AMERICAN CHIROPRACTIC ASSOCIATION POLICIES ON PUBLIC HEALTH AND RELATED MATTERS 2002

2American Chiropractic Association

Policies on Public Health and Related Matters Preface Master Plan Definitions The ACA Master Plan, ratified by the House of Delegates in June 1964 (Amended June 1979, June 1989, July 1994 and September 2000), and will govern future policies of ACA as quoted:

“With regard to the core chiropractic principle, which holds that the relationship between structure and function in the human body is a significant health factor and that such relationships between the spinal column and the nervous system are highly significant because the normal transmission and expression of nerve energy are essential to the restoration and maintenance of health.

“Chiropractic shall be described in accordance with the foregoing principle as follows:

“Chiropractic is a branch of the healing arts which is concerned with human health and disease processes. Doctors of Chiropractic are physicians who consider man as an integrated being and give special attention to the physiological and biochemical aspects including structural, spinal, musculoskeletal, neurological, vascular, psychological, nutritional, visceral, emotional and environmental relationships and are trained in diagnosis so they may treat patients effectively and make timely referral to appropriate health care providers. “The practice and procedures which may be employed by Doctors of Chiropractic (chiropractic physicians) are based on the academic and clinical training received in and through accredited chiropractic colleges and include, but are not limited to, the use of current diagnostic and therapeutic procedures. Such procedures specifically include the adjustment and manipulation of the articulations and adjacent tissues of the human body, particularly of the spinal column. Included is the treatment of intersegmental aberrations for alleviation of related functional disorders.

“Chiropractic is a drug-free, non-surgical science and, as such, does not include pharma-ceuticals* or incisive surgery. Due regard shall be given to the fact that state laws, as well as the nation’s antitrust laws, [may] allow Doctors of Chiropractic (Chiropractic Physicians) to utilize ancillary health care procedures commonly referred to as being in the common domain.”

*Without prejudice to our commitment to this vital core concept and, in conformity with the nation’s antitrust laws, Doctors of Chiropractic (Chiropractic Physicians) may elect in their practice to use common domain procedures, otherwise allowed by applicable law, and assuming they are properly qualified by background, education and training to do so.

3 ACA POLICIES ON PUBLIC HEALTH AND RELATED MATTERS ACUPUNCTURE The board of governors of the ACA encourages the judicious development of curricula, research, and clinical procedures of this ancient healing method, and that it be integrated, when appropriate, as an adjunctive and supportive procedure which may complement the chiropractic adjustment. This modality should be utilized only by the doctor of chiropractic who is qualified by education and clinical experience, and who has been examined and certified by an appropriate accredited body. (Ratified by the House of Delegates, June 1975). ALCOHOLISM Alcoholism is established as a disorder manifested by complete absorption with and loss of control over consumption of alcohol and characterized by chronicity, intoxication and tendency toward relapse. Excessive drinking causes physical disability leading to impaired emotional, occupational, spiritual and social adjustments. The American Medical Association, the American Psychiatric Association, the American Hospital Association, the American Bar Association, the National Council on Alcoholism and the World Health Organization (among others) have endorsed similar stands. Resolved, that the American Chiropractic Association continues to recognize alcoholism as an illness, which should be so treated; that the alcoholic is a person with an illness who can be helped and is worth helping and that alcoholism is a significant public health problem. (Ratified by the House of Delegates, June 1982). AMERICAN MEDICAL ASSOCIATION Resolved, that the ACA is opposed to unnecessary compulsory medication, unnecessary surgery, and the arbitrary monopolistic attitude of the American Medical Association which is not in the best interests of the public’s health and welfare. (Ratified by the House of Delegates, June 1966). BLOODBORNE PATHOGENS The ACA recommends the use of universal precautions, when dealing with blood and body fluids of all patients. The ACA also encourages its members to periodically attend seminars dealing with HIV, AIDS and HBV to remain up to date on protocols for use in their offices. The ACA recognizes that treating patients via casual contact with the use of normal hygiene practices and universal precautions poses no currently recognized threat of contracting or spreading diseases in practitioners' offices. (Ratified by the House of Delegates, May 1992). For additional information, a Summary of OSHA Bloodborne Pathogens Regulations is available from the ACA.

4CALCIUM INITIATIVE The American Chiropractic Association and its Council on Nutrition support a Calcium Initiative that includes all the nutrition, dietary and lifestyle factors to support strong bones and prevent osteoporosis and will: 1. Execute a public private partnership between government and non-government organizations, academic and corporate America to increase the daily dietary calcium intake of most Americans. 2. Encourage the "Calcium Menu" into institutions and programs as appropriate. 3. Quantify the costs of health care associated with calcium deficient diets and roll those savings back into education and research. 4. Execute a successful model to emulate across the U.S. (Ratified by the House of Delegates, September 2000). Note: Calcium Menu available on request.

CHIROPRACTIC DEFINITION – ACA MASTER PLAN “Chiropractic is a branch of the healing arts which is concerned with human health and disease processes. Doctors of Chiropractic are physicians who consider man as an integrated being and give special attention to the physiological and biochemical aspects including structural, spinal, musculoskeletal, neurological, vascular, psychological, nutritional, visceral, emotional and environmental relationships and are trained in diagnosis so they may treat patients effectively and make timely referral to appropriate health care providers. (ACA Master Plan, ratified by the House of Delegates June 1964, amended June 1979, June 1989, July 1994 and September 2000) CHIROPRACTIC DEFINITION - ACC Resolved, that the House of Delegates endorse the position on chiropractic as developed by the ACC as follows:

Chiropractic is a health care discipline, which emphasizes the inherent recuperative power of the body to heal itself without the use of drugs or surgery. The practice of chiropractic focuses on the relationship between structure (primarily the spine) and function (as coordinated by the nervous system) and how that relationship affects the preservation and restoration of health. In addition, Doctors of Chiropractic recognize the value and responsibility of working in cooperation with other health care practitioners when in the best interest of the patient.

The Association of Chiropractic Colleges continues to foster a unique, distinct chiropractic profession that serves as a health care discipline for all. The ACC advocates a profession that generates, develops, and utilizes the highest level of evidence possible in the provision of effective, prudent, and cost-conscious patient evaluation and care. (Ratified by the House of Delegates, June 1997, reaffirmed September 2000) [Note: This does not replace the current definition of chiropractic as found in the ACA Master Plan.] CHIROPRACTIC DISCIPLINES Resolved, that the American Chiropractic Association reject any attempt inside or outside the profession to lock our discipline into any static a priori positions, be they past, present or future. (Ratified by the House of Delegates, July 1974). CHIROPRACTIC PRACTICE AND PROCEDURES “The practice and procedures which may be employed by Doctors of Chiropractic (chiropractic physicians) are based on the academic and clinical training received in and through accredited chiroprac-tic colleges and include, but are not limited to, the use of current diagnostic and therapeutic procedures.

5Such procedures specifically include the adjustment and manipulation of the articulations and adjacent tissues of the human body, particularly of the spinal column. Included is the treatment of intersegmental aberrations for alleviation of related functional disorders. “Chiropractic is a branch of the healing arts which is concerned with human health and disease processes. Doctors of Chiropractic are physicians who consider man as an integrated being and give special attention to the physiological and biochemical aspects including structural, spinal, musculoskeletal, neurological, vascular, psychological, nutritional, visceral, emotional and environmental relationships and are trained in diagnosis so they may treat patients effectively and make timely referral to appropriate health care providers. (ACA Master Plan, ratified by the House of Delegates, June 1964, amended, June 1977, June 1979, June 1989, July 1994 and September 2000) CHIROPRACTIC MEDICINE The applicable definition of “medicine” from the Oxford Dictionary is “that department of knowledge and practice which is concerned with the cure, alleviation and prevention of disease in human beings, and with the restoration and preservation of health.” The applicable definition of “medicine” from the Merriam-Webster Dictionary is “the science and art dealing with the maintenance of health and the prevention, alleviation, or cure of disease.” The healing art of chiropractic meets those parameters since the applicable definitions of “medicine” do not mention or include the utilization of drugs. The American Chiropractic Association Master Plan in part states chiropractic utilizes only “drugless and non-surgical methods,” and “Chiropractic is a drug-free, non-surgical science and, as such, does not include pharmaceuticals or incisive surgery.” Therefore, be it Resolved, that if the word “medicine” is used in conjunction with the word “chiropractic,” the word “medicine should only be considered in the context of a healing art that preserves, maintains and restores health; and be it further Resolved, that if the word “medicine” is used in conjunction with the word “chiropractic,” the word “medicine” should not be interpreted to mean that drugs are part of the practice of chiropractic; and be it further Resolved, in order to avoid confusion to the public, the American Chiropractic Association will encourage use of the terms “chiropractic,” “chiropractor,” “chiropractic physician,” and “doctor of chiropractic” in publications, presentations and communications. (Ratified by the House of Delegates, September 2000). CHIROPRACTIC PRINCIPLE Chiropractic is based on the premise that the relationship between structure and function in the human body is a significant health factor and that such relationships between the spinal column and the nervous system are the most significant, since the normal transmission and expression of nerve energy are essential to the restoration and maintenance of health. (ACA Master Plan, ratified by the House of Delegates, June 1964, amended, June 1975). Resolved, that the House of Delegates reaffirms the core principle of the subluxation. The ACA will strive to reiterate this principle and further state that the core treatment of chiropractic is manual manipulation/adjustment of the articulations, both spinal and extra-spinal, to reduce subluxations, when called upon in relation to Federal legislative efforts, in addition to full scope of practice as allowed by state law. References to subluxation and chiropractic adjustments/manipulation should be made in ACA releases, whenever possible. (Ratified by the House of Delegates, September 2000).

6 CHIROPRACTIC UNITY The American Chiropractic Association reaffirms its policy in favor of professional unity and invites the International Chiropractors Association to join the ACA in forming a “Unity Committee” that will be charged with the responsibility of developing a merger proposal that will be presented to both organizations for formal adoption at the earliest possible time. (Ratified by the House of Delegates, September 2000). CLINICAL FACILITIES Resolved, that the House of Delegates reaffirm previous position by establishing that any and all facilities used by members of the chiropractic profession should meet jurisdictional licensing requirements for such facilities and that all practices and procedures used therein should be consistent with academics and clinical training in chiropractic colleges accredited by the accrediting agency of the Council on Chiropractic Education with reasonable scientific acceptability. (Ratified by the House of Delegates, June 1975). COLLECTIVE BARGAINING

Resolved, that the ACA Board of Governors in concert with legal counsel and the legislative committee, write and promote legislation on the federal level, to enable in-network health professional members to form collective bargaining units, and be it further Resolved, that the ACA will seek out other health care professional organizations to form a united coalition in order to help bring this legislation to fruition. (Ratified by the House of Delegates, March 2002). COMPREHENSIVE HEALTH PLANNING Resolved, that in all federally operated or supported health programs (e.g. armed services, CHAMPUS, VA, Medicare, Federal worker’s compensation) the ACA endorses the following criteria:

1. There should be a universal eligibility for the appropriate health care for all U.S. citizens,

regardless of income or ability to pay.

2. There should be a full range of licensed health care services (e.g. medicine, osteopathy, chiropractic, dentistry, psychology) available to the consumers (patients) in all-federal programs. The consumer should be guaranteed freedom of choice in the selection of a licensed health care provider without discrimination against the consumer or any licensed health care provider he may choose.

3. When appropriate, ambulatory or out-patient care should be encouraged over more

expensive and in some cases less effective hospitalization or in-patient care.

4. Based on the growing amount of scientific evidence that supports the clinical effectiveness, cost-effectiveness and relative safety of chiropractic care it should be included in the mainstream of the nation’s health care system. There is an established need for federal emphasis and support of research and research training programs in chiropractic. Without creating new programs, existing ones could be broadened to reach these needs (e.g. NIH, AHCRP, HRSA). Additionally, it is appropriate and necessary to

7include qualified doctors of chiropractic in public/federal activities that involve health care policy development and implementation.

5. Medicare or Medicaid patients that choose chiropractic health care should not be

discriminated against. They should be allowed full coverage of those chiropractic services that are conterminous with state licensure.

6. Under all federal health care programs, all supportive health care services (e.g. clinical

laboratory, diagnostic imaging, neurodiagnostics) should be equally available to all licensed health care providers without discrimination, provided they fall within their scope of practice.

7. In all federal health care programs there should be conformity to uniform standards for all

health care intermediaries or carriers functioning in those programs. Such standards should include, but not be limited to eligibility, coverage, utilization, etc. Additionally, there should be uniform quality assurance programs that are not discriminatory toward certain professions.

8. The health care consumer in all health care programs, Federal or private, must have direct

access to chiropractic care. Chiropractic is traditionally considered an alternative and therefore a “competitor” to medicine. Since formal medical training does not typically include the integration of chiropractic, it is unreasonably discriminatory, not cost-effective and potentially monopolistic to make chiropractic services available to the health consumer only on medical prescription.

9. The doctor of chiropractic, as with all licensed health care providers, is obligated to seek

consultation with or referral to other appropriate health care providers (e.g. MD, dental, chiropractor) if a patient’s complaints or condition are not suitable for that chiropractor’s care.

10. In the interest of providing quality health care there should be an established

peer/utilization review mechanism for all federally supported or administered health care programs. Where applied, peer review should be conducted by members of the same profession with consumer interests represented.

