. No, the Departments said in answer to a question, they will not be issuing regulations interpreting this provision.

Until any further guidance is issued, group health plans and health insurance issuers offering group or individual coverage are expected to implement the requirements of . . . section 2706(a) using a good faith, reasonable interpretation of the law. For this purpose, to the extent an item or service is a covered benefit under the plan or coverage, and consistent with reasonable medical management techniques specified under the plan with respect to the frequency, method, treatment or setting for an item or service, a plan or issuer shall not discriminate based on a provider’s license or certification, to the extent the provider is acting within the scope of the provider’s license or certification under applicable state law. This provision does not require plans or issuers to accept all types of providers into a network. This provision also does not govern provider reimbursement rates, which may be subject to quality, performance, or market standards and considerations.

This got Sen. Harkin and the pro-CAM crowd in a tizzy. In response, the following was inserted into a committee report accompanying the 2014 appropriations bill for the Departments of Labor, HHS, Education and “related agencies.” The Appropriations Committee “is concerned” that the Departments “FAQ” response

advises insurers that this nondiscrimination provision allows them to exclude from participation whole categories of providers operating under a State license or certification. In addition, the FAQ advises insurers that section 2706 allows discrimination in reimbursement rates based on broad ‘‘market considerations’’ rather than the more limited exception cited in the law for performance and quality measures. Section 2706 was intended to prohibit exactly these types of discrimination.

The Committee advised the Departments to work together and issue new guidance within 30 days of the appropriations bill being passed (which has yet to happen) and in time for insurers to understand their obligations before Section 2607 goes into effect in 2014.

This is alarming indeed and is contrary to the plain language of the statute. Even though Section 2607 states that no insurer is required to contract with any particular provider, it appears Sen. Harkin and his committee think that each insurer must have at least one provider of each type licensed under a particular state’s law. And likely more, because if all provider types must be included then having only one or two could give the appearance that tokenism is afoot. Will insurers have to include CAM providers in all geographical areas? Will this require quotas?

John Weeks over at the Huff Po/Integrator Blog was even more apoplectic. According to him (even though this didn’t seem to bother the Harkin committee):

It doesn’t take a legal expert to read this document as a declaration that the plans and states can use “reasonable medical management techniques” to essentially blow off the section.

So insurers should not control “the frequency, method, treatment or setting for an item or service” with “reasonable medical management techniques” even if they are, well, reasonable? Of course, I can see where these controls might upset CAM providers. After all, “frequency” limitations might prevent chiropractors from convincing patients they need weekly “adjustments.” “Method” and “treatment” limitations could practically wipe out naturopathic practice coverage – no more colonic irrigation, peat baths, green tea suppositories, live blood analysis, and the like. And it would eliminate anything a homeopath could do.

What do chiropractors want?

Which brings us to an interesting question: what do CAM providers think should be covered under the ACA in order for insurers to be in full compliance with Section 2607? Chiropractors have been the most vocal, and we’ll look at what they are saying in this and the next post. We’ll also take a look next time at the views of naturopaths, acupuncturists and direct-entry midwives. But the short answer is: they want to be primary care providers and they want insurance to pay for it.

As we have seen, it doesn’t seem like Congress had chiropractors and naturopaths in mind at all when it defined primary care provider. Unfortunately, that doesn’t necessarily mean insurers will be able to avoid reimbursing chiropractors when they provide certain services normally provided by PCPs. In fact, if there is one thing you can be sure of, it is that chiropractors and other CAM providers will be screaming “foul” if anything they do (no matter how they do it) isn’t paid for if MDs, DOs, or nurse practitioners are being paid for doing it.

The ACA requires insurers to cover certain “essential health benefits” (or “EHBs”):

  1. Ambulatory patient services
  2. Emergency services
  3. Hospitalization
  4. Maternity and newborn care
  5. Mental health and substance use disorder services
  6. Prescription drugs
  7. Rehabilitative and habilitative services and devices
  8. Laboratory services
  9. Preventive and wellness services and chronic disease management
  10. Pediatric services, including oral and vision care

An article just out from Chiropractic & Osteopathy focuses on how chiropractors might claim a slice of the insurance reimbursement pie by providing “evidence-based clinical preventive services.” (The ACA eliminated co-pays for those services rated A or B by the U.S. Preventive Services Task Force [USPSTF].) According to the authors, except for recommendations on screening and counseling for infectious diseases, the following services are within the scope of chiropractic practice in most states:

Screening

  • Alcohol misuse
  • Colorectal cancer
  • Depression
  • Diabetes (type 2)
  • Hearing Loss
  • Hypertension
  • Iron deficiency anemia
  • Obesity
  • Osteoporosis
  • Tobacco use
  • Lipid disorders
  • Vision

Counseling/interventions

  • Alcohol misuse
  • Breastfeeding
  • Folic acid supplement
  • Iron deficiency anemia screening
  • Obesity weight management
  • Tobacco use intervention

Abdominal aortic aneurysm (ultrasound), breast cancer (mammography) and cervical cancer screening, and aspirin for CVD prevention, are noted as not within the chiropractic scope in most states, which implies that they are within the scope of practice in some. (Note that we are talking only about preventive services here, which is only a portion of the coverage chiropractors want. Should you wish to see what chiropractic treatment of diabetes might look like, you can read about it here.)

The authors admit, however, that even though the listed services are within the chiropractic scope of practice, “many chiropractic college faculty do not have specific training in clinical preventive services.” Instead of adding additional coursework to the DC curriculum, they recommend that basic science material like microbiology and biochemistry could be reduced in favor of more on health behavior and education.

Clinical education for the vast majority of chiropractic students takes place in small chiropractic college clinics as a requirement for the DC degree. (MD and DO primary care physicians must undergo an additional 3 years of clinical training in primary care after getting a medical or osteopathic degree.) Here’s how the authors propose to incorporate training into the DC curriculum:

it seems quite feasible to simply “get more mileage” out of existing standardized and actual patients. That is, rather than restricting the history and examination to vital signs, orthopedic, neurological, postural or palpatory findings, simply broaden them to include BMI assessment, health habits and other lifestyle factors. In fact, many and perhaps most chiropractic colleges already do include lifestyle in the history. The next step, not uniformly taken as yet, would be to require students to counsel patients on changing risky health behaviors. These patients may be presenting for musculoskeletal complaints, or like many patients in chiropractic teaching clinics, may be presenting for “wellness care.” These are opportunities to screen for health risks, particularly those which are extremely common, such physical inactivity and overweight/obesity, and to counsel patients when the risks are present. Thus, current patients (both standardized and actual) could provide opportunities for screening and counseling at the same time that they are being treated for symptoms/conditions.

The authors’ advice contains some stunning, and most certainly unintentional, admissions about deficiencies in chiropractic education and training that are at odds with any number of claims otherwise, a subject we’ll look at in more depth in the next post.