11. In the interest of quality assurance, there should be continuing education with

certification procedures that require demonstration of ongoing professional competency for all licensed health care providers.

12. In the advent of managed care there is evidence that some health care professionals or

specialties are still numerically deficient or inadequately distributed. Most of these shortages occur in those providers that supply first contact (portal of entry) care. Since chiropractic serves as a first contact health care profession it is in the public interest to provide federal funding for chiropractic education. Such educational support should be universal for all underserved professions with obligations for those who accept this support to provide service for an appropriate period in underserved geographic areas at a reasonable remuneration.

Additionally, in post-graduate programs where there is federal support or special incentives to universities that provide these programs there should be emphasis to make these programs non-discriminatory. Therefore, these programs should be equally

8available to all licensed health care professionals. (Ratified by the House of Delegates June 1998).

CONTINUING EDUCATION, IN-PERSON CLASSROOM STUDY Resolved, the American Chiropractic Association supports in-person classroom study annually for relicensure and encourages doctors of chiropractic to attend local, state, and national meetings to foster better understanding, cooperation, and unity within our profession. (Ratified by the House of Delegates, March 2002). CULTISM Resolved, that the ACA disassociate itself from cultism and trade practices in keeping with the standards and conduct of a scientific branch of the healing arts, and shall sever all bonds of association or activity which would detract from our identification with scientific objectives. (Ratified by the House of Del-egates June 1965). CURRENT PROCEDURAL TERMINOLOGY (CPT) Current Procedural Terminology (CPT) has been devised to “provide a uniform language that will accurately designate services and will thereby provide an effective means for reliable nationwide communication among physicians, patients and third parties.” Health care providers have utilized this CPT system since 1966 to describe their services, and such specific description of services is usual, customary, reasonable, appropriate, accurate and equitable. Many in-state and out-of-state review organizations arbitrarily delete the “office call of the day” (900XX series) as non-reimbursable, since the chiropractic profession has not set a policy on this matter. Many chiropractic physicians consistently utilize only one code, such as 97260, billing in a global fashion and failing to itemize specific services. This may result in the inequitable practice of rendering a uniform charge to all patients, thus under-charging or over-charging certain patients who undergo differing procedures. Therefore, be it resolved that ACA encourage the correct itemization of services and procedures under accepted CPT code numbers, in accordance with federal and state statute or administrative rule. (Ratified by the House of Delegates, June 1991). For additional information, a CPT Recommendations Booklet is available from ACA. CURRENT PROCEDURAL TERMINOLOGY (CPT) AUDIT Resolved, that ACA adopt as ACA policy the audit requirements used by physicians for the CPT evaluation and management codes. These audit requirements are to be reviewed for updates as appropriate by the insurance committee. (Ratified by the House of Delegates, June 1997). CYTOTOXIC LEUKOCYTE TEST ACA recommends that the cytotoxic leukocyte test be considered experimental, and that without stronger evidence from well-designed controlled clinical studies, the procedure not be employed in the evaluation of patients suspected to have adverse reactions to foods. The test lacks acceptable sensitivity, and its use may result in a high number of false positive findings. Moreover, there is evidence that the procedure is of limited value in confirming the presence of food allergy and other adverse reactions.

9 The cytotoxic leukocyte test is also tedious and time-consuming, two factors that render the procedure impractical and costly. Interpretation of the test is also highly subjective so that the training and experience of technicians performing the procedure may assume major importance with respect to its accuracy and reproducibility. (Ratified by the House of Delegates, June 1986). DCM DEGREE Chiropractic, as defined in the ACA Master Plan relating to education, experience, and training is sufficient to define the precepts, tenets and responsibilities of the practitioner and the profession. Any effort to develop a Doctor of Chiropractic Medicine (DCM) degree is not necessary and may in fact be in conflict with some existing state scope of practice laws. (Ratified by the House of Delegates, July 1994). DIAGNOSIS When a doctor of chiropractic clinically observes a condition in a patient, he seeks to find why, just as is done in physics, chemistry, and medicine. After such clinical observations are made, an attempt is made to explain the condition by a hypothesis. Such hypotheses are found in chiropractic literature under the heading of “Chiropractic Principles or Philosophy”, but they are chiropractic hypotheses. The probability or non-probability of the hypothesis does not alter the chiropractic clinical facts, for the hypothesis is simply an interim attempt to explain the etiology of the clinical fact. Chiropractic treats the ailment disclosed by the clinical facts, not by hypothesis. The patient’s needs are met by the clinical efficacy of chiropractic, not by conflicting arguments on hypothesis. Every chiropractic college teaches physical examination and diagnostic procedures and examines (or tests) in physical, clinical, laboratory, and differential analysis, in addition to chiropractic analysis. Before receiving a license to practice chiropractic, candidates are examined in diagnosis either by official state boards or by the National Board of Chiropractic Examiners, or both. The chiropractic curriculum is oriented toward patient management, that is, to the recognition of the measures best suited to the restoration and maintenance of the patient’s good health (whether such mea-sures are applied by a doctor of chiropractic or by another health professional on referral). Present day chiropractic does not hold that the subluxation is the only cause of disease. Whatever may have been said in chiropractic literature years ago, today’s chiropractic education and practice recognizes multiple causes of, and multiple methods of treatment for, disease. The doctor of chiropractic must first evaluate the needs of the patient before administering any type of care. If he should determine that the case is within his scope, he proceeds to provide appropriate care. But if he determines that the patient requires another type of care, he refers the patient to that method which he believes is most advantageous. (Chiropractic White paper, May 1969, Board approved, July 1975). DIAGNOSTIC ULTRASOUND OF THE ADULT SPINE

10Diagnostic Ultrasound has been shown to be a useful modality for evaluating certain musculoskeletal complaints. Fetal, pediatric and intra-operative applications have been published in the scientific literature. The quality of ultrasound images is extremely dependent on operator skill. The resolution abilities of the equipment may have an impact on diagnostic yield and accuracy. Consequently, the importance of training to establish technologic as well as interpretive competency cannot be understated. The application of diagnostic ultrasound in the adult spine in areas such as disc herniation, spinal stenosis and nerve root pathology is inadequately studied and its routine application for these purposes cannot be supported by the evidence at this time. Be it further resolved that the House of Delegates recommend the American Chiropractic College of Radiology re-evaluate annually diagnostic ultrasound and report to the House of Delegates. (Ratified by the House of Delegates, May 1996). DISASTER SCENE PRIMARY CARE PROVIDERS Resolved, that the ACA seek to gain national and state recognition for doctors of chiropractic to serve in disasters and seek to establish a protocol for doctors of chiropractic serving as primary care providers at the scene of disasters. (Ratified by the House of Delegates, August 2002). DOCUMENTATION Resolved, that the American Chiropractic Association support the following:

Clinical (Medical) Documentation Recommendations Based on these findings and trends, the ACA recommends certain basic requirements be considered as appropriate medical documentation in patient record keeping. A concerted effort by the chiropractic profession to standardize medical documentation will improve the frustration level and reimbursement experience exponentially.

1. The nationally accepted HCFA billing 1500 form must be completed in detail. This means all required fields must be completed.

2. Subjective, Objective, and Treatment, if rendered, components should be incorporated into patient records on each visit. A customized format is not needed but these elements must exist consistently. Any significant changes in the clinical picture (e.g. significant patient improvement or regression) should be noted.

3. All ICD-9-CM diagnosis codes and CPT treatment and procedure codes must be validated in the patient chart and coordinated as to the diagnoses and treatment code descriptors.

4. Uniform chiropractic language should be used within the profession for describing care and treatment. Non-standard abbreviations and indexes should be defined.

5. Documentation for the initial (new patient) visit, new injury or exacerbation should consist of the History and Physical and the anticipated Patient Treatment Plan. The initial Treatment Plan except in chronic cases should not project beyond a 30-45 day interval. Subsequent patient visits should include significant patient improvement or regression if demonstrated by the patient on each visit. As the patient progresses, the treatment plan need to be re-evaluated and appropriately modified by the treating doctor of chiropractic (chiropractic physician) until the patient can be released from care, if appropriate.

6. If the patient is disabled, a statement(s) on the extent of disability and activity restriction is needed at initial and subsequent visits as appropriate over the course of care.

117. Records can be attached to each billing to pre-empt requests, however, it is not mandatory.

Local insurers should be contacted for preferences (i.e., No fault PIP insurers may require records every visit while health insurers may not).

8. All records must be legible and understandable, released within the authority given by the patients, in a secure confidential manner, and in compliance with existing state (or federal) statutes.

9. The patient name and initials of the person making the chart notation (especially in multi-practitioner offices) should appear on each page of the medical record.

10. If the above recommendations have been met then the answers as to why the necessity for continuing treatment is answered.

11. The insurance industry must improve their claim adjusting procedures by utilizing chiropractic consultants. The ACA can use its resources to assist in this initiative. (Ratified by the House of Delegates, September 2000).

Resolved, that the American Chiropractic Association through the Insurance and Managed Care Committee work with the different third party payors to establish and utilize a uniform set of forms, when additional documentation is required by the third party payor in support of claims submission. (Ratified by the House of Delegates August 2002) DOMESTIC VIOLENCE LEGISLATION – SPOUSAL AND ELDER Resolved, that the American Chiropractic Association encourage the federal legislature and all state legislatures to enact domestic violence legislation mandating physician reporting, to the appropriate legal authorities, of suspected domestic violence, co-habitant/spousal or elderly. Be it further Resolved, that the domestic violence legislation should include a physician indemnification section regarding the reporting of suspected domestic violence to protect the physician against any retaliatory action that might be taken against the physician for the act of notification. (Ratified by the House of Delegates, August 1999). EARTH DAY Resolved, that the ACA does pledge support to “Earth Day” and such other public health endeavors as may arise. (Ratified by the House of Delegates, June 1970). ELECTRONIC TEXTBOOKS Resolved, the American Chiropractic Association actively pursue and promote a relationship with schools and textbook publishers to develop electronic copies of textbooks on DVDs or other such appropriate electronic means for students to use as a second text copy as a means to limit the weight of backpacks. (Ratified by the House of Delegates August 2002) ERISA (EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974) AMENDMENT Resolved, that the American Chiropractic Association continue its efforts to amend the Federal ERISA (Employee Retirement Income Security Act of 1974). ACA will continue to explore state legislation which is corrective of problems related to self-funded plans, and will consider legal avenues to challenge the ERISA pre-emption similar to challenges in Massachusetts, Pennsylvania and Michigan. (Ratified by the House of Delegates, July 1987). ETHICAL CONDUCT

12 Resolved, that the ACA vigorously condemns suggestions which infer the application of chiropractic treatment primarily for personal monetary gain rather than for the patients' health, safety and welfare. Resolved, further, that the ACA emphasizes the highest ethical conduct in both research and patient care. (Ratified by the House of Delegates, June 1982). EXERCISE, PHYSICAL FITNESS Because doctors of chiropractic know that physical fitness is an essential part of wellness, and a lack of exercise contributes to obesity, cardiovascular disease, osteoporosis and other health problems, the American Chiropractic Association recommends 20-40 minutes of daily exercise to help people regain and maintain physical fitness. As a precaution, before starting any exercise or fitness program, people should consult their health care practitioner to help determine their fitness level and how to start a fitness program for themselves without injury or health risk. (Ratified by the House of Delegates, June 1997). FEDERAL ADMINISTRATIVE RULINGS Resolved, that the ACA develop a mechanism to effectively challenge adverse federal administrative rulings, as they are made, and attempt to furnish input from our profession into these rulings. ACA will also aggressively challenge any current adverse Federal administrative rulings. (Ratified by the House of Delegates, July 1987). FEES Professional Services The ACA holds the position that professional fees charged by the chiropractic physician and paid by the patient are a part of the doctor-patient relationship and does not advise nor condone interference with this relationship or other contractual relationships of the respective parties. Reimbursement where third-party contracts call for reimbursement on the basis of usual, customary, and reasonable should be consistent with the customary fees of the profession in a given geographical and/or socioeconomic area. Current reimbursement policy for chiropractic services under Medicare is not consistent with customary chiropractic practice. Such policy creates an economic hardship for the Medicare recipient and deprives the recipient of the greater benefits, which are available through customary chiropractic diagnostic and therapeutic procedures. (Approved, July 1975) Third-Party Payers Resolved, that the American Chiropractic Association condemns the practice of arbitrarily limiting the scope of practice and/or professional care of Doctors of Chiropractic by any third party payer. These activities may represent a significant health hazard for patients who require chiropractic care. Doctors of Chiropractic should be allowed the latitude to employ the full scope of chiropractic services as established by their respective state statutes. Third party payers should reimburse for appropriate professional services performed by Doctors of Chiropractic if services performed by other physician-level providers are reimbursed for the care of same or similar conditions. Such professional services should be reimbursed in parity with the reimbursement levels of other physician-level providers. (Ratified by the House of Delegates, August 2001)

13Resolved, that the American Chiropractic Association investigate the feasibility and utility of a study to determine if the Chiropractic profession as a whole is receiving the same type of contractual arrangements as other providers and if there is a pattern of frozen fee schedules among third party payers, and to determine what the cost of living clauses are, if any, in the major third party payers for the chiropractic profession. (Ratified by the House of Delegates August 2002) Waiver (NOOPE) Resolved, that the ACA caution its members that it regards the practice of routine waivers of third-party payer deductibles and co-insurance amounts to be an unacceptable and possibly illegal method of patient inducement. A chiropractor should consult with his or her state licensing board, insurance carrier, Medicare/Medicaid carrier or personal legal representative to determine if such a waiver violates a statutory or regulatory prohibition. (Ratified by the House of Delegates, June 1990). FOOD LABELING Resolved, that ACA supports legislation and regulatory directives making food labeling more easily understood by the consumer and to more clearly describe the nutrients and additives in various foods and beverages. In addition, the ACA supports labeling of food and beverage products when such products may cause health problems or be hazardous for certain segments of the populous. (Ratified by the House of Delegates, June 1990). FRAUD AND ABUSE POLICY Resolved, that the American Chiropractic Association supports the attached “Policy Statement on Fraud and Abuse: Healthcare fraud is everyone’s concern. It exists, in some degree, in every Healthcare profession and in every area of the United States. As the nation’s foremost and largest professional chiropractic association in the country, the American Chiropractic Association (ACA) takes a strong position against any form of healthcare fraud. Healthcare fraud can be defined as wantonly misleading or misrepresenting patient treatment circum- stances or any other dynamic of the healthcare industry, resulting in any type of financial gain for the doctor, patient, or any other third party of entity. It is important to note that insurers who use unfair medical review practices that create obstacles to chiropractic access and reasonable and necessary care for patient constitutes fraud and abuse. The ACA opposes any type of fraud within the chiropractic profession and within the insurance industry; third party payors, managed care organizations or other entities where restrictive and unfair reimbursement practices toward the chiropractic profession exist. However, the ACA will continue to work with both the insurance industry to ensure the equal treatment of Doctors of Chiroproactic, and with the chiropractic profession to educate doctors as to

What may constitute fraud and/or abuse.” (Ratified by the House of Delegates, August 2001).