First, at this point, chiropractic schools aren’t educating and training students in preventive care. Second, chiropractic education and training is woefully inadequate to support chiropractic scope of practice. After all, the authors listed many screening and counseling/intervention services recommended by the USPSTF as within the scope of chiropractic practice. Yet, they admit these same services are not part of chiropractic education. Furthermore, in their recommendations for improving clinical education, I don’t see anything about, for example, how to screen for breast or colorectal cancer, lipid disorders, vision, or hearing loss. And breastfeeding? Well, chiropractic “pediatricians” do claim that “subluxations” in an infant’s spine can lead to breastfeeding difficulties. I suppose they may be learning that. Third, apparently practically all patients present with musculoskeletal complaints or for wellness care, not with the broad range of patient presentations typical of primary care clinical training and practice. This goes not only to their lack of training, but also demonstrates that the public doesn’t consider chiropractors as suited for preventive care even when they are using them for “wellness care.”

Wellness care?

If there is one so-called preventive health technique chiropractors are being trained for and are using, it is certainly “wellness care.” But it is nothing you will find in the USPSTF recommendations. Nonetheless, according to the 2012 chiropractic journal article Consensus Process to Develop a Best-Practice Document on the Role of Chiropractic Care in Health Promotion, Disease Prevention, and Wellness, wellness care is most certainly part of the DC primary care tool kit. But as it is with many aspects of chiropractic practice, the term “wellness care” means different things to different chiropractors.

To some it is synonymous with “maintenance care”, that is, periodic “adjustments” of “subluxations” to improve overall health and prevent disease and “for prevention of future musculoskeletal disorders.” This is ironic, considering their emphasis on USPSTF recommendations, because the Task Force has concluded “the evidence is insufficient to recommend for or against the routine use of interventions to prevent low back pain in adults in primary care settings.” And you can bet if there were some evidence in favor of interventions they wouldn’t include maintenance care. Other chiropractors use the term more broadly, meaning a combination of maintenance care along advice about such things as exercise. Still others don’t recommend maintenance care at all. According to these authors, there is currently no evidence to either support the “theory” underlying maintenance care or to reject it. An odd position considering there is no evidence subluxations exist.

Thus, the authors undertook what they describe as:

The first attempt at developing a comprehensive set of best-practice statements that address the issues of providing wellness care within the context of chiropractic practice. It is a synthesis of the best current evidence and collective expert opinion about a reasonable clinical approach to health promotion within chiropractic practice.

The first attempt? They’re just getting around to this in 2012?

So, based on “the best current evidence and collective expert opinion” is “maintenance care” an appropriate part of health promotion, disease prevention, and wellness in chiropractic practice? Yes, the only limitation being that chiropractors shouldn’t use it “without counseling on lifestyle and screening for risk factors.” Or, at least, they shouldn’t call it “wellness care” without this window dressing.

All of this raises some interesting questions regarding coverage of chiropractic services under the ACA. For example, will chiropractors be able to bundle an episode of “maintenance care” into a screening package and bill the insurance company for it? And if the medical specialty societies are correct and insurers won’t be able to take into account differences in education and training, must insurers cover, for example, breastfeeding advice and lipid screening by chiropractors, even when they have little, or no, training in these areas? Or use bogus methods? And if the chiropractor gets to the patient first and bills for an annual panel of screening tests and preventive care advice (no matter how poorly done), will the primary care physician have to eliminate those items from his billing, or do them for free? What if he sees that the chiropractor has botched the diabetes screening or sold the patient on a bunch of dietary supplements as “nutritional advice?”

Next time, we’ll look into what the chiropractic industry associations are saying about chiropractors and Obamacare coverage for primary care, as well how naturopaths, acupuncturists and direct-entry midwives see themselves as PCPs.

Posted in: Chiropractic, Legal, Politics and Regulation

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84 thoughts on “CAM practitioners as primary care providers under the Affordable Care Act: Part 1

  1. David Gorski says:

    Depressing.

    One wonders if chiropractors fancy themselves capable of taking care of children as PCPs. After all, the International Chiropractic Pediatric Association is rabidly antivaccine, to the point of proudly and openly working with Barbara Loe Fisher’s antivaccine group the Orwellian-naned National Vaccine Information Center:

    http://scienceblogs.com/insolence/2013/08/22/chiropractic-and-antivax-two-quacky-tastes-that-taste-quacky-together

    First NCCAM and now inserting Section 2607 into the PPACA, is there no end to Tom Harkin’s assault on science-based medicine and promotion of quackery?

    1. “…is there no end to Tom Harkin’s assault on science-based medicine and promotion of quackery?”

      Apparently not. He is retiring, but there seem to be any number of replacements to fill the void.

      Depressing, indeed. Pass the beer.

      1. windriven says:

        “He is retiring, but there seem to be any number of replacements to fill the void.”

        Sadly true. Hopefully his replacement won’t be another quackery crusader slashing away with the singing sword of stupidity.

        But that doesn’t mean they will fight to turn the lights. That would be too much to ask.

  2. stuastro says:

    And yet, here in Australia we have banned private health insurers from paying out on most quackeries, with the notable exceptions of acuquackery and chirooquackery. What is wrong with the legislators in the US. I am not saying that ours are perfect, far from it, but they have been brave enough to at least start to stamp out these quacks.

  3. windriven says:

    HR 2817 has no cosponsors.
    It might make it out of the Health subcommittee (Govtrack rates its chances as 5%) as part of the Republican effort to repeal or dismantle ACA.
    No chance of being passed in the Senate.
    No chance of being signed by the President.

    Still, I hope you will all join me in writing your Congressperson to support passage. You can bet your bippie that the quacks and charlatans are writing theirs.

    1. Done (the Congresspersons).

      And, by the way, we like the Negra Modelo! Hubby is very impressed at your ability to so closely match his fav brew. While on a recent camping trip to N. Wisc/UP Michigan, we stopped at a small store and found two six packs of Beck’s Dark in the cooler! We then, stopped at three more and found six more six packs as well as a nice supply at the bar of the river rafting place! We were buying foam coolers and ice like crazy to get it all home! You cannot believe the elation and resultant jumping up and down of two aging boomers at finding this stuff!

      Many thanks :-))

      1. windriven says:

        Glad you found the Beck’s Irene. I was pretty sure the good folks in Bremen hadn’t evaporated. I do suspect that specialty imports are taking a beating from local and regional craft brewers. But there ought to be room in the market for everyone.

        Some of my friends are Mexican and they put me on to Negra Modelo a long while back.

        Which brings me to a bit of info for all my friends out there who chuck back Corona while listening to Jimmy Buffet ( :-) ) , I don’t know a single Mexican or Mexican-American who thinks Corona is fit for anything except, perhaps, cleaning chrome or laughing at gringo putas who actually drink it. Victoria is probably the most popular among mi compadres but it is hard to find except in bodegas.

      2. nybgrus says:

        You should try Xingu if you can find it. Brazilian ale. Very similar to Negra but, IMO, a little bit more flavorful with a slightly richer body.

        1. windriven says:

          I love Xingu! Delicious and quite full-bodied. Hard to come by in the PNW sad to say. Hop mania rules here at the moment (I’m hoping it is 15 minutes of fame) so more balanced beers have a hard time finding an audience. Xingu certainly deserves one.

          1. Chris says:

            Dream on. One of the largest hop growing areas in the world is just on the other side of Cascades.

          2. nybgrus says:

            I first discovered it in a Brazilian restaurant in DC (Adams Morgan area, with a cheesy name – “The Grill from Ipanema”; but it was good food). I’ve loved it since then.

            That said, I am partial to hop bombs myself. In general I like beers that kick me in the mouth and make me work for it. Have you ever had Green Flash? Now that’s a hop bomb!

          3. windriven says:

            @Andrey

            ” I like beers that kick me in the mouth and make me work for it. ”

            I’m that way with Scotch. The wussified blended whiskeys that roll across the tongue like a mocha hazelnut latte disgust me (with the exception of well-aged McCallans as a post-prandial). Give me a fine Highland single malt with a burred edge.

          4. windriven says:

            @Andrey

            “Ferry?”

            Chris lives in Seattle. I live on the Olympic Peninsula* during the week** and take a ferry when I have to travel to the city. It makes for a long evening if Seattle Skeptics runs till, say, 21:00 then a 60 minute ferry crossing and another half hour drive home.

            *If there was a god the Olympic Peninsula would be proof of her benevolence. It is spectacularly beautiful and the waters to the north offer some of the best sailing on earth.

            **I have a second home near Portland, OR and prefer the dining, nightlife and zeitgeist of Portland to that of Seattle. Portland lives up to its motto – Keep Portland Weird. Seattle is just doctrinaire leftie in my estimation and the stupid variety of leftie at that. It is joyless and purposeless; a membership badge rather than a philosophy. It really isn’t fair to characterize a city that way but it is indisputable that Seattle and Portland have very different vibes.

            Sorry for the ramble. It is Friday. I am struggling to avoid starting meaningful work that I would then expect myself to complete before I declare the week over and done with.

          5. Chris says:

            It is better than Yakima.

          6. windriven says:

            I didn’t really mean to come down so hard on Seattle, Chris. Seattle is a fine city.

            It is just that I’ve encountered an unusual number of Seattlites who, in explaining their position on some issue will say “I’m a liberal” as if that explains everything or, in fact, anything. This lot are simply the yang to the yin of the wingnut conservatives. Theirs are not positions, not philosophies; they are just sides.

            Me? I’m a Braves fan.

        2. Chris says:

          Heads up. Dr. Hall will be presenting to the Skeptic Meetup in October. That should give you time to plan for the ferry.

          1. Sorry – maybe it is because I am only 2 sips into my first coffee… ferry?

          2. windriven says:

            Thanks! I saw that she was coming Chris. Unfortunately, I will be away at ASA in San Francisco. I would have enjoyed meeting her.

          3. Chris says:

            She did present at http://www.skepticstoolbox.org/. I might miss her in October depending when we meet my sister in Oregon.

            Also we are where the job is, and try not to commute over water.

        3. Chris says:

          It is also closer to spouse’s family and very far away from mine.

          Oh, I hate it when people make a black and white claim of anything. There is a reason why I refuse to be associated with any political party, and was very very glad when the Supreme Court turned down the plea from the group trying make us declare a party.

          A few years ago I had to explain to someone who used that kind of “liberal logic” that a hologram was not what she thought it was. She now works at Bastyr. Aargh.

          I am still recovering from visiting family in Arizona, especially where the TV was always tuned to Fox News. Though going through the years high pile of mail, I did find the the newsletter mentioned here.

          Nonsense is neither “liberal” nor “conservative.” So I understand what you mean.

          I do list my location on a certain forum as “Wacky Washington Way Out West.”

          1. Now hold on you immigrant lot! I was born and spent my early childhood in Yakima–the hop capital of the WORLD–to say nothing of a childhood filled with apples, peaches, apricots, pears and more right off the tree. I spent the rest of my youth in Seattle and 15 years of my parenting years in Portland, then back to Washington and the Olympic Peninsula. Some time in Spokane and a degree from EWU in there between Seattle and Portland.

            Each of those has its pluses and minuses and the biggest thing I face now is which the heck one to choose for my final stretch (when I finally get to leave the Midwest in the dust).

            Good Lord, Windriven, do you live in one of those terribly artsy-fartsy woo towns I used to live in? I can honestly say I will not return to PT in spite of how much I love the Rose. Microsoft and it’s monied spawn have wrecked Seattle, Portland spurned fluoride just to show how stupid they are–so, it just may turn out to be…..YAKIMA! Possibly Vancouver (WA) as my gkids are there and it’s less cutesy than Portland. Then again, I understand that one can pick up a house for nearly nothing in Detroit. :-))

            I’ll try the Xingu if I can find it–thanks Andrey and WD! I had something up in UP called Pepe Nero that I liked very much as well, but can’t find yet here in the Brew City. FYI, Beck’s Dark has been replaced by something gawdawful called Sapphire, and I really think we cleaned up the very last of the Dark up North.

          2. Chris says:

            Yakima was my legal residence through out my childhood. My father was born and grew up there, and his aunt’s address was our legal address while he was transferred all over the place. My family homesteaded there starting in the late 19th century. My great-grandfather grew peaches in Tieton.

            We also visited it often, and yes, the peaches were lovely. I watched salmon spawn in the Naches River near my mother’s cousin’s house on Highway 410. I remember shopping at the Bon Marche downtown, and my great-aunt’s house not far from there. She was the one that told me to save at Washington Mutual since it had been on the same corner for fifty years.

            We just visited a couple of months ago, and the downtown is just a shadow of its former self. Mostly empty buildings. All of my family has essentially left. Though one huge improvement is the area around the Yakima River is now a very nice park.

            Prosser is now where it is happening.

            I’m not an immigrant, I’m an emigrant. Though on our trip through the Gorge and up the Yakima Valley, we saw a lovely town where you can see Multnomah Falls across the river. It is a not far from Portland, OR and had both a library and public pool.

          3. windriven says:

            No offence meant, Irene. I am an immigrant and thankful to be here.

            My primary home is in Ridgefield, WA and my weekday home is in Allyn, not one of the artsy-fartsy places up north (though I love to visit!).

            @Chris

            “She was the one that told me to save at Washington Mutual since it had been on the same corner for fifty years.”

            This made me smile. A close friend bought a Texas s-load of WaMu stock on the advice of another friend. I, happily, did not. Hard to believe the WaMu corner bank and the WaMu mortgage mill were the same institution.