FRAUDULENT CURES Resolved, that the American Chiropractic Association support enforcement efforts against quack medicines, medical devices and other fraudulent cures that endanger the public health or substantially mislead consumers. (Ratified by the House of Delegates, June 1991). GENETICALLY MODIFIED PLANT TECHNOLOGY

14 Resolved, that the ACA adopted the following as its position on: Genetically Modified / Engineered Plant Technology: In consideration that genetically modified plant technology is at an early stage of development and since the scientific community acknowledges that the use of genetically modified plants is not without risk both to the environment and human health. The ACA supports the right of consumers not to be involuntarily subjected to possible risks by supporting the right of consumers to choose not to consume genetically modified foods through clear and informative labeling. The ACA supports strong and effective regulatory control with comprehensive long term monitoring as part of an ongoing assessment as to the possible adverse effects on the environment, food chain and human health. (Ratified by the House of Delegates, September 2000). References available on request. HEALTH CARE Cost Containment The American Chiropractic Association affirms the responsibility of the chiropractic profession separately and in concert with the allied health professions to provide all the people with optional and affordable health care under the democratic principles of freedom of choice and freedom from govern-ment control of the professions. The American Chiropractic Association will continue to work for meaningful cost containment within the framework of a free society and under provisions that apply equally and uniformly to all segments of our economy. (Board approved, June 1984). Paradigm Resolved, that the ACA reaffirm chiropractic’s leadership role in the promotion of the natural health care paradigm by: 1) Developing a presence in the appropriate periodicals, journals, and conferences 2) Taking additional steps to promote research beyond musculoskeletal conditions 3) Developing relationships through the media as experts in alternative and complementary

procedures 4) Developing a relationship with professional organizations to foster and exchange ideas and to

further understand their disciplines 5) Developing a committee to investigate and report to the public and our membership on

alternative and complementary health care techniques and procedures. (Ratified by the House of Delegates, June 1998).

HEALTH FACTORS Good health is not the equivalent of medical or health care for sickness. The health care system is not the only factor, which affects or determines the nation’s health. Good health depends on other factors such as

15 (1) Good housing and proper sanitary facilities, including waste water disposal and garbage

removal; (2) Good nutrition, including safe and healthful foods; (3) Good public environment, including freedom from air and water pollution, from toxic chemicals,

and from communicable diseases; (4) Good working environment, including freedom from exposures to industrial accidents and

occupational health hazards; (5) Good life style, including freedom from deleterious effects of smoking, drugs, and alcohol, and

reduction of traffic accidents and injuries; (6) Good health attitudes and widespread use of preventive health care techniques and facilities. In the long run, factors such as above outlined and others may be more important health programs than health care delivery itself, and the nation’s health care delivery system must be developed for appropriate coordination with all these factors affecting good health. Thus, good health is broader than the health care industry itself. Furthermore, good health is not dependent upon the control of any one segment of the health care industry over the other participants. The health care industry must not be subject to the monopoly of medical doctors; all licensed health care providers (including doctors of chiropractic) must be regarded as having a valid role to play in the health care delivery system, to the degree of their licensed authority. (Guidelines for National Health Planning Goals, Approved, November 1975). HEALTHY EATING Resolved, that the American Chiropractic Association recommend good nutrition and healthy eating habits to help prevent health disorders and maintain wellness. Healthy nutritionally sound eating should include foods high in fiber, such as whole grains, beans, legumes, fruits and vegetables, and a lowered fat intake (particularly saturated and trans fats). (Ratified by the House of Delegates, June 1998). Resolved, that the House of Delegates adopt the “Building Blocks for Healthy Eating” as the American Chiropractic Association’s dietary guidelines. (Ratified by the House of Delegates, August 1999). Note: Full text available from ACA. HIPAA Resolved, that ACA sort out the essential elements of HIPAA, which are relevant to our members. Be it further Resolved, that ACA offer a simplified, straightforward list of essential elements and action steps for compliance. Be it further Resolved, that ACA strongly encourage all ACA members to file an extension prior to October 16, 2002, to give them another year to become compliant with all final HIPAA issues. (Ratified by the House of Delegates, August 2002). HIV POLICY

16 The ACA recognizes that non-invasive chiropractic procedures pose no currently recognized threat of spreading HIV infection. Chiropractors performing invasive procedures should observe universal precautions as is standard in all the health care professions. No patient should be denied chiropractic care based on real or perceived risk for HIV infection. The license of HIV-infected chiropractors should not be restricted assuming they are capable of performing their duties in a responsible manner. Confidentiality of the HIV infection status of patients and staff must be maintained with disclosure limited to situations defined by local laws, statutes or regulations. The ACA encourages state chiropractic associations to conduct periodic HIV education sessions and to develop resources for chiropractors and their staff. Specific annual training mandated by OSHA must be provided by employers with employees whose duties put them at risk of exposure to blood borne pathogens. Patient education efforts are encouraged, as well. (Ratified by the House of Delegates, July 1994). (The text printed above is an abstract of a policy statement ratified by the House of Delegates, July 1994. A copy of the complete policy statement can be obtained from ACA Headquarters). HOSPITAL STAFF GUIDELINES Resolved, that the ACA adopt guidelines and a program for doctors of chiropractic seeking inclusion on the staffs of hospitals and other health care institutions. It is further recommended that the guidelines proposed hereafter be formally adopted as ACA policy for inclusion of the doctor of chiropractic in hospital staff privileges for the mutual benefits of the health care institutions and the chiropractic profession. The following guidelines are proposed for those chiropractors seeking to be integrated into the established hospital system. We must fit into the existing mechanisms, plans and protocols of hospital staffing. Hospital staff members generally stay within their limited specialties and call upon consultants for problems outside those specialties. Chiropractic doctors will secure entrance into hospitals only by working within the system. The logical point of entry is to seek admission for the neuromusculoskeletal disorders most commonly treated by the majority of our chiropractic colleagues. We would perform related examinations, order related X-rays, perform manipulative procedures (adjustments), order physical therapy, and other supportive measures all within the scope of existing state laws governing the practice of chiropractic. In conjunction with the committee’s general objectives and stated guidelines, additional currently limited objectives are recommended: Within the legal scope of practice, utilization of diagnostic facilities and procedures for responsible differential diagnosis as essential to management, co-management or referral of the patient. Utilizing chiropractic manipulation, physical therapy, external immobilization and nutrition where applicable.

17Providing, where needed, training in hospital protocol and procedures through CCE approved programs in our accredited colleges. Provide for screening procedures of chiropractic applicants with consideration of education, training, scope of practice, reputation and ability to work in harmony with medical and other hospital personnel. Referring to medical specialists for management of infectious, neoplastic or primary neurologic disease. (Ratified by the House of Delegates, June 1983). INFANT AND CHILD CARE The Doctor of Chiropractic gives particular attention to spinal biomechanics (including the subluxation complex), musculoskeletal, neurological, vascular, nutritional, and environmental relationships in the restoration and maintenance of health. Infant and childcare is included in the scope of care provided by the chiropractic profession, as taught in and through accredited colleges of chiropractic. These colleges teach physical examination, diagnostic procedures, and patient management skills necessary for the quality care of children. The chiropractic profession recognizes that poor posture, and physical injury, including birth trauma, may be common primary causes of illness in children, which can have a direct and significant impact on not only spinal biomechanics, but on other bodily functions. The American Chiropractic Association advocates, endorses and supports the freedom for all persons to seek health care from the provider of their choice. This policy statement must be interpreted and be subject to appropriate companion policies as published by the American Chiropractic Association. (Ratified by the House of Delegates, July 1994). INFANT SLEEPING POSITION The ACA encourages member doctors to recommend to their patients to have their infants placed on their back for sleeping, unless otherwise indicated. (Ratified by the House of Delegates, March 2001). INFORMED CONSENT Informed consent is generally applied, from a legal standpoint, when measuring the degree of responsibility and/or liability of a doctor in malpractice cases. In other words, the fact that a patient submits to treatment and does so voluntarily does not in itself lessen the liability of the doctor. Today, the stand by which the doctor is judged is that of “informed consent”. By that is meant, to what degree has the patient been informed of all of the potential consequences, dangers, and other factors, so that his consent is given with full knowledge of the inherent dangers to which he is exposed. Full knowledge in this sense could be construed as “informed consent” and would relieve the doctor of much liability, as there would be an assumption of the risk on the part of the patient. The concept of “informed consent” can also be applied to other contractual relationships such as those for examination and treatment, which are every day occurrences in the doctor’s office. (Approved, July 1975). INFORMED CONSENT REGARDING EXPERIMENTAL TREATMENT

18Any procedure not taught in a chiropractic college maintaining a standard of reputability and training with the U.S. Department of Education should be considered experimental and the patient should be so informed. (Board approved, June 1983). INFRARED IMAGING High Resolution Infrared (HRI) Imaging (electronic infrared imaging) is a diagnostic procedure, which measures skin surface temperature. It is a germane to chiropractic practice in cases where a physiologic test is required for the diagnosis of selected neurological and musculoskeletal conditions. High Resolution Infrared Imaging requires a high level of operator and interpreter competency and an adherence to established and consistent protocol. The results of High Resolution Infrared Imaging must be properly correlated with a thorough history, an appropriate clinical examination, and other diagnostic studies/ tests as may be indicated by clinical necessity. In this setting, High Resolution Infrared Imaging may be an aid in establishing a differentiated diagnosis and in determining a prognosis. Guidelines for Infrared Imaging in Chiropractic Practice Infrared Imaging is a diagnostic procedure, which measures skin surface temperature distribution. This diagnostic imaging procedure is germane to chiropractic practice in cases where a physiologic test is required. High Resolution Infrared (HRI) Imaging is a useful procedure for the diagnosis of selected neurological and musculoskeletal conditions. The treating doctor shall certify as to the medical necessity of the infrared imaging study based upon a diagnostic clinical question and the effect of the results on case management decisions. The referring doctor shall certify to the medical necessity by prescription. HRI Imaging is of value in the diagnostic evaluation of patients when the clinical history suggests the presence of one of the following situations: 1. Early diagnosis and monitoring of reflex sympathetic dystrophy syndromes. 2. Evaluation of spinal nerve root fiber irritation and distal peripheral nerve fiber pathology for

detection of sensory/ autonomic dysfunction. 3. To evaluate and monitor soft tissue injuries, including segmental dysfunction/ subluxation,

sprain and myofascial conditions (strains and myofascial pain syndromes) not responding to clinical treatment.

4. To evaluate for the physiological significance of equivocal or minor anatomical findings seen on

Myelogram, CT and/or MRI. 5. To evaluate for feigned disorders. Because of the detailed knowledge, training, and skill level required, infrared imaging studies ordered, produced or interpreted by chiropractic physicians must be reviewed only by a licensed chiropractor who holds appropriate credentials with regard to knowledge, skill and experience in infrared imaging. Only licensed chiropractors holding such credentials can claim sufficient competence to make valid judgments of comments regarding appropriateness, necessity, or accuracy of infrared imaging studies,

19and their relevance to chiropractic case management. (Ratified by the House of Delegates, June 1991; amended August 1999). INSURANCE ACA Coding Policies Resolved, that the American Chiropractic Association approves of the following list of policy and position statements relating to coding: Inappropriate X-Ray Bundling, Down-Coding and Bundling, CPT 97012 Mechanical Traction, Properly Appealing CCI Edits, Testing and Measurement Codes, Troubleshooting CCI Edit Denials, 2001 Radiology Code Clarifications, Physical Medicine Modalities, Tens Unit Professional Component, CPT 97010 Hot/Cold Packs, CPT 97124 Massage, and be it further Resolved, that the American Chiropractic Association acknowledges that insurers should recognize the legitimacy and accuracy of these policy and position statements. [full text available on request or check the ACA website] (Ratified by the House of Delegates, August 2002). Blue Cross & Blue Shield Resolved, that the ACA consider the following to be key outcome measures of the success of the clinical integration process: 1. The adoption of the Medicare RVRBS fee schedule with fee conversion factors equal to other

physician providers. 2. Reimbursement for the full scope of chiropractic practice established by state licensing law. 3. Appointment of chiropractors to BCBS Credentialing, Quality Review and other policy-making

panels. (Ratified by the House of Delegates, August 2002). Contract Exclusions The ACA is opposed to the contractual exclusions of diagnosis and manipulation of subluxation as presently written into various insurance contracts. The ACA Insurance Committee is directed to pursue every conciliatory and/or legal means to alleviate these restrictive contract riders without compromise of cost, peer review, or physician responsibility to his patient. (Approved, February 1975). Discount “Benefit” Plans Resolved, that the ACA is on record in opposition to these various discount schemes which are proposed to the public and the profession as “benefit” programs for Chiropractic, which result in the employer, the HMO or the insurance companies having no financial outlay for these services they purport to provide and which provide for doctors to discount their services and enrollees to pay for those discounted services out of pocket, and, be it further Resolved, that the ACA will notify these insurers that are promoting these discount Chiropractic services as real Chiropractic benefit plans to include Chiropractic Health Care in their core benefit package as described in ACA’s mission statement, legislative agenda, and long-range plan. (Ratified by the House of Delegates, March 2000). Equality A consumer’s freedom of choice to select among all state-licensed health care providers is an essential attribute of any effective and responsive national health goal. Currently, the right to choose chiropractic

20treatment is currently protected under the laws of 45 states. These laws have come under attack as mandating additional benefit and therefore additional costs. These laws, in fact, only provide the basis for the provision of alternative rather than additional services. Resolved that the ACA adopt the following Position Paper on State Insurance Equality: There is currently underway an effort by certain vested interests in the insurance industry and by certain others (United States Chamber of Commerce and many of its constituent and component state and local chambers) to repeal “state mandated” insurance benefits. Such efforts are either self-serving (carrying profit motives in the instances of the former) or based on inaccurate information in the latter. Led by Sen. Edward Kennedy (D-MA), legislation has been introduced in the United States Congress to force small businesses to provide health care coverage for any employees who work more than 17.5 hours per week and to pay the premiums for such coverage (minus deductibles and co-insurance). Driven by this legislation, the insurance industry and others have mounted opposition to its passage based on the argument that such “additional” coverage as mental health, podiatry, optometry, nurse midwifery, chiropractic services and drug-dependency programs (plus almost 700 others) could only be included at a confiscatory cost to small businesses. Many of these services are now “mandated” by certain state laws. To understand the confusion created, one must see the difference between what is an add-on service (costing additional monies/ premiums) and what is a displacement service (the same covered service but one possibly being provided by an alternative, state-authorized health care provider). State laws that seem to mandate certain health care services often do not do so; rather, they “mandate” non-discrimination. In other words, they mandate that a privileged economic position -- a competitive advantage -- will not be given to one class of state authorized health provider over another. Such laws paraphrased say this: “Any health benefit covered under an insurance policy that reimburses for treatment of a particular type of health condition when provided by one class of authorized health care practitioner must be reimbursable when provided by any health care practitioner licensed to provide such service.” The law does not even mention any practitioners or any health condition. It is anathema, however, to any group, which hopes to hold an exclusive economic “right” to the entire health care field. To state the practical impact of a state law such as quoted above, we would see that if an insurance policy already covers the examination of the eyes and the provision of corrective lenses when done by an ophthalmologist, then it must pay for these same procedures when performed by an optometrist (both ophthalmologists and optometrists are licensed by the state to provide these services). This nondiscrimination statute does not cost any business (or an insurance company) additional money since going to the optometrist for these services displaces the need to seek the same services from the ophthalmologist (M.D).; in fact, the net cost may be lower because of the competition involved. If an insurance policy pays for treatment of back conditions by an osteopath or a competing orthopedic surgeon, then it must pay for the same health condition when provided by a chiropractic physician (under the law). A different service is not being provided; only a different health care provider is being reimbursed. The competition is obvious, as are the resulting lower net costs, including less cost to the patient, less cost to the employer, less loss of time on the job to the employee and less pain to the employee. The net result is a cost saving rather than an added financial burden. The costs of health care are burgeoning, taking an ever-larger portion of the nation’s gross national product. Now is the time to look more aggressively at the savings, which can be realized by the use of alternative, reliable (chiropractic care has the lowest incidence of adverse side effects of any known medical modality) and more economical health care services. Each time the argument is made against “state mandated” health care benefits, the listener should ask the question, “is this benefit reimbursed if it is provided by a certain privileged group of practitioners or is it not reimbursable under any conditions?” If the answer reveals

21that competition exists in the system, then, like the United States Congress long ago stated competition will provide us with the most efficient, quality oriented and lowest cost health care any-where. (Ratified by the House of Delegates, June 1990). Inclusion Resolved, that the ACA work for the inclusion of chiropractic in all public and private health programs by name, when possible. (Ratified by the House of Delegates, June 1975). INTRAPROFESSIONAL POLICY The American Chiropractic Association accepts all the responsibilities to society that are required of the chiropractic profession. ACA reaffirms its position that chiropractic must be preserved as a separate and distinct branch of the healing arts. The position of the American Chiropractic Association is as originally established and annually reaffirmed that the individual doctor of chiropractic (chiropractic physician) has the privilege and the obligation to practice in accordance with his education received in a recognized college of chiropractic and in accordance with the statutes of the state in which he practices. The American Chiropractic Association extends an open invitation to meet with any other chiropractic group or organization to discuss, in accord with the statements above, those other items upon which they feel compelled to negotiate agreement in order to achieve a unified profession. The American Chiropractic Association will continue its program for greater recognition and acceptance of the profession to the ultimate benefit of health service to the public and doctors of chiropractic (chiropractic physicians) everywhere. The American Chiropractic Association will continue to work with and aid all state associations to develop their individual programs. The American Chiropractic Association believes this is the best course for professional progress and invites all doctors of chiropractic (chiropractic physicians) to unite in this effort. (Adopted by the House of Delegates, June 1967,reaffirmed, June 1985, July 1993, July 1994, June 1995, May 1996, June 1997, June 1998, reaffirmed and amended August 1999, reaffirmed September 2000, September 2001, August 2002). LASER FACE-LIFT The ACA has noted for some time the use by some D.C.s of laser devices for non-surgical face-lifts. The FDA has ruled that such devices are in Class III, which requires FDA’s formal pre-market approval, which has not yet been granted. While Class II devices do not appear to present any direct health hazard, Class III devices could cause severe eye injury according to FDA. Until FDA approves such devices, and until appropriate state bodies determine that such therapy may legally be provided by D.C.s through either Class II or Class III devices, ACA calls upon chiropractic colleges to seek to determine by appropriate research not only whether such devices are safe but also whether they are effective and are appropriate for use by D.C.s. Pending such approval and determinations, ACA recommends that, for the protection of patients and D.C.s alike, D.C.s should refrain from using these laser devices except for investigational purposes authorized under state and federal law. (Board approved, November 1982).

22 LICENSURE LEGISLATION Resolved, that the ACA recommend to each examining board and the Federation of Chiropractic Examiners standardized licensure legislation and universal acceptance of the National Board of Chiropractic Examiners. (Ratified by the House of Delegates, July 1974). LIVING WILLS The American Chiropractic Association endorses the efforts by the various states to enact legislation that will guarantee a patient the right to execute an advance directive concerning their possible medical care through “living wills” or other comparable documents. In addition, the ACA endorses the efforts to assure that a properly executed advance directive in one state is given full recognition in all other states. (Ratified by the House of Delegates, May 1992) MANAGED CARE Direct Access Resolved, that the ACA must develop the background research and statistics relative to the quality and effectiveness of care in managed care programs that eliminate or restrict the use of chiropractic care verses those that allow direct access. Be it further Resolved, that the ACA must aggressively pursue the implementation of direct access as an essential model in the managed care industry. Be it further Resolved, that the ACA should strive to create a general understanding in the minds of all health professions, legislators, employers, payors and the general public the devastating impact medical gatekeepers have on the ability of patients to access doctors of chiropractic. Be it further Resolved, that the ACA should develop data, strategies and methods of implementation to ensure direct access as a universal managed care model. Be it further Resolved, that the ACA should enlist the help of interested parties, including consumers, legislators, employers, payors and health care providers in pursuing direct access. (Ratified by the House of Delegates June 1998). Resolved, that the ACA actively seek to have doctors of chiropractic included on managed care organization panels on a direct access basis, and on managed care organization’s medical advisory committees, medical credentialing committees, etc. This will ensure chiropractic availability for the health consumer. (Ratified by the House of Delegates August 1999). Discriminatory Practices Resolved, that the ACA vehemently opposes these harmful and discriminatory practices, including but not limited to: limiting full scope of practice, inappropriate CPT applications and reimbursement policies, use of discount/affinity programs, restrictive limits of care, and improper utilization review. Be it further resolved that ACA staff and leadership are directed to communicate our concerns to the profession; obtain detailed data on these abuses; develop and implement a plan to halt these unfair practices; and give a status report in August 2002 and at each subsequent House of Delegates meeting. (Ratified by the House of Delegates, March 2002).

23 Educational Requirements Resolved, that the American Chiropractic Association House of Delegates adopt the following policy position:

ACA opposes any attempt to impose artificial educational requirements beyond those established by colleges accredited by the Council on Chiropractic Education and state licensing boards, as criterion for credentialing as a provider in any managed care or third party payor plan. Such artificial educational requirements serve as an improper restraint on the ability of a licensed doctor of chiropractic to freely practice his profession. (Ratified by the House of Delegates, June 1998).

Malpractice Levels Resolved, that in response to ACA member concerns regarding the requirement of high levels of malpractice insurance required by managed care organizations and the substantial cost incurred by ACA members to meet these inflated requirements, the ACA makes the following statement: 1. For the protection of the patient and the doctor of chiropractic, doctors of chiropractic should

purchase and be covered by malpractice liability insurance; 2. The ACA calls upon all managed care organizations to justify to the doctor of chiropractic the

necessity of their required levels of malpractice liability. (Ratified by the House of Delegates, June 1998).

Providers The use of specialty board certification as a criterion for inclusion in managed care would discriminate against, create an artificial barrier to, and preclude the use of the vast majority of quality-based and qualified, doctors or chiropractic. It is the policy of the American Chiropractic Association that specialty board certification should not be a criterion for membership as a provider in any managed care or third party payer’s plan. The American Chiropractic Association opposes any attempt to impose any artificial standard of qualification as a criterion for credentialing participation by DC’s in health care plans. (Ratified by the House of Delegates, June 1997). Resolved, that in keeping with current policy of the American Chiropractic Association that specialty councils and their members adhere to the policy that specialty board certification not be a criterion for membership as a provider in any managed care or third party payer plans and that the councils promote the use of all doctors of chiropractic in all managed care and third party payer claims. (Ratified by the House of Delegates, August 1999). Resolved, that the HOD, in order to develop an improved platform of managed care, adopts the Matrix and instructs staff and leadership to seek out and promote those networks that agree with these responsibilities, as evident in their policies and operational procedures.

ACA/Chiropractic Network Professional Responsibility Matrix

24The American Chiropractic Association (ACA) and chiropractic networks have common interests in finding ways to cooperate with one another. Those interests center on the value in selecting chiropractic care and the patient’s ability to obtain direct access to a doctor of chiropractic and quality care within payer plans. To further the market value initiative, a forum has been established for the ACA and chiropractic networks to discuss issues of common interest and seek the greatest good for the patient. It is understood there are various market factors for both the networks and plan providers that need to be fully assessed as this collaborative initiative moves forward and that each group needs to assist the other in that regard. The following matrix identifies major priorities and serves as a roadmap to an improved business relationship to benefit the chiropractic patient and the advancement of chiropractic in insurance paid plans. This is a living document to represent the beginning of a process to be improved upon over time. It is fully understood that market forces and membership concerns may be at cross purposes at times but more good is gained in collaborative efforts than adversity.