          4. Chris says:

            windriven:

            Hard to believe the WaMu corner bank and the WaMu mortgage mill were the same institution.

            There is a book about it, The Lost Bank by Kristen Grind. I have not read it, but I did listen to the author describe the debacle on a library podcast: http://www.spl.org/Audio/7_26_12_Kirsten_Grind.mp3

  4. EO says:

    Although I don’t agree that CAM practitioners deserve reimbursement through insurance companies for the care they provide, I don’t think it should be ignored the fact that more and more patients are resorting to treatment modalities such as acupuncture for things such as chronic and acute pain which does have some proven efficacy through clinical trials. If these treatments truly do work for patients after researching more, then It would be hard to argue with providing some form of funding for certain interventions. For more information on the efficacy of acupuncture and other complimentary modalities of medicine, check out naturalstandard.com

    1. Beamup says:

      Actually you are incorrect. What the clinical trials ACTUALLY show (as opposed to how proponents try to dishonestly distort the data) is that acupuncture has no efficacy beyond placebo. There is no need for more research – they do not “truly work for patients.” That’s a firmly settled question based on the data already available. Therefore, there is no possible justification for funding them.

    2. Jann Bellamy says:

      I find that Natural Standard has a pro-CAM/integrative medicine bias. I think Natural Medicines Comprehensive Database is a better source. http://naturaldatabase.therapeuticresearch.com/home.aspx?cs=&s=ND Quackwatch is also great for information about all sorts of CAM practices. If you review the articles on acupuncture here at SBM you will find that there is no good evidence of efficacy for pain conditions or anything else. I think the main reason they are used is that no one seems to be interested in making acupuncturists or other CAM practitioners give their patients accurate information about their diagnostic methods and treatments. Deprived of their misrepresentations, CAM practitioners would likely see a huge decline in patient numbers.

  5. duggansc says:

    Huh… I wonder if that would prevent the kind of dickery we have going on here in Pittsburgh between UPMC and Highmark Blue Cross Blue Shield. UPMC has sort of a monopoly on hospital care here and has both a non-profit hospital division and a for-profit insurance division. About a year ago, Highmark started investing in West Penn Allegheny, the only other real hospital chain in the area and UPMC responded by saying that they planned to stop taking Highmark insurance and that the UPMC insurance wouldn’t cover care at West Penn. The local government has stepped in and forced them to hold off, but they’re still at loggerheads. Would a provision like this prevent an insurance company from funneling their business through their preferred partners who they may or may not have financial ties with?

  6. Carl says:

    Checking BMI? Heck, I could do that. I wonder if I will be able to take only the 9-12 hours of mundane courses they are adding to qualify as real doctors. Then I could play doctor just like they do, but without having to sit through years to chiropractic nonsense. I would also like to learn how to do that thing with the pen flashlight where you point it at the patient and say stuff like “can you look over here? Good, thanks” or whatever that is. I already have one of those Welch Allyn flashlights, so I am pretty close to setting up shop and billing insurance companies.

  7. R. Wade Covill MD, MTDoc says:

    Hey Carl! My first laugh of the day. At age 78, I’ve seen my profession reduced to a level I would have never considered when I selected my career in the 1950s. Primary care in my day meant you took care of your patients 24 hours a day, in the office, or in the hospital. We also trained many years in programs that required 80 to 100 hour work weeks. And we took care of everybody without regard to there ability to pay. Then the government said we should be paid our “usual and customary fee”. In 1985 I had to abandon my practice because medicare fees for my services were $12, while my overhead cost was $20. And my patients were not allowed to make up the difference. All my partners have also quit, found other work, or died. Be careful what we ask the government to do for us!

    1. windriven says:

      My hat is off to you, Dr. Covill. I grew up in Cleveland, OH where Alex Marcus was our family doctor. He delivered my father in my grandparents home and he delivered me 24 years later – but in a hospital. He also scalped my weewee, snatched my tonsils and adenoids, yanked my great aunt’s uterus and occasionally stopped by my grandparent’s house for a housecall or a martini or both. My dad was born in 1927 so Dr. Marcus started a good bit before you did. But the work ethic and the patient focus was much the same. And he was a no bullshit guy. Medicine was medicine and everything else … wasn’t. My mother took me to a chiropractor once for a football injury and he nearly came unglued.

      I hope you enjoy your richly deserved retirement.

      “Be careful what we ask the government to do for us!”

      Indeed. I can’t say I have a very clear idea how we should reform our healthcare system but I’m convinced that ACA as it is currently structured isn’t it. Actually, ACA is more insurance reform than health care reform. And while it includes some essentials like the individual mandate the implementation of ACA has been a textbook study in institutional incompetence*.

      *Apparently the President lacks the resolve to fire Ms. Sibelius and apparently Ms. Sibelius lacks the character to resign. The dysfunction in the legislative branch can be written off to partisan intransigence. I’m not sure how to classify the dysfunction in the executive branch.

      1. Calli Arcale says:

        Also partisan intransigence. Firing Ms Sibelius (or her resigning) would be tantamount to admitting error, and that is something neither party can stomach right now, as it would undermine their posturing of being the only right and true way to do what is good for America. (And, of course, this also means they’re exceptionally cagey about just what exactly it is that is good for America; they are easy to nail down on the subject as microwaved Jello, since clear promises are so much harder to keep.)

        ACA is . . . marginally better than nothing. And indeed, it is insurance reform only. The reaction to it has appalled, but not surprised me, as corporations use it to excuse all sorts of things that in total honesty cannot have had anything whatsoever to do with it. Politics and even business today seems to be largely about scapegoating and not about getting things actually done.

        1. windriven says:

          I would agree and perhaps even go a little farther – ACA is arguably a lot better than what we have now. My fear is that the political class will now brush their hands off and declare: mission accomplished.

      2. Stella B says:

        Yes, you’ve got it! The ACA is a modest reform of insurance regulations. It was originally developed as the Republican response to Hillarycare. It became law in MA as Romneycare in 2005, Newt Gingrich wrote a book in 2006 touting the plan, jim DeMint supported it in 2007 in support of Romney’s primary candidacy, and Republicans supported this kind of plan as late as February 2009 until Obama embraced. Then, instead of declaring victory, the Republicans suddenly repudiated it. There is no socialism or “death panels”, just modest insurance regulation. The Republicans billed the individual mandate as “personal responsibility” for over 15 years before it became an anathema in a blink. A lot of health cqre policy wonks feel the law is adequately constructed to make health care universally available. It’s not the “best” or the cheapest approach, but if you are fair, it moves us in the right direction. A similar system works in Switzerland and in MA and there’s no reason to think it won’t work here.