(Ratified by the House of Delegates August 2002) [Full text available on request] MANIPULATION QUALIFICATIONS Resolved, that the ACA inform the American public that there are inherent dangers in the misuse of the manipulative adjustment by persons other than those adequately trained and qualified by due educational and examination process. (Ratified by the House of Delegates, July 1971). Resolved, that the ACA considers the use of manipulative adjustments by persons with less training than that required in the core curriculum of approved chiropractic, or osteopathic educational institutions to be a danger to the public health, safety and welfare. (Ratified by the House of Delegates, June 1984). MEDICAL NECESSITY Third-party contracts usually call for a direct relationship between covered services and medical necessity. There is also much concern in this area by federal and state legislators, particularly as it pertains to quality assurance and professional standards review organizations. The ACA agrees that there should be a responsible position relative to this by our profession and has researched the subject as it is understood by numerous of the third-party payers. The ACA position refers to those appropriate examinations, therapeutic substances, and treatment procedures that are used by licensed practitioners to diagnose and treat patients with a specific condition. Implied is the fact that the condition be a recognized one and that the examinations, tests, therapeutic substances, and treatment procedures used are based on scientific principles and studies, are generally accepted by the profession as being needed, essential, and appropriate to properly diagnose and treat patients with the particular condition. Quality and quantity of examination and therapeutic procedures must be within the norms and/or criteria established by the profession as a whole for such a condition. Implied also is the fact that there must be documentation in the medical records and/or reports to substantiate the need for the services rendered. (Approved, July 1975). Resolved, that medical necessity should be based on a standard that is tied to principles of professional practice as accepted by the particular field of professional practice. Health plans should be prohibited from interfering with medically necessary care as determined by the treating health care provider acting within the scope of his or her practice. The patients of all health care providers should have the right to receive medically necessary care as determined by their practitioners. This position should also be included in the list of patient protections in any managed care legislation that is passed by Congress. (Ratified by the House of Delegates, August 1999). MEDICAL QUALITY Resolved, that the ACA adopt the following professional policies and definitions concerning standards of care, the medical decision-making process, development and usage of practice parameters for medical

25quality decision-making, the definition and application of medical necessity, cost-benefit analysis in health care, limiting health care benefits, appeals of determinations not establishing medical necessity, the effect of the medical review process on the clinical practice of medicine, the definition of medical quality, documentation, physician, physician advisor and economic credentialing, report cards/profiling and outcome data, the provision of specialty medical care, gag clauses, financial incentives that impact upon medical decision-making, compliance with the medical review process, standards of medical quality review systems, the definition and application of experimental or investigational medical services and supplies, and medical expert consulting/testifying. And, be it further Resolved, that these policies and definitions do not represent, nor are they intended to be, Standards of Care. And, be it further Resolved, that these policies and definitions do not supersede any established governmental laws, official administrative regulations or judicial rulings. Resolved, that these policies are developed with a general reference to all health care providers. Therefore, all references to medicine or medical and physician are universal and interchangeable with doctor of chiropractic (chiropractic physician, chiropractor) respectively. (The text printed above is an abstract of a policy statement ratified by the House of Delegates, August 1999. A copy of the complete policy statement can be obtained from ACA Headquarters). MEDICARE Change in Statutory Wording Resolved, that efforts be made by the ACA, when and as appropriate, to amend the involved clause in the Medicare law to strike “to correct a subluxation” and insert “for treatment of subluxations and symptoms referable to same”. (Ratified by the House of Delegates, June 1983). Fee Schedule The Physician Payment Review Commission has adopted the policy of eliminating “specialty differentials” in the Medicare fee schedule, and the ACA testified before the PPRC in support of the elimination of Medicare specialty differentials. The ACA believes doctors of chiropractic are either equally or better trained than M.D.s, D.O.s, or P.T.s in performing manipulative services. The PPRC has recognized the distinction between chiropractic and medical manipulation in its 1990 Report to Congress. The PPRC has proposed to institute this recognition through the creation of “a separate budget neutral fee schedule that incorporates a geographic adjustor . . . constructed for the single chiropractic service covered by Medicare.” Based on the recognition that chiropractic manipulation is distinct from any other manipulation, the Medicare system has no basis for continuing to deny the provision of chiropractic services to Medicare HMO patients. Resolved, that any fee schedule should reimburse chiropractic manipulation at a rate equal to or higher than, but in no instances less than, the rate paid for M.D.s, D.O.s or P.T.s manipulative services. (Ratified by the House of Delegates, June 1990). Health Subcommittee Recommendations

26A joint statement of the American Chiropractic Association and the International Chiropractors Association submitted to the Subcommittee on Health, Committee on Ways and Means, House of Representatives on Medicare, concluded that if the ACA/ICA recommendations are adopted, the following legislative changes would result: (1) The authorization of the payment to beneficiaries for x-rays performed or required by doctors of

chiropractic and for physical examination (and related routine laboratory tests) for the purpose of determining subluxations and/or referral to other health care providers;

(2) The authorization of doctors of chiropractic to demonstrate the existence of spinal subluxations

by “other chiropractic procedures”, as well as by x-ray, therapy avoiding unnecessary radiation to patients; and

(3) The authorization for doctors of chiropractic to interpret their x-rays. (Submitted September

1975 and in similar language in June 1974). Reviews Resolved, that ACA will continue to be in contact with HCFA for clarification of why the chiropractic consultants are not used in the review process, why the GA modifier is being ignored during the prepayment review, and why the denial rate is so high for chiropractic claims, even for a new patient. (Ratified by the House of Delegates, September 2000). MILK Because whole and 2% milk are leading sources of saturated fat in American’s diets, the American Chiropractic Association supports the consumption of 1% or skim milk (after the age of two years) as part of a healthier lifestyle when choosing to drink milk. (Ratified by the House of Delegates, June, 1997). MONO-CAUSAL CONCEPTS Resolved, that the House of Delegates officially clarify its position and disaffirm the doctrine that holds to a singular approach to the treatment of disease. (Ratified by the House of Delegates, June 1975). NOMENCLATURE DEFINED The following chiropractic nomenclature was developed by ACA’s Task Force on Primary Care, and approved by the House of Delegates, to eliminate confusion within the profession about the true definitions of commonly used terms and phrases. Adjustment: Any chiropractic therapeutic procedure that utilizes controlled force, leverage, direction, amplitude, and velocity, which is directed at specific joints or anatomical region. Chiropractors commonly use such procedures to influence joint and neurophysiological function. Manipulable Subluxation: A subluxation in which altered alignment, movement, and/or function can be improved by manual thrust procedures.

27 Manipulation: A manual procedure that involves a directed thrust to move a joint past the physiological range of motion, without exceeding the anatomical limit. Manual Therapy: Procedures by which the hands directly contact the body to treat the articulations and/or soft tissues. Mobilization: Movement applied singularly or repetitively within or at the physiological range of joint motion, without imparting a thrust or impulse, with the goal of restoring joint mobility. Motion Segment: A functional unit made up of the two adjacent articulating surfaces and the connecting tissues binding them to each other. Spinal Motion Segment: Two adjacent vertebrae, and the connecting tissues binding them to each other. Subluxation: A motion segment, in which alignment, movement integrity, and/or physiological function are altered although contact between joint surfaces remains intact. Subluxation Complex: A theoretical model of motion segment dysfunction (subluxation), which incorporates the complex interaction of pathological changes in nerve, muscle, ligamentous, vascular and connective tissues. Subluxation Syndrome: An aggregate of signs and symptoms that relate to pathophysiology or dysfunction of spinal and pelvic motion segments or to peripheral joints. (Ratified by the House of Delegates, July 1994). NUTRITIONAL COUNSELING Resolved, that the House of Delegates adopt the following as the ACA position on nutrition: “Doctors of chiropractic (chiropractic physicians) are primary care physicians who have the requisite training and education to provide clinical nutritional counseling and interventions. (Ratified by the House of Delegates, September 2001.) ORTHOPRACTIC MOVEMENT Resolved, that the ACA view the “Orthopractic Movement” to be another attempt to limit or reduce the legitimate scope of chiropractic practice. Be it further,

28 Resolved, that the ACA House of Delegates direct the Board of Governors to take all appropriate legal, legislative and public educational efforts to preserve the integrity of the practice of chiropractic as embodied in the ACA Master Plan. Be it further, Resolved, that the [following] Notice to ACA Members concerning the use of the term “Orthopractor” or “Orthopractic” prepared by the ACA Legal Department be prominently displayed in all current ACA publications. Use of Term “Orthopractor” or “Orthopractic” by Chiropractor Recently, a Canadian organization has forwarded materials to various chiropractors around the country suggesting that chiropractors limit their practice of chiropractic. The materials outline specific limitations that a chiropractor should follow in order to be “designated” as an “orthopractor” and practice “orthopractic.” Please be advised that no state law recognizes or permits the practice of orthopractic. In addition, no state law recognizes or permits the use of the term orthopractor by a chiropractor. Such use may be construed by a state licensing board as a false, misleading and deceptive advertising claim and, in a worse case situation, the unauthorized practice of medicine or chiropractic without a license. Care should be taken by all ACA members to assure that they properly identify their position as a chiropractor, doctor of chiropractic or, in those states that permit such a designation, a chiropractic physician. In addition, while a chiropractor may be free to limit the range of treatment modalities utilized in patient care, he or she may nevertheless not limit his or her responsibility to properly diagnose and, if appropriate, refer a patient for specialized care. Any suggestion by the so-called orthopractic organization or any other group to the effect that a chiropractor may limit his or her diagnostic responsibility is fraught with potential problems to the chiropractor. Finally, the orthopractic materials recommend in the “eleven step approach” that practitioners “encourage all physicians to work only with orthopractic and not chiropractic.” Members should be aware that this type of concerted refusal to deal can constitute a group boycott in violation of federal and state antitrust laws. ACA members should consult with their state licensing board, malpractice insurer and private legal representative before attempting to practice as anything other than a chiropractor, under the duly constituted statute in the state in which he or she practices. Members should also consult with their private legal representative before engaging in concerted activity with any group that would limit the range of referrals. (Ratified by the House of Delegates, July 1994). OSTEOPOROSIS Resolved, that the American Chiropractic Association recognize and advise the public that: Osteoporosis is a silent insidious disease process, primarily of the post menopausal female, which if undiagnosed or untreated may lead to severe crippling and deformity. Its initial diagnosis may often be made by the chiropractic physician in sufficient time to arrest or hinder its progress.

29Its prevention is enhanced by timely and appropriate dietary recommendations, consideration of hormone replacement therapy if indicated, and common sense exercise. Its cure has yet to be identified, if by cure, it is meant the return to normal architectural strength and integrity of bone. (Ratified by the House of Delegates, June 1986). OWNERSHIP IN CLINICAL/THERAPEUTIC FACILITIES The ACA strongly discourages the referral of patients to clinical or therapeutic facilities in which the health care provider has ownership or investment interests, when that facility is outside the providers office practice at which he directly provides care or services. The ACA recognizes that financial interests in such facilities by referring health care providers may constitute an inherent conflict interest between the financial interest of the referring provider and the health interest of the patient. The ACA cautions its members that it regards financial conflicts of interest, which may increase the patient’s overall health care costs to be unacceptable. (Ratified by the House of Delegates, May 1992). PATIENT DISABILITY Sickness and injury in America account for more than 500,000 days lost from work each year (estimated by Bureau of Labor Statistics) at a cost to the country of over 21 billion dollars (estimated by National Safety Council). It is the best interest of both the employer and the worker that sickness absence be kept at the lowest level. Economists agree that better productivity per hour will be an essential feature of our nation’s effort to return to a stable economy. Less absence from work would contribute to the American Chiropractic Association’s effort to control cost of health care. Chiropractors are responsible for the amount of time an employee should be allowed to be away from work for the purpose rehabilitation. Resolved, that the American Chiropractic Association continues to encourage chiropractors everywhere to have their patients return to work at the earliest date compatible with health and safety. (Ratified by the House of Delegates, June 1982). PAYER MEDICAL REVIEW ACCOUNTABILITY Resolved, medical review functions performed by insurers and managed care companies or their agents may be necessary to determine financial liability and coverage issues on certain claims, however, it should not be a deterrent to patient access or prevent providers of care from rendering quality care. Implementation of medical review for all claims or classes or providers, or conditions treated by certain providers is objectionable and may not be prudent use of premium dollars. It can unnecessarily lengthen the claim settlement time for the insured patient, and burdens the provider with added administrative expenses. Furthermore, when medical review is provided in a discriminatory fashion, it may cause additional expense to the insurer or managed care organization. ACA believes it is necessary to have certain requirements in place when chiropractic policy and claim decisions are made to assure the claim is fairly evaluated by those who are knowledgeable and educated in current chiropractic science. These guidelines would apply to any payer, insurer, MCO or any health plan, medical coverage or fund including its claim management, adjusters, medical review staff, professional consultants, utilization reviewers or other agents or vendors of the insurer or company who develop medical review policy and make medical review determinations, especially as they pertain to chiropractic care claims. In order to have true review accountability by chiropractic consultants, there needs to be independence of the consultant. This can be accomplished when the consultant is chosen from a panel of volunteers independent from the patient or insurance company. The fee for the review would be paid by the person

30or company requesting the examination. If an insurance company picks from an established list of consultants and then pays to have the review performed, the selection process would be contrary to independence and/or objectivity. The full text of this policy including: Operational Philosophy, Compliance with State Laws and Regulations, Consultant and Independent Medical Exam Selection Criteria, Data Integrity and Treatment Provisions, Clinical Documentation, Appeal Process, Training and Referrals for Medical Review Fraud, and Communications and Coding, is available upon request. (Ratified by the Housoe of Delegates, August 2001). PEER REVIEW PANELS The ACA shall support, endorse and recommend to the states the development of non-profit peer review panels formed under the direct auspices and control of the state governmental agencies in order to minimize those inherent antitrust concerns related to the peer review process. The ACA shall also, through its legal department, make those informational resources available to the states upon request, to assist the states in the development of non-profit peer review programs under respective state authority. (Ratified by the House of Delegates, July 1987). PHYSICAL EXAMS BY D.C.S Numerous private, state and federal organizations require certain individuals such as truck drivers, interscholastic athletes, employees, youth camp and sports league participants to undergo physical examinations in order to be certified or eligible for participation. Because accredited chiropractic colleges which are approved by the Council on Chiropractic Education require proficiency in physical examination procedures, including the areas of cardiovascular, respiratory, renal, gastrointestinal, neurological, orthopedic and laboratory diagnostic procedures, the ACA reaffirms its position of support regarding the performance of physical examinations which require the examiner to diagnose the presence or absence of health conditions and illnesses. An ACA staff task force will be initiated to prepare a comprehensive report on the educational requirements of a doctor of chiropractic as they relate directly to the right to conduct physical examinations. Further, the task force will develop model legislation for use by state chiropractic associations, which would protect the rights of a doctor of chiropractic to perform physical examinations. The ACA will serve as a clearinghouse for information regarding programs and organizations that currently utilize doctors of chiropractic to conduct physical examinations including legal and attorney general opinions and other materials. (Ratified by the House of Delegates, June 1997). PHYSICIAN STATUS AT FEDERAL LEVEL Resolved, that ACA take steps to change federal statutes and regulations, which relegate DCs to anything less than “physician” status. Be it further, Resolved, that DCs be recognized as “physicians,” federally, as opposed to any other “health care provider” status. (Ratified by the House of Delegates, July 1995, reaffirmed August 1999) PHYSICIAN STATUS AT STATE LEVEL

31Resolved, that DC s be recognized as “physicians,” throughout the fifty states and District of Columbia, as opposed to any other health care providers. Be it further, Resolved, that ACA draft model legislation to be made available to state associations to maintain and expand DCs as “physicians.” (Ratified by the House of Delegates, July 1995 reaffirmed August 1999). POST-DOCTORAL EDUCATION Continuing Education Programs Resolved, that the ACA request the Council on Chiropractic Education join the American Chiropractic Association in a petition to the Federation of Chiropractic Licensing Boards seeking a uniform approval procedure for continuing education and convention programs conducted under the auspices of the CCE and its member institutions for the purpose of license renewal. (Ratified by the House of Delegates, July 1974). The ACA supports the position of the Council on Chiropractic Education on continuing education which states in part, “The Council holds that only academic institutions can and should conduct postgraduate courses and deplores the itinerant, privately conducted programs generally presented for private gain.” The ACA subscribes to and recommends the Educational Standard for Postgraduate (Continuing) Education of the Council on Chiropractic Education. (Approved, July 1975). Resolved, that the ACA encourages and recommends its members to obtain consistent continuing education which may include self-study. (Ratified by the House of Delegates, June 1985). Continuing Education, In-Person Classroom Study Resolved, the American Chiropractic Association supports in-person classroom study annually for re-licensure and encourages doctors of chiropractic to attend local, state, and national meetings to foster better understanding, cooperation, and unity within our profession. (Ratified by the House of Delegates, March 2002). Diplomate Definition Resolved, that the following is the ACA policy on diplomate status: A diplomate is a specialist within the healing arts. The diplomate has completed a course of study in a specific healthcare discipline and/or domain (specialty or subspecialty) of a discipline. A healthcare board in his specific discipline has credentialed the successful diplomate. The diplomate maintains and enhances his skill, knowledge and abilities through scholarly endeavors and periodic re-certification. (Ratified by the House of Delegates, September 2000). Diplomate Programs Diplomate programs are postdoctoral courses available in various aspects of chiropractic practice. They are in-depth programs requiring a complete foundation of basic medical/chiropractic education. Diplomate programs have always been the purview of the field practitioner; and most chiropractic colleges allow only licensed doctors of chiropractic to attend diplomate programs. Therefore, be it

32Resolved, that the ACA commend chiropractic colleges for conducting postdoctoral diplomate courses for licensed field doctors of chiropractic. Be it further Resolved, that diplomate programs should be and remain available for doctors of chiropractic. Be it further Resolved, that the opening of diplomate programs to individuals who do not possess a doctor of chiropractic degree may serve to dilute the value, credibility, and status of diplomates and diplomate programs. (Ratified by the House of Delegates, July 1995, Reaffirmed, June 1998). Resolved, that the American Board of Chiropractic Specialties (ABCS) study and correlate the post-graduate syllabi for the transfer of credits to avoid duplication of the educational requirements for specialty education credits. (Ratified by the House of Delegates, August 1999) Resolved, that the specialty councils and their respective boards be notified by letter that unrealistic and perceived punitive re-certification requirements should not be imposed on their respective membership and that these requirements should not be used as criterion for credentialing in any managed care or third party payor plan. (Ratified by the House of Delegates, August 1999) Post Graduate and Continuing Education Resolved, that the ACA House of Delegates adopts the following position on Chiropractic Postgraduate and Continuing Education. The American Chiropractic Association recognizes that the extensiveness of accumulated knowledge and rapid growth of new knowledge requires that today’s doctors of chiropractic continue their education throughout their professional careers. The ACA is in accord with the concept of requiring continuing education as a requisite to chiropractic license renewal. The ACA recognizes, supports and encourages all programs and endeavors in postgraduate and continuing education which are of acceptable academic and ethical quality and which are presented in the best interests of the profession. Generally, the following areas of interests and sources of postgraduate and continuing education my be considered to be among those appropriate for professional growth, and meeting the requirements of the profession and expectations of society. 1) Programs in basic, clinical and chiropractic sciences and arts, in research, health planning,

institutional protocol, insurance practices and procedures, peer review, industrial practices, forensic practices, insurance consultation, labor relations, patient counseling, and practice management.

2) Programs of independent study of professionally related journal articles, monographs, texts, and

other materials. 3) Programs relevant to chiropractic presented in conventions, workshops, seminars, and

conferences that are presented, sponsored and/or approved by recognized, professionally related associations, organizations, governmental agencies and/or academic institutions having status with accrediting agencies recognized by the U.S. Department of Education.

It is the position of the ACA that only chiropractic academic institutions having status with the Council on Chiropractic Education can and should conduct postgraduate courses leading to eligibility for board certification in specialized or select areas of chiropractic practice.

33 The ACA, along with CCE, deplores the itinerant, privately conducted continuing education programs which are presented primarily for private gain, as well as the programs which promote unlearned and unscientific concepts and cultism, and the programs which emphasize the pecuniary interests of chiropractic practitioners above the best interests of the public and the profession. (Ratified by the House of Delegates, June 1982). POSTURE AWARENESS The ACA advises and recommends to the public that good posture in all age groups has a direct and significant impact on not only spinal biomechanics but on all bodily functions. Recognition of the interrelationship and interdependence of good posture to good health requires that an increased awareness be developed by the public regarding the necessity of developing good postural habits in order to assist the body in achieving and maintaining good health. (Adopted by the House of Delegates, July 1987). PRACTICE MANAGEMENT COURSES Resolved, that the House of Delegates of the American Chiropractic Association goes on record as endorsing only those practice building, practice promotion, practice management, and other related courses, lectures and/or services found acceptable to an Evaluation Committee appointed by the president subject to the approval of the House of Delegates and consistent with academics and clinical training in colleges having status with the Council on Chiropractic Education. (Ratified by the House of Delegates, June 1975). PREFERRED PROVIDER ORGANIZATIONS Resolved, that the ACA approves an effort to develop full information on Preferred Provider Organizations (PPOs), their effectiveness in dealing with the health delivery system and the preparation and development of informational and educational materials for the American Chiropractic Association. (Ratified by the House of Delegates, June 1983). PRIMARY HEALTH CARE: ROLE OF CHIROPRACTIC Resolved, that the ACA adopts the following as the chiropractic profession’s role in Primary Health Care: The chiropractic profession’s role in Primary Health Care is to educate its students and practitioners in providing primary care at the undergraduate and graduate levels of instruction. The doctor of chiropractic is qualified to provide primary health care and may choose to further develop their primary care practice (specializing in family practice, pediatrics, generalist with subspecialty in neurology, sports medicine or occupational health) providing for a wide range of services with a long term patient - doctor relationship or choose to provide specialty care (neurology, orthopedics, radiology, rehabilitation, occupational health) providing for a narrower range of services with a short term patient - doctor relationship. The Doctor of Chiropractic is qualified to provide primary care with respect to the definition from the Institute of Medicine: “Primary care is the provision of integrated, accessible health care services by clinicians (doctors of chiropractic / chiropractic physicians) who are accountable for addressing a large majority of personal

34health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.” (1). Integrated-incorporating comprehensive, coordinated, and continuous services throughout the patient’s life span:

A. Comprehensive -“addresses any health problem at any given stage of a patient’s life cycle.” (2).

B. Coordinated -ensures the integration of health services and information necessary for the patient’s health and well-being in a rational manner and including the resources of the healthcare community. C. Continuous -“care over time by single clinician (doctor of chiropractic / chiropractic physician) or team of health care professionals (‘clinician continuity’) and to effective and timely communication of health information (events, risks, advice, and patient preferences) (‘record continuity’).” (2). Accessible -unrestricted direct access for any problem at any time. Health care services - chiropractic service which primarily focuses on the restoration of the inherent recuperative abilities of the body through natural means. Chiropractic focuses on the relationship between structure, primarily the spine, and function primarily coordinated by the nervous system of the body as that relationship may affect the restoration and preservation of health. Chiropractors also provide patient evaluation and instructions regarding disease prevention and health promotion through proper nutrition, exercise and lifestyle modification among others. The range of diagnostic and therapeutic services offered by chiropractic is dynamic and will be modified by education, research technological change and society’s evolving health care needs. Referral to other healthcare providers for conditions beyond the chiropractic scope of practice is integral to chiropractic practice. Clinician (doctor of chiropractic / chiropractic physician) - responsibilities as a primary care clinician include wellness promotion, health assessment, diagnosis and the chiropractic management of the patient’s health care needs. When indicated, the doctor of chiropractic consults with, co-manages, or refers to other health care providers. Accountable - responsible to the patient and community for the large majority of personal health care needs by establishing a sustained patient - doctor relationship Majority of personal health care needs - chiropractors “receive all problems that patients bring - unrestricted by problem or organ system - and have the appropriate training to diagnose and manage a large majority of those problems and to involve other health care practitioners for further evaluation or treatment when appropriate. Personal health care needs include physical, mental, emotional, and social concerns that involve the functioning of an individual.” (3). Sustained partnership - the expected establishment of a patient - doctor relationship over one’s lifetime and is inclusive of mutual trust, respect and responsibility. Patient - the individual who seeks care from a naturally based and/or chiropractic perspective. Context of family and community - providing care in consideration of the patient as they relate to their family and communities and with reference to the community in which the clinician practices.

35Primary care is the domain of all whole body healing arts professions, providing the avenue by which individuals and their community’s may pursue the establishment and maintenance of good health care consistent with their personal ideals and philosophy of life. It is incumbent of all healing arts professions to cooperatively integrate a respectful utilization of each others expertise in the best interests of the patient and community.

References

1. Donaldson MS, Yordy KD, Lohr KN and Vanselow NA, Primary care: America’s health in a new era. Institute of medicine, Washington, DC: National academy of press, 1996; 31.

2. Ibid. p. 32. 3. Ibid. p. 33.

(Ratified by the House of Delegates, March 2001). PROFESSIONAL PARITY Resolved, that monopoly of drug-oriented doctors in the public health field be discontinued so that parity and equal treatment be accorded to all licensed healing arts. Fair representation be established on all public health boards, commissions, and committees for all licensed branches of the healing arts. All members of all licensed healing arts shall have equal access to the use of the facilities of all tax-supported health institutions. (Ratified by the House of Delegates, June 1972). PUBLICATIONS Resolved, that all tracts and brochures published by the ACA cease bearing statements that chiropractic is a drugless profession. (Ratified by the House of Delegates, July 1974). PUBLIC SAFETY All-Terrain Vehicles The ACA recommends that ATVs not be sold as toys for children; ATV drivers be licensed and appropriately trained in driving an ATV and in safety measures regarding the ATV, particularly the utilization of proper safety equipment to include safety helmets. ACA also recommends that ATV manufacturers investigate redesigning the ATV to include: passenger restraint system, safety roll bars and automatic engine shut-offs in case of accident or roll over. (Ratified by the House of Delegates, July 1987). Drinking Age ACA supports a uniform drinking age of 21 to be adopted legislatively in all states to help curb the increasing numbers of accidents and deaths due to teenage drinking. (Ratified by the House of Delegates, July 1987). Helmets Resolved, that the ACA supports the use of safety helmets for both the driver and the passenger of motorized two and three wheel vehicles; which would help to prevent serious injuries and traffic fatalities, and is in the best interest of the general public. (Ratified by the House Delegates, June 1985). Public Transportation

36 Resolved, that the American Chiropractic Association does support the implementation of passive restraints/seat belts and headrests for use in public transportation. Seat belt restraints have a proven record for prevention of serious injury and/or death resulting from vehicular trauma. We believe it is in the interest of public safety that passive restraints/seat belts and headrests be made available for all form of public transportation. (Ratified by the House of Delegates, September 2000). Safety Equipment Resolved, that the ACA recommends the use of safety equipment where relevant, for recreational activities for both child and adult participants. (Ratified by the House of Delegates, June 1989). Seat Belts Resolved, that the American Chiropractic Association endorses the use of seat belts or passive restraints, and recommends appropriate safety devices for children that all states in the U.S. which do not currently have laws requiring their use by drivers and passengers of all ages, introduce such laws to their legislatures. Furthermore, the American Chiropractic Association recommends that all state and local chiropractic associations work for the passage and the strict enforcement of such laws in a campaign to safeguard the American public. (Ratified by the House of Delegates, June 1985). RELIGION The ACA supports Freedom of Religion practices, but holds that the practice of chiropractic has no connection with any religious organization. (Approved by the House of Delegates, June 1988). RESEARCH - PATIENT SOLICITATION The American Chiropractic Association is committed to the highest standards of the professional practice of chiropractic and to the highest standards of chiropractic research. However, there exists within the profession individuals and groups, which attempt to utilize what appears to be or may in fact be research efforts as a means to solicit patients. Such research/patient solicitation efforts erode the credibility of legitimate chiropractic research and threaten to endanger the professional relationship between patient and chiropractor. Therefore, be it resolved that the American Chiropractic Association encourage research by individual doctors of chiropractic, e.g. case studies, as part of a continuing learning process that will ultimately result in better practitioners. This research will also contribute to the ever-growing body of knowledge and to a better understanding of the benefits of chiropractic care. Chiropractors are encouraged to participate in and support chiropractic research as part of their commitment to the chiropractic profession. Be it further resolved that the American Chiropractic Association recognizes that a normal part of the everyday chiropractic practice involves communication in some form that will allow members of the public to better understand the benefits of chiropractic care and to recognize the services available from a specific doctor of chiropractic. This communication can take many forms of advertising and marketing. Ultimately, this communication is governed by applicable federal and state laws as well as specific chiropractic codes of ethical conduct.