        Obama is about as far left as Ike Eisenhower. The bill is wordy as complex bills usually are. Funding was slashed for implementation and some minor aspects of the bill need to be delayed or tweeked. Nancy Pelosi is a lousy speaker, but a pretty good Speaker and it’s easy to take some things she’s said out of context and make great attack ads. A few high-income, young men will pay higher premiums … while they are young and unmarried. However, this bill makes it possible for my hard working, healthy brother-in-law to buy insurance with his own money despite having a common, minor, congenital heart valve problem. It makes it possible for cancer survivors, asthmatics, diabetics and others to get insurance to protect themselves from financial ruin.

        I”m recently retired, but I made a fine living seeing Medicare and Medicaid patients. I can’t afford a Porsche and I don’t live in Rancho Santa Fe, but I’m quite comfortable despite “government control” of a portion of my income. I grew up in a fancy neighborhood in the 60s and 70s and the docs who lived their drove nice cars and sent their kids to fancy schools, they weren’t going out of business despite the same “socialism” and “ruining the best health care system in the world” predictions that we hear now. Take a deep breath. If superwealth is your goal, then maybe you need a different line of work. If a very comfortable living is adequate (our pay is really not that far from European or Canadian pay as it is, believe it or not), then these changes are likely to have little impact on you at all.

      3. Hmmm…I’ve been thinking what an amazing job Sec. Sibelius has done with the monumental task she’s been handed–including having to do all the work for states like Wisconsin where Gov. Teaparty refuses to set up exchanges or expand Medicaid. I say this making no judgement about ACA, about which I have very mixed feelings. The best I can muster is that it’s a baby step and will hopefully lead to further improvements. But, I know a few people who will be online at http://www.heathcare.gov (the website is impressive), on Oct 1 regardless of the shortcomings and for their sakes (and millions like them) I’ve supported it and try not to cry over spilt milk.

        Some of my friends/relatives have had no insurance for many years as self-employed people of modest income and pre-existing conditions. They’ve had to make do with very spotty care, and hardly ever see the same person twice, to say nothing of muddling through with only the bare minimum of lab work and rx. The crumbs of ACA will be an improvement for them.

        I’m not clear on why you feel so strongly about Sebelius, perhaps I’ve missed something?

        1. windriven says:

          Given the budget that DHHS has and the nearly four years she’s had to put this together, I struggle to share your amazement, Irene.

          Various governors haven’t made it easier for her but that didn’t emerge as a last minute surprise.

          There have been ample resources and abundant time to get this launched. I am almost inclined to think that the Secretary has ‘slow walked’ the roll out but I can’t for the life of me imagine why.

          In the event the thing is launching like a wounded duck. That will not make it more acceptable to the substantial number of Americans who already dislike it.

          Actions have consequences. So does inaction.

  8. Andrey Pavlov says:

    I’m exactly the same with my Scotch as well. Which is why I was never a big fan of Johnny Blue – no real flavor to it. Just buttery smooth. Which I suppose is fine if that is what you are going for, but if I want something smooth with no flavor I’ll stick to my vodka.

    I prefer Laphroaig myself. And if I am having Johnny the Green is my favorite of the line. Nice and peaty with a smoky bite. It can still be smooth but retain some bite and a heap of flavor.

    My only problem is that in my old age these days I tend to get hangovers much too easily and the congeners in Scotch and red wine absolutely kill me. I don’t even need to get inebriated – just a small buzz off nothing but Scotch leaves me wishing I hadn’t indulged the night before. Which is why I generally stick to good vodkas and beer and save the Scotch for special occasions.

    One of the more fun things I have done was become a member of the Scotch Whiskey Heritage Appreciation Club when I was in Edinborough many years back. It cost about 45 quid and for that included a tour, an educational video, a Disneyland-esque ride, and 1 sample each from all 5 regions of Scotch making. If you are ever in Edinborough I highly suggest doing it.

    1. windriven says:

      Couldn’t agree more on the Johnny. I’ve never understood the cachet surrounding Blue or any of the Chivas products. But you and I part company on the Islay malts, the peaty buggers that suggest old wound dressings to my palate.

      I served for many years on the board of a company in Sweden. The chairman took it in his head that I liked Islays and for years he would gift me with a bottle of Laphroaig or Bowmore when I’d arrive for the annual meeting. They’ve been splendid for regifting. I prefer the Highlands and Speysides. As I mentioned earlier, McCallans – a Speyside – is finished in old sherry casks and is a fabulous after dinner drink. For general boozing I like Dalwhinnie and Knockando.

      “I generally stick to good vodkas”

      I’ve been drinking Luksusowa for years. Other alcohol comes and goes at my house but there is always a bottle of Luks in my freezer. Those who claim that vodka ‘has no flavor’ should stick to Coke.

  9. Andrey Pavlov says:

    Ah. Yo comprende. Sadly, a ferry will not take me to your land of the gods.

  10. Andrey Pavlov says:

    Well, to each their own. I do enjoy a good Speyside but not as much as my peaty marshes.

    As for Luksusowa… never heard of it. I’ll have to see if I can wrangle up a bottle. In my impoverished student lifestyle I have gravitated towards Tito’s vodka. It is excellent and smooth and very inexpensive. Made by an engineer in Texas. Prior to that I enjoy Hangar One, a Californian vodka, particularly the orange blossom flavor on the rocks.

    1. windriven says:

      Luksusowa is a Polish potato vodka. I highly recommend it! Thanks for the tip on Tito’s and Hangar One. I’ll look for them.

  11. Andrey Pavlov says:

    It’s funny, I often get pegged as a “liberal Democrat” and would often be derisively chided as having voted for Obama the first time around. Actually, I voted for McCain. Which typically raised a few eyebrows.

    I think this sort of dualistic tribalism is both easy and dangerous. It becomes very easy to pull shenanigans when you can effectively polarize into two groups, which is why Washington himself warned against exactly this – a two party system would be the downfall of America. Funny how they love to cite stuff the founding fathers never said or intended, but conveniently forget that one.

    I like good ideas no matter where the come from. Whether they be Republican*, Democrat, a janitor, a nuclear physicist, or a 10 year old. A good idea is good because of its merits, not because of who it comes from. Which means I cannot possibly be completely described by a single moniker (except, perhaps, “rigorously evidence based”). And people who are content to be described that way are sacrificing a ridiculous amount of autonomy.

    *That said, I do believe there is enough evidence to say that, on the whole, Repubs are generally much more anti-science, pro-religious, and authoritarian than Democrats. But the Dems are just as anti-science when it comes to certain topics and have their own heaping helping of problems. People just need to think rather than pick a convenient tribe and abrogate their thinking to the tribal leaders.

    1. Chris says:

      Due to a local election coming up (the primary was early this month), I get calls that are surveys on my opinion. One was my feeling on who I will vote for mayor. Since it was June, the primary was going to be early August I had not even paid any attention. So I said I will know when I read up on them.

      Then she kept asking me to rate one to five some random names (I think it was the stable of candidates). To which I told her I cannot make an opinion without data. She did really did not like me being the Star Trek computer saying “Insufficient Data.”

    2. windriven says:

      My favorite bumper sticker of all time had “Democrats” in blue on one side and “Republicans” in red on the other. In small letters underneath it said: same shit, different piles.

    3. Fine–I’ve just never met a Republican with a good idea, not in the last 30 years anyway. McCain did all right when he worked with Russ Feingold, but that’s all history now. I don’t think of my Democratic affiliation as “tribalism”–just party affiliation. It makes it easier by just having to pull one lever in the booth.

      1. windriven says:

        ” It makes it easier by just having to pull one lever in the booth.”

        I guess all I’ll say is that I’ve never ‘pulled one lever’ in my life.

        1. Chris says:

          Neither have I.

          And in this state you don’t have to. Oddly enough we have had Republicans who were more environmentally aware than Democrats. Evergreen State College, a place of much silliness, was created with the influence of a Republican governor (Dan Evans). Then there was anti-communist hawkish Democrat Scoop Jackson.

          It is a weird state. I am a native, and our family puts the “fun” into dysfunctional. One of the reasons there are none left in Yakima. They moved West to get away, but after hitting the coast they started heading elsewhere.

  12. Marion says:

    How did this thread turn into a discussion over the quality of booze?
    Is that the new cure-all treatment for kidney failure, cancer (all kinds), halitosis, schizophrenia, and hair loss?

    1. windriven says:

      Nope. But it does, in moderation, cure the blues!

  13. I knew I was going to mess up by calling you all immigrants! Your family’s history just might trump mine, so now who’s Johnny-come-lately-shut-the-door-behind-them, eh? Thanks for the clarification and yes, it’s sad about downtown–I remember when the Bon Marche was the biggest store (two floors!) and had the only escalator in town–just wide enough for one (normal weight) person. I visit when I come home and it’s quite dull; still it’s hard to believe the action is in…eeek, Prosser!

    I still think it might be a good place to spend the twilight. I hope you’ll all visit.

    1. Chris says:

      Yep, Prosser. It is because of the wineries. They are building kind of a tasting mall. Across the street is a large hotel (which was full), then and entire block had tasting rooms, a couple of restaurants and a soon to be built bed and breakfast. You can do all the tasting you want without getting in a car.

      A restaurant owner in Seattle has a farm in Prosser, which he talks about lots on his radio show/podcast.

  14. Please visit the website. It is very thorough and everything is in place for Oct. 1.

    Again, I’m not sure what you mean about not getting it launched. I’ve called the number at the site and got through to a live person in less than a minute, who spoke Standard American English and was extremely knowledgeable. She answered all my questions and told me they will be ready to take applications on Oct. 1–which I immediately passed on to my uninsured, and very sick, granddaughter who has been getting very patchwork care.

    It’s easy enough not to like it as long as you’re covered or have enough resources to self-pay, or if you’re just ideologically opposed to anything the Kenyan, socialist baby-eater does, but it really was the best we could get at the time (not saying the exec branch went it about it correctly, but that’s done) and it is a start.

    I don’t mind the disagreement, I just can’t figure out where your impression comes from.

    1. windriven says:

      As a businessperson I haven’t been able to get anything useful. I have no idea what impact this will have on my insurance plan. I’ve already been notified by my carrier that my premiums will go up dramatically in January when my current contract expires. I may have no choice but to eliminate insurance for my employees and give everyone a raise equal to what I’m paying now so that they can buy their own. But I question whether some will, choosing instead to take their chances and spend the money on something else. Not my business I suppose. But it stinks on ice.

      I’ll try calling again to see what I get. But my experiences over the past several months have been markedly different than yours.

      1. Chris says:

        So how would you feel if you sat at a restaurant table with two retired Army officers who demonized “ObamaCare”, but then said how great that their totally free TriCare health insurance was?

        Um, yeah. I love my brother (who is more sane than either of my sisters), but sometimes I have to wonder about what he says. One time about thirty years ago he told me that the federal government should stop all payments. I decided to not create a mind altering schism by reminding him that his Army paycheck came from federal taxes.

        Perhaps you should just hire recently retired military officers. Due to the glut they get at middle management (captains, majors and lieutenant colonels), most are forced into retirement after just twenty years in their early 40s. And since for last couple of years new legislation allows them get free health care for life through TriCare (according to my father and brother), it makes them “cheaper.”

        Just a thought. ;-/

        1. windriven says:

          Ah Chris, you have my sympathies. I have a brother of similar mental cast. I’ve long since stopped talking religion or politics with him. I’ve had more fruitful and compelling conversations with my dog.

          I’m more or less agnostic about ACA. I like the idea that it brings everyone into the system. But I doubt that it will. The administration has backpedaled to the point that confusion reigns supreme. Politically connected businesses have gotten waivers. The individual mandate appears toothless. There has been zero, zip, nada outreach to employers – at least to small business employers. Meanwhile, private insurers have let no grass grow; they have told us to prepare for a hosing.

    2. windriven says:

      Irene,

      This morning’s Reuters report seems to disagree with your assertion re ACA.

      http://www.reuters.com/article/2013/08/28/us-usa-healthcare-obamacare-idUSBRE97R04X20130828

      Just saying. It is one thing to say ‘everything’s peachy’ quite another to say ‘This is the coverage and this is the actual cost’.

      You may have also seen that today the IRS released the rules governing the individual mandate. Failure to procure insurance will result in a 1% of income fine in 2014 rising to 2.5% of income in 2016.

      My company’s health plan costs on average $4801.92 per employee per year. That works out to $1.61 per hour. For, say, a $12 per hour employee that amounts to 13.4% of income. Deduct the IRS penalty and they’re getting better than a 10% raise if we have to bail on health insurance and they decide to forgo coverage. Makes it a lot easier to save for a house with a 10% raise.

  15. Ridgefield is lovely–very close to my son’s place, but I have to confess, I’ve never been to Allyn, and furthermore, I had to look it up! Sounds a bit like Port Ludlow. I’ll have to swing through on my next road trip–watch for a black Jeep with a little red and black trailer! :-)

  16. windriven says:

    Don’t blink! No stop light. No stop sign. But my home is high on the hill with a great view of Mt. Rainier and the water.

    1. Chris says:

      Looking at map. Oh, wow, you are further away from Michael Belkin and his terrible band than I am. Good show.

      Though one reason I live in the city is that of all the places I lived in as an Army brat* I found that I liked places where I can walk to the grocery store, library, etc, instead of driving for a half hour one way if I need an ingredient. Which we did too often when I stayed in Naches with my mother’s cousin (who did show me that you can incorporate veggies into a flower bed and make it look good!). My two favorite places were Pacific Grove, CA and Ft. Amador in Panama (this Frank Gehry designed museum is exactly on the bit of causeway that I lived on, though I did hang out with friends in Panama City).