37Be it further resolved that the American Chiropractic Association caution its members that it regards the practice of utilizing research programs for the designed purpose of patient solicitation to be an unacceptable and possibly illegal method of patient inducement that will ultimately damage the credibility of chiropractic as a whole and in particular damage the credibility of chiropractic research. Chiropractic examining boards and other authorized governmental regulatory agencies are encouraged to investigate and to take proper action in regard to these improper patient solicitation/research pro-grams. (Ratified by the House of Delegates, June 1991). SALE OF NON-HEALTH RELATED GOODS Resolved, physicians should not sell non-health-related goods from their offices. The only exception is physicians may sell non-health-related goods from their offices for community or charitable organizations provided patients are not pressured to make purchases, the physician does not personally profit from the sales, the goods are inexpensive, such sales are not a regular part of the physician’s practice and the sales are conducted in a professional manner. (Ratified by the House of Delegates, August 1999). SCOLIOSIS Scoliosis, in all its forms, regardless of etiology, is recognized as a leading cause of biomechanical dysfunction of the spine and in some instances may be life threatening. Therefore, be it resolved, that the ACA encourage all of its members to remain vigilant regarding the early detection of scoliosis, to remain abreast of any new treatment methods, and to voluntarily participate in all legitimate, structured assessment programs such as school scoliosis screening programs. (Ratified by the House of Delegates, June 1991). SCOPE OF PRACTICE Limitations - Condemned Resolved, that the ACA condemns any efforts to limit or reduce the scope of chiropractic practice more limited than that embodied in the ACA Master Plan. (Ratified by the House of Delegates, June 1985.) Resolved, that the American Chiropractic Association condemn the practice of arbitrarily limiting the scope of practice and / or professional care of Doctors of Chiropractic by any third party payer. These activities may present a significant health hazard for patients who require chiropractic care. Doctors of chiropractic should be allowed the latitude to employ the full scope of chiropractic services as established by their respective state statutes. Third party payers should reimburse for appropriate professional services performed by Doctors of Chiropractic if services performed by other physician-level providers are reimbursed for the care of same or similar conditions. Such professional services should be reimbursed in parity with the reimbursement levels of other physician-level providers. (Ratified by the House of Delegates, September 2001.) Resolved, the House of Delegates reaffirm the ACA Master Plan. Be it further Resolved, that doctors of chiropractic are primary care physicians. Be it further Resolved that the American Chiropractic Association continue to resist any future legislation that violates the proposition of the full scope of practice of chiropractic as it is embodied in the ACA Master Plan. Be it further Resolved, that doctors of chiropractic treat human ailments without the use of prescription drugs or incisive surgery, as taught at chiropractic colleges having status with an accrediting agency recognized

38by the U.S. Department of Education, or an agency having a reciprocal agreement with the recognized agency and ACA will strive to reiterate this when called upon in relation to Federal legislative efforts. (Ratified by the House of Delegates, September 2001.) Statutory Since the practice of chiropractic is regulated in all states, Puerto Rico, nine provinces in Canada, and a number of foreign countries, the present scope of practice is necessarily determined locally by existing statutory enactment and judicial determination in the separate jurisdictions. (ACA Master Plan, ratified by the House of Delegates, June 1964, amended, June 1975.) SMOKING/ANTI-TOBACCO Resolved, that ACA in recognition of its long established position that cigarette smoking is a health hazard expresses its support for the World Health Organization’s (WHO) efforts in the anti-tobacco initiative, specifically the WHO’s Framework Convention on Tobacco Control (FCTC) and the Framework Convention Alliance (FCA) which supports it. Resolved, that ACA recognize the World Federation of Chiropractic (WFC) efforts in supporting the WHO in the area of tobacco control and its establishment of a “Health-for-All Committee” which has set the anti-tobacco initiative as its first priority and will be developing guidelines for defining a role for doctors of chiropractic world-wide in this multi-disciplinary endeavor to improve human health. Resolved, that ACA support the United States government efforts in tobacco control, including those put forth by the United States Public Health Service (USPHS), and the Office of the Surgeon General. Resolved, that ACA encourage all doctors of chiropractic to incorporate anti-tobacco messages to every patient, and provide guidance for tobacco use cessation to patients who express an interest in them. Resolved, that ACA recognize observance of the WHO annual No Tobacco Day on May 31 each year and the Great American Smoke Out on the third Thursday of November each year. Resolved, that ACA prohibit cigarette smoking and other tobacco product use at all ACA events and at ACA’s Headquarters. Resolved, that ACA encourage all DCs to discourage any tobacco product use in their offices, and to set positive examples themselves by not using any tobacco products. (Ratified by the House of Delegates, September 2001). SPINAL AND NEUROMUSCULOSKELETAL CARE IN THE AGING The American population age 65 and over continues to grow, accounting for an increasingly larger portion of health care expenditures. The primary goal in caring for the elderly should be to maximize function and achieve the highest level of well-being in everyday life activities. This will require the development of creative new ways to keep senior citizens functionally independent -- including the utilization of chiropractic care. In the long run, this may help to reduce costs.

39The American Chiropractic Association (ACA) has long recognized that spinal and neuromusculoskeletal health care are essential for the total health and well-being of the elderly. Such health care ' aids in maintaining proper mobility and freedom from, or reduction of, neuromusculoskeletal and joint pain -all critical factors in enhancing independent living and quality of life. The ACA recommends that senior citizens must be able to have access to, and freedom to choose, chiropractic, spinal and neuromusculoskeletal care. The ACA further recommends that health maintenance organizations (HMOs) and managed care organizations should not exclude or prevent chiropractic services to elderly patients. Also, the Medicare benefit for chiropractic services needs to be updated, to include x-rays required for Medicare reimbursement; and expanded to cover services, which are currently provided to elderly patients by Doctors of Chiropractic, but are not reimbursable. A primary objective of elderly care, by all health care providers, should be the concept of “Healthy Aging.” Such factors as nutrition and diet, exercise and fitness, safety and fall prevention, lifestyle, living conditions, intellectual stimulation, social support, and disease prevention all contribute to a healthy lifestyle and an enhanced quality and dignity of life. The ACA also recommends that educational programs be conducted for the public and health practitioners to encourage preventive, inter-disciplinary care for the aging. In addition, long-term care for the elderly is a priority, and should be provided humanely and cost-effectively. (The text printed above is an abstract of a policy statement ratified by the House of Delegates, July 1995. A copy of the complete policy statement is available from ACA headquarters). SPINAL CARE Resolved, that a vigorous program be instituted by the ACA for the dissemination of information as to the importance of the maintenance of a normally functioning spine and the necessity for early detection and correction of any problem that may develop. (Ratified by the House of Delegates, July 1968). SPINAL MANIPULATION POLICY Doctors of chiropractic (chiropractic physicians) assert that they are the best trained and qualified provider group in chiropractic spinal manipulation/adjustment and reaffirm their inherent interest in this procedure for the purpose of preserving quality patient care and favorable outcomes. As competition in the field of health care delivery systems (HCDS) increases, multidisciplinary interest is developing in spinal manipulation primarily to expand the market share of certain providers. Individuals with less training and expertise than doctors of chiropractic (chiropractic physicians) may provide outcomes that are less than optimal, and can pose unnecessary health and safety risks and possible complications for patients. Recommendations It is incumbent upon the chiropractic profession to continue its research to exponentially expand the gathering of scientific evidence on quality and affordable health care, especially in the area of chiropractic spinal manipulation/adjustment. It was, therefore, agreed by Committee members that a high-level policy statement on chiropractic spinal manipulation/adjustment be developed to invite further research and to facilitate widespread public understanding. Recommendations include:

40• Develop a research program to enhance future studies of chiropractic spinal

manipulation/adjustment. • Create medical profession awareness about the benefits of early, integrated chiropractic

care to restore and maintain spinal health. • Disseminate this important safety and quality information to consumers, policymakers

and payors. (Ratified by the House of Delegates, August 1999) (The text printed above is an abstract of a policy statement ratified by the House of Delegates, August 1999. A copy of the complete policy statement can be obtained from ACA Headquarters). STANDARDS OF PRACTICE, MERCY CENTER CONFERENCE GUIDELINES The ACA House of Delegates endorses the process culminating in the formulation of the guidelines contained in the preliminary draft copy of the document “Guidelines for Chiropractic Quality Assurance and Standards of Practice,” (Mercy Center Conference Guidelines) noting that the standard setting process is perpetual in function. The House of Delegates endorses the draft guidelines, subject to the qualifications expressed below, and acknowledges the guidelines to be dynamic, changeable and revisable as the profession, research and practice of chiropractic grows in knowledge and develops in the future. Resolved, that chiropractic practice may include a variety of responses to a particular clinical problem and that adherence to any particular guideline is voluntary. Except where provided otherwise, all practice guidelines should not be considered inclusive of all proper methods of care or exclusive of other methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of a specific procedure must be made by the practitioner in light of the individual circum-stances presented by the patient. Be it further resolved that in formally endorsing the process and draft guidelines, the ACA takes specific exceptions to those areas in the document which may be inconsistent with existing ACA policy, and affirms that the guidelines are subordinate to federal and state law, whether by statutes, regulations, court decisions, or otherwise. The House of Delegates recommends that the document be reviewed in detail at the 1994 Annual Meeting, which will allow for meaningful critiques from the chiropractic practitioners in the field. (Ratified by the House of Delegates, May 1992) STATE SALES TAX Whereas, numerous disease processes possess nutritional / biochemical imbalances or deficiencies as well as structural imbalances; and Whereas, the practice of chiropractic includes the investigation, examination, and diagnosis of conditions of the human body and the treatment of such conditions by clinical procedures to include but are not limited to chiropractic manipulation / adjustments, physiotherapy, and the administering or dispensing of orthopedic appliances and/or clinical nutrition including vitamins, minerals, herbals, homeopathic and other nutritional supplementation; and Whereas, orthopedic appliances and nutritional medicines, when administered or dispensed by doctors of allopathic medicine or osteopathic medicine, are generally exempt from state sales tax. Therefore, be it

41Resolved, that the American Chiropractic Association acknowledge that the orthopedic appliances and/or nutritional supplements / articles dispensed or administered during the professional course of practice by a doctor of chiropractic, should be considered exempt from state sales tax. (Ratified by the House of Delegates August 2002) SUBLUXATION – CORE PRINCIPAL Resolved, the House of Delegates reaffirm the ACA Master Plan. Resolved, that doctors of chiropractic are primary care physicians. Resolved, that the American Chiropractic Association continue to resist any future legislation that violates the proposition of the full scope practice of chiropractic as it is embodied in the ACA Master Plan. (Ratified by the House of Delegates, August 2001) Resolved, that doctors of chiropractic treat human ailments without the use of prescription drugs or incisive surgery, as taught at chiropractic colleges having status with an accrediting agency recognized by the U.S. Department of Education, or an agency having a reciprocal agreement with the recognized agency and ACA will strive to reiterate this when called upon in relation to Federal legislative efforts. (Ratified by the House of Delegates, August 2001). SUPPORTIVE CARE Resolved, that the ACA use all legitimate means to insure that supportive chiropractic care, as defined by the Mercy Guidelines, be available to all patients who will benefit from this type of care. (Ratified by the House of Delegate, June 1998). Resolved, the ACA House of Delegates petitions the Foundation for Chiropractic Education and Research to develop a study of the existing scientific literature that would assist the ACA in developing policy regarding the appropriateness of chiropractic treatment or management (e.g., chronic care, supportive care) of chronic or recurring conditions typically seen by Doctors of Chiropractic. (Ratified by the House of Delegates, August 1999). Definition There is a growing concern within the chiropractic profession regarding the coverage and interpretation of long-term chiropractic care by Medicare and other third party payors. There is an escalating tendency for Medicare, insurance carriers and managed care organizations to categorize long-term chiropractic care as preventative or maintenance; therefore, it is considered elective, not medically/clinically necessary and not covered. There is increasing data that indicates most musculoskeletal conditions (e.g. low back pain) do not completely resolve within thirty to sixty days. There is increasing clinical scientific support for chiropractic care, short-term or corrective as well as long-term or supportive, in chronic conditions. There is an increasing number of scientific studies that indicate regular preventative/maintenance chiropractic care has a “Health Optimizing” effect. There are federal court decisions that support the appropriateness of health care even though it may not “affect the course” of a condition or provide “significant progress”. A significant number of chiropractic patients receive long-term chiropractic care of a supportive or preventative/maintenance nature, be it therefore Resolved, that the American Chiropractic Association acknowledges chiropractic care is appropriate for a broad range of conditions that may be categorized as acute, subacute, chronic, complicated or uncomplicated, and be it further

42Resolved, that the American Chiropractic Association acknowledges a preponderance of clinical research to date has focused on and therefore supports chiropractic care (especially spinal manipulation / adjustment) in the treatment of acute, uncomplicated low back pain, and be it further Resolved, that the American Chiropractic Association acknowledges that long-term chiropractic care, beyond short-term corrective care for a chronic condition, may fall into one of two categories, either therapeutically necessary supportive care or elective preventative/maintenance care, as defined in the attachment and hereby incorporated into this resolution. Resolved, the American Chiropractic Association also recognizes there is a growing amount of outcomes-based clinical evidence that supports long-term corrective and supportive chiropractic care for a range of subacute, chronic or complicated conditions, and be it further Resolved, the American Chiropractic Association has long advocated preventative/maintenance care as appropriate within the context of optimizing and promoting health and wellness, a principle of the chiropractic paradigm, and be it further Resolved, that the American Chiropractic Association should pursue a broad based program to continue to develop the research and educate all publics (e.g. all health care providers, third party payors, legislators, government agencies) regarding the appropriateness and value of long-term chiropractic care. (Ratified by the House of Delegates, March 2000).