      * I attended nine different school districts, and this includes only counting the Killeen Independent School District as one. I started kindergarten there, and graduated from high school there… but none of the years in between. And the last time was off base in a tiny one bathroom house with two sisters and no transportation in the boonies. My choice was to either take driver’s ed or graduating a year early. I delayed learning to drive by four years to avoid going to a third high school in a tenth school district.

  17. Janet Camp says:

    I did vote for Dan Evans…

  18. Janet Camp says:

    I have every sympathy–we have a family business with lately (since recession) less than 50 employees. We may do better with ACA but won’t know for sure until Oct 1, when all the charts and figures are released. Even if it doesn’t help me personally, though, it will help lots of people I care about who struggle to make a living in the beautiful PNW who didn’t happen to become Microsoft Millionaires. :-) Some were helped by Washington Basic Health, but it suffered from cutbacks almost from the outset.

    1. windriven says:

      And Janet, I’m not even concerned whether or not it helps me. I currently provide health insurance for my employees (I pay, I think, 70% and they pay the rest – I like everyone to have a little skin in the game). I am deeply concerned that I will not be able to continue. I’ve already discussed this with the employees. We’re going to wait and see. If it is unsustainable I’ll give everyone on the program a raise equal to my portion of the health insurance and they’ll have to get insurance through the exchange.

      “Some were helped by Washington Basic Health, but it suffered from cutbacks almost from the outset.”

      How certain are you that ACA will not suffer a similar fate? ACA is insurance reform. We are bringing supposedly 30 million people into a system with the same number of hospitals, physicians and nurses. I’ve taken Econ 101. More demand chasing the same number of products or services makes prices rise. And to the best of my knowledge the feds have not funded a single additional residency in preparation for this change.

      Think for a moment how that will bias people to seek treatment from ‘alternative’ PCPs. I have a great relationship with my internist and can see her immediately if I need to. But making a general appointment means a 6 week wait. When 30 million more Americans are looking for PCPs what will the wait be? But the wait to see Chad Dufus, ND is 30 minutes. Hmmm….

      1. duggansc says:

        Indeed. The wait to see the doctor these days is pretty terrible. They can’t necessarily help it — there are a lot of patients out there and one can generally get a rush appointment by virtue of sacrificing half a day to a full day of work to pick an inconvenient time — but I have to say that over half of the times I’ve been sick the last year, I’ve seriously considered the cost-benefits of waiting and my condition either getting worse or going away on its own, or doing something like the urgent care centers where I’ll get horrendously soaked and have to spend several hours waiting for a doctor to get to me (and, at that, risk them treating me as a severe case and telling me they can’t give me basic care until they’ve run another half a dozen premium tests to rule out zebras).

        Regarding the ACA, I think it may be well-meaning, but it’s going to get worse before it gets better. I already know people who are having their hours slashed because it puts them under the threshold where their employer has to pay for health insurance. Gets even worse for college professors, apparently. One of the local universities has switched almost entirely to adjunct professors to cut costs. And then the expenses… it’s possible, I guess, that hospitals might start reining in inflation to only double the Medicare costs instead of 10-15 times, but I’m not holding my breath, not when hospitals make so much money in the process.

        1. windriven says:

          You address precisely my frustration with the administration’s handling of the roll-out. Private insurers – for whom I have exactly zero love – have told me pretty much what to expect. Meanwhile, the administration is painting pretty pictures of future glories to come. I can’t base business decisions on fluff.

          The President said recently that for many the cost of health insurance will be less than their cell phone bills. The average for my company’s plan is about $400 per employee per month. Who is paying the difference between a cell phone and $400?

          So I figure I’m likely out of the health insurance business. And if I’m not subsidizing workers’ insurance (mine pay about 120 of that 400) who is?

          I just want the numbers to add up so that I can make an intelligent decision.

  19. Janet Camp says:

    Thanks for the link, Chris. Debacle indeed! A sad tale.

  20. goodnightirene says:

    Who knew? It used to strictly trailer trash. Microsoft changed everything.

  21. Dan Evans is the one Rep I voted for (that was a long time ago), and there are times I have to hold my nose to vote for Dems, or not vote at all (heresy to my civic-mindedness), so I just pull the Dem lever to make it easier, not because it’s required (jut to be clear). Even if I liked an individual Rep, the platform contains things I could never vote for.

    I moved a lot as a kid too! I went to ten schools by fourth grade and then it slowed down a little and I only had to go to two jr. high’s and finally ONE high school. No military, just a Dad in construction. People think this is awful, but I found it interesting to go to new places and have never thought it did any real harm, although for a shy kid it would be devastating I think.

    1. windriven says:

      “there are times I have to hold my nose to vote for Dems, or not vote at all ”

      In the last election I wrote in Pat Paulson for president. I couldn’t in good conscience vote for either Mr. Obama or Mr. Romney. And not voting wasn’t an option. It was a wasted vote, like firing a round into the ground during a duel. But like the round in the ground it signaled my intense contempt. Not voting only signals apathy.*

      And please, we’re already far off into the weeds here. I do not intend to get into a discussion about the relative (or absolute) qualities of either candidate. The election is over.

      *Not that I actually believe that anyone is paying the slightest attention to these signals.

  22. No weeds intended–an interesting discussion, the kind civil people used to have without becoming rabid. But yes, enough said on the topics for now. :-)

    1. Chris says:

      Irene: “No weeds intended–an interesting discussion, the kind civil people used to have without becoming rabid.”

      Agreed.

      I have an almost 25 year old child who has obvious cognitive and mental health disabilities, plus a genetic heart condition. The problem is that he is too functional to qualify for the state’s department of developmental disabilities.

      It was due to ObamaCare that his heart surgery at the Mayo Clinic was covered because he was not yet 26 years old. Sitting near me is the phone number of a company that does trusts (it includes both lawyers and others), that I hope will guide me through the process. Yes, I know I need to call them. I have also need to call to get a rabies vaccine for Child #3′s cat. Give me a break.

      All I am hoping for is catastrophic coverage. We can handle the twice a year cardiologist appointments and the once a year visit to the family doctor. It is the migraine mimicking a stroke that scares me. That is how I know it costs $700 to go less to than two miles by private ambulance to a hospital. Which then turns into a five digit financial burden.

      Our plan is to move to where Child #2 ends up. His plan is to become a high school math teacher. My want to depend on him as much as his paternal grandmother depends on his father (once a month he goes over to help with household stuff). The place will include a place for Child #1. And even though Child #2 has voiced that he will take care of his older brother, I hope there is a formal plan in place.

      Child #3 plans a career in liberal arts academia. It seems that Child #2 may also be taking care of her/him. Le sigh. At least she/he (who knows?) is fiscally cheap, so we have intrusted the location of all financial data to our youngest.

      (Do not even think of linking to the “Visit to Holland” essay, I hate it… late father-in-law was Dutch, and we have actually traveled to North Holland, a province of the Netherlands, on purpose. This why when youngest child changed “their” name the only part that stayed the same, the surname, was misspelled differently by both the Social Security offices and the WA State Department of Licensing. At least they let a person correct those mistakes. By the way, this is why I never changed my name. It also took my step-mother ten years to learn how to spell it, and she never did learn how to pronounce it!)