Attachment Supportive Care: Long-term treatment/care that is therapeutically necessary. This is treatment for patients who have reached maximum therapeutic benefit, but who fail to sustain benefit and progressively deteriorate when there are periodic trials of treatment withdrawal. Supportive care follows appropriate application of active and passive care including rehabilitation and/or lifestyle modifications. Supportive care is appropriate when alternative care options, including home-based self-care or referral have been considered and/or attempted. Supportive care may be inappropriate when it interferes with other appropriate primary care, or when risk of supportive care outweighs its benefit, i.e. physician/treatment dependence, somatization, illness behavior or secondary gain. 1,2,3,4. Preventative / Maintenance Care: Elective health care that is typically long-term, by definition not therapeutically necessary but is provided at preferably regular intervals to prevent disease, prolong life, promote health and enhance the quality of life. This care may be provided after maximum therapeutic improvement, without a trial of withdrawal of treatment, to prevent symptomatic deterioration or it may be initiated with patients without symptoms in order to promote health and to prevent future problems. This care may incorporate screening/evaluation procedures designed to identify developing risks or problems that may pertain to the patient’s health status and give care/advice for these. Preventative/maintenance care is provided to optimize a patient’s health. 1,2,3,4.

1. Chapman-Smith D. Scope of Practice. The Chiropractic Profession. NCMIC. Toronto, Canada; Harmony Printing Limited, 2000; 94-5. 2. Chapman-Smith D. Long-Term Care-Justification and Reimbursement. The Chiropractic Report. Jan 1994; 8(1); 2. 3. Haldeman S, et al, eds. Guidelines for Chiropractic Quality Assurance and Practice Parameters. Gaithersburg, Maryland; Aspen Publishers;

1993; Chapter 8; 115-127. 4. Henderson DJ, et al, eds. Clinical Guidelines for Chiropractic Practice in Canada. Supplement to JCCA; 1994; Glossary; 193-4. TEAM PHYSICIAN CONSENSUS STATEMENT

43Resolved, that the House of Delegates recommend that the American Chiropractic Association, the Council on Sports Injuries and Physical Fitness denounce and protest the exclusion of doctors of chiropractic from the current Team Physician Consensus Statement. And be it further Resolved, that the American Chiropractic Association and Council on Sports Injuries and Physical Fitness simultaneously seek inclusion of doctors of chiropractic into the Tem Physician Consensus Statement by using all appropriate means necessary to promptly, definitively and equitably resolve this issue. (Ratified by the House of Delegates, August 2001). THIRD-PARTY PAYERS Resolved, that the American Chiropractic Association condemns the practice of arbitrarily limiting the scope of practice and/or professional care of doctors of chiropractic by any third-party payer. These activities may represent a significant health hazard for patients who require chiropractic care. Doctors of chiropractic should be allowed the latitude to employ the full scope of chiropractic services as established by their respective state statutes. Third-party payers should reimburse for appropriate professional services performed by doctors of chiropractic if services performed by other physician-level providers are reimbursed for the care of same or similar conditions. Such professional services should be reimbursed in parity with the reimbursement levels of other physician-level providers. (Ratified by the House of Delegates, August 2001). VACCINATION Resolved, that the American Chiropractic Association (ACA) recognize and advise the public that: Since the scientific community acknowledges that the use of vaccines is not without risk, the American Chiropractic Association supports each individual’s right to freedom of choice in his/her own health care based on an informed awareness of the benefits and possible adverse effects of vaccination. The ACA is supportive of a conscience clause or waiver in compulsory vaccination laws thereby maintaining an individual’s right to freedom of choice in health care matters and providing an alternative elective course of action regarding vaccination. (Ratified by the House of Delegates, July 1993, Revised and Ratified June 1998). “VETERINARY” CHIROPRACTIC Resolved, that the application of manipulative techniques to animals may constitute a form of veterinary procedure but does not constitute what is commonly defined by this Association and a majority of States as “chiropractic.” But it further, Resolved, that the term “veterinary chiropractic” is a misnomer, and should not be used when referring to the application of manipulative techniques to animals. (Ratified by the House of Delegates, July 1994). VITAMINS, MINERALS AND FOOD SUPPLEMENTS: THE USE OR RECOMMENDATION OF The ACA’s Council on Nutrition holds the position that it is appropriate for doctors of chiropractic to recommend the use of vitamins, minerals and food supplements for their patients, to the extent this is not in conflict with state statutes and regulations.

44 The recommendation of nutritional supplements should include a nutritional assessment of the patient. The practitioner shall record the rationale for the supplements in the patient’s chart. The doctor should attempt to determine that the products being recommended are not experimental. The ACA’s Council on Nutrition holds the position that it is appropriate for a doctor of chiropractic to recommend the use of vitamins, minerals and food supplements, in conjunction with weight control programs, to the extent this is not in conflict with state statutes and regulations. A nutritional assessment should be made of the patient prior to the use of nutritional supplements, and duly recorded in the patient’s file. Doctors should attempt to determine that products used for weight control are not experimental. Further, the doctor should request of the companies with which they are doing business research reports from independent sources regarding their products. (Ratified by the House of Delegates, June 1991). WELLNESS MODEL

RESOLVED, since its inception, chiropractic has been based on an active care model that emphasizes wellness. Wellness requires active patient participation. It is a process of achieving the best health possible given one’s genetic makeup by pursuing an optimal level of function. The goal of wellness is to maintain the most favorable balance between internal and external environments. Wellness care incorporates active lifestyle changes consistent with the goals of Healthy People 2010(1). Wellness begins on day one of chiropractic care. As an active care model, the commitment of the doctor of chiropractic to wellness emphasizes collaboration with patients on the development of a life-long path for health promotion and disease prevention.(2) Wellness is a patient-centered process. Incorporating knowledge, skills and attitudes acquired through professional training, the doctor of chiropractic works with patients in a number of domains, including:

• Evaluation/Assessment of Patients (risk factors, health needs) • Information/Education of Patients (awareness) • Intervention/Monitoring (including counseling) • Integration with other Community Resources

ACTIVE WELLNESS CARE DOMAINS

Evaluation/Assessment of Patients: As an integral part of the routine history and examination process, the doctor of chiropractic uses appropriate instruments and procedures to determine, a) his/her assessment of the patient’s health and wellness needs; and b) the patient’s perception of his/her health

(1) Health and Human Services, Office of Disease Prevention and Health Promotion. Healthy People 2010 Objectives, Clinical

Preventive Care. Section 1-2. (Developmental) “Increase the proportion of insured persons with coverage for clinical preventative services.” Section 1-3. “Increase the proportion of persons appropriately counseled about health behaviors.” Website link www.health.gov/healthypeople/document

(2) ACA Resolution 2000 [9] – 4: Chiropractic Wellness Campaign, June 2000.

45and wellness needs. This stage represents the initial assessment of the patient’s current health status, and includes identification of constitutional (genetic), behavioral, and environmental risk factors. Information/Education of Patients: The doctor of chiropractic determines a working diagnosis and communicates this to the patient, along with strategies for meeting his/her health and wellness needs. The doctor and patient then discuss a management plan, taking into consideration the risks, benefits, and lifestyle implications of selected strategies. A plan for immediate, intermediate, and long-term active/wellness care, based upon both the doctor’s assessment and the patient’s perception of health and wellness needs, is negotiated. Intervention/Monitoring: The patient consents to treatment and agrees to initiate the selected active/wellness care plan. The case of a patient who presents to the doctor of chiropractic with a complaint of acute low back pain is used to illustrate the concept of immediate, intermediate, and long-term active/wellness care. The assessment reflects that the patient is also obese, a smoker, and has high normal blood pressure.

• The immediate intervention focuses on decreasing the patient’s pain and returning him/her to normal daily function and activities. From day one of intervention, the doctor of chiropractic makes health and wellness recommendations to optimize recovery and prevent recurrence.

• During the intermediate phase, the spinal care is continued, and the patient’s obesity and elevated blood pressure are addressed through lifestyle modifications, including diet and exercise.

• Long-term active/wellness care includes continued attention and assessment of the patient’s progress in order to identify changing health needs and to facilitate self-reliance and personal well-being.

The following chart shows the dynamics of the active/wellness care model and how the patient reaches self-reliance. (Figure 1)

Figure 1

Long term

Intermediate Immediate

Doctors

Responsibility

Best

Health Status

Worst

Health

Status

Patients Responsibility

TIME

46Monitoring/Ongoing Reassessment: The doctor of chiropractic monitors the patient’s progress and suggests appropriate modifications to intervention (treatment) strategies based upon changing health and wellness needs of the patient. Integration with Other Community Resources: The doctor of chiropractic serves as a resource to the community for health care, health promotion, and wellness. As a direct access provider, he/she serves as a conduit to other health care practitioners, services and information resources. All phases of the active/wellness model allow the patient to engage in preventive care as well. The various levels of injury prevention include:

• Primary Prevention: prevents a disease or condition from occurring. • Secondary Prevention: detects early signs of a condition or disease and intervenes.

• Tertiary Prevention: reduces sequellae and is supportive or rehabilitative in nature.

Primary Role of the Doctor of Chiropractic Consistent with the traditional chiropractic active/wellness care approach, the primary roles of a doctor of chiropractic are to act as a:

1. Primary Care/Direct Access Practitioner 2. Health Information Resource 3. Health and Wellness Advocate 4. Disease and Injury Prevention Manager 5. Spinal Care Specialist within the health care system

Tasks of a Doctor of Chiropractic The following task list is not intended to be exhaustive but rather representative of the types of health promotion activities that are commonly preformed by the doctor of chiropractic. Primary Care/Direct Access Practitioner Initial History and Evaluation & Treatment Health Assessment Direct Patient for Appropriate Consultation and Referral Develop Health Management Contracts with Patient Health Information Resource Health Status; Self-Assessment for Patients Battered Child/Spouse Information Dietary and Dental Health Information Disease Prevention packages Age-Specific Health Protection Cancer Prevention Drug Alert Immunization Emporiatrics: Advice for travelers AIDS information

47 Prevention of Sexually Transmitted Diseases Drugs Used in Pain Relief (Analgesics & Anti-Inflammatory Agents) Community Resource Information Unintended Pregnancy Health and Wellness Advocate Avoiding or Minimizing Exposure to Pollution Physical Activity or Exercise (Benefits and Risks) Performance Enhancement Healthy Sleep

Nutritionally Guidance (RDA, Dist and Disease, Food Processing and Preparation) Weight Control Smoking Cessation Reduced Alcohol Consumption Stress Management Breast Feeding Disease and Injury Prevention Manager Athletic Injury Prevention Automobile Injury Prevention

Industrial & Back Injury Prevention (Preplacement Screening, Workplace Design) Childhood Injury Prevention (vehicle restraints)(Bicycle helmets)(Backpack Safety) Hyperlipidemia Hypertension Diabetes Mellitus Osteoporosis Menopause Headaches Breast Cancer (Early Detection)

Spinal Care Specialist within the Health Care System

Spinal Hygiene Skeletal Health Promotion (Exercise, Calcium, Vitamin D, Early Detection) Backaches (Low-Back pain of Musculoskeletal Origin, Disability, Intervention) The recognition of Backache Attributable to Visceral Pathology

Implementing a Wellness Model

Strategies for implementation of a chiropractic wellness model may include the following activities:

1. Recognition by chiropractic profession that the greatest need in health care today is promotion of health and wellness. (Dental prophylaxis)

2. Fundamental shift in chiropractic college curricula to emphasize wellness philosophy and strategies for implementation of the wellness model.

3. A campaign to inform health educators in schools, colleges, and