  23. I never meant to imply “peachiness” (wwww) and I too, am ambivalent on ACA, but am willing to see how it moves forward. I was simply impressed with the effort of Sebelius’ Dept to move ahead with implementation, separate from other aspects. I can see that our points-of-view come from different places, you as an employer and me as a private citizen with loved ones without coverage, but I don’t think we disagree on the basics. It’s a topic better left for personal interchange than off-topic comments, perhaps. We should have a conference! :-))

  24. Good points on all counts and see my last two entries. It is definitely a complex issue and I would only say its been made more complex by the whole process. We will just have to wait and see now–paltry comfort for all involved.

  25. My answer to all this (all valid and complex issues) is two words–and no one says you have to agree:

    Single Payer (or Medicare for All)

    1. windriven says:

      Let me know next time you’re passing through. I’d love to have a conference.

      As to your two words, I wouldn’t entirely disagree. I would have liked to see a program that expanded and improved the VA hospital system and then folded some Medicaid and uninsured in as a model of what single payer might look like. I tend to prefer pilot projects before wholesale changes. A little mistake is a lot easier to clean up than a large one. And a small success is easy to scale up to a huge success.

      One place that we absolutely agree is that there is no excuse for anyone in this country to endure substandard medical care or to bankrupt themselves to keep a loved one alive (though limits must necessarily be part of that discussion).

  26. Agree on all accounts! I would mention that there are a lot of pilot programs embedded in ACA and some have already shown some merit. I really am trying to see the bright side here–and that’s a tough call for a natural born cynic. Thanks for highlighting the problems from the employer perspective; it’s an area I need to read more about.

    See you at the conference!

  27. Chris, I’m not sure what you are actually responding to, but I’m very glad your eldest was able to get treated under Obamacare. I have looked for the good in it, perhaps with too much bias, but I am still glad to see any change at all come to our system.

  28. Jonathan Vestal says:

    Good evening all, thought I’d keep this debate going a little bit further, if you don’t mind.
    First off, I am a chiropractor. I recently graduated from a small university in Dallas, TX, and did a brief internship at a hospital in Tulsa (Cancer Treatment Centers of America). It was a great experience to be in an environment where we all treated each profession as equals, in our respective fields of course. The oncologist didn’t consult the chiropractor about whether interventional radiology should have been combined with chemo, but what they did do was ask each professional “What can you provide for this patient to help them get better?”
    Now that I’m outside the confines of the hospital, I find many MD/DO/PA’s are not as willing to accept that chiropractic can help much of anything at all. In fact, most that I encounter in the greater Oklahoma City area equate chiropractic with placebo.

    Instead of debating how qualified chiropractors are, let me first ask your opinion.. Is chiropractic good for anything? Are there any conditions or people that you may even suggest seek chiropractic care? Why or why not?
    Note: I’m talking the three basic interventional modalities.. 1. The adjustment 2. Passive modalities (E-Stim, Ultrasound, etc) 3. Active physiotherapy

    1. Harriet Hall says:

      1. Spinal manipulation therapy (not “the adjustment,” whatever that is) is effective for low back pain, although it is not more effective than other treatments. It is a reasonable alternative for those who like the hands-on treatments and want quick relief without pills. There is little convincing evidence for its effectiveness in other musculoskeletal conditions, and no evidence that it works for any non-musculoskeletal condition. Spinal manipulation is not “chiropractic” but is a manual modality offered by other professionals.
      2. and 3. These are PT modalities. If chiropractors use them, they are practicing PT, not chiropractic.

      Non-chiropractors use all these treatments, so what does chiropractic offer that defines it as a separate profession? Historically, the mythical subluxation. Today? It’s not clear. I can’t think of one good reason to choose a chiropractor over a good physical therapist.

    2. WilliamLawrenceUtridge says:

      How much of your education was geared towards growing your patient volume?

      How much of your education was spent discussing the harms of conventional doctors and medicine? Was the word “allopathy” ever used?

  29. Chris Johnsen says:

    Hello, I am a chiropractor and I have been in practice for 18 years. I have an entirely evidence based practiced and in addition to manipulation for lower back pain and neck pain, both of which have considerable evidentiary support, I also provide instruction in exercise for back pain and perform physiotherapy modalities on my patients. There are certainly some chiropractors who perform bizarre “therapies” on their patients that would be better suited to a new age crystal shop, however, most practitioners that I am aware of also practice in an evidence based manner. SImply put, it is difficult to get paid by insurers if you don’t practice this way. Most insurance panels ask what type of manipulative technique you practice upon sign up and will not permit those doctors who perform strange, unsupported techniques to be reimbursed for those services. Chiropractors have the most skill in manipulation (also called an “adjustment” by some doctors) because they do it much more than any other profession including osteopaths and physiotherapists. As there are unethical MD’s there are also unethical chiropractors. Do not condemn the entire profession because of a handful of nuts. Quackwatch is a rabidly anti-chiropractic website begun by Steven Barret who administered it from a garage in Pennsylvania and is now on the run from collection agents over attorneys fees after losing a lawsuit several years ago. Its views are extreme and should not be relied upon for defining evidence based chiropractic practice or those practitioners who practice in a reasonable manner. Scope of practice for most chiropractors includes the ability to perform manipulation and instruct a patient in exercise. Visit http://www.acrb.org/ to find a quality chiropractic doctor who is board certified in rehabilitation. These doctors get several years of additional training in exercise and evidence based practice.

    Thank you,
    Dr. Christopher Johnsen DC

    1. Harriet Hall says:

      @Chris Johnsen,
      You are out of line. You accuse Stephen Barrett (you didn’t even get his name right: it’s not “Steven Barret”)of being rabidly anti-chiropractic and you throw in assertions that he administered his website from a garage and is on the run from collection agents (do you have any evidence that either of these statements is true?). You might be interested to know that he was once successfully treated for back pain by a chiropractor and he recognizes that manipulation is effective for that condition, and he runs the Chirobase website with a chiropractor. He is not against all chiropractors, only those who misbehave. His website even features advice for patients on how to choose a chiropractor. You have not shown that anything on Quackwatch is inaccurate. In fact, your comments about Quackwatch are entirely gratuitous, since the article did not refer to it in any way. You need to be adjusted for “chip-on-shoulder disease.” I support chiropractors like Samuel Homola (and presumably like you, if your practice is evidence-based as you claim), but if “most chiropractors” you know are evidence-based, your experience is unusual. Nearly 40% of chiropractors in the US use applied kinesiology, and it is the 10th most frequently used chiropractic technique. Surveys show a preponderance of chiropractors endorse non-scientific beliefs. It’s demonstrably more than a “handful of nuts.”

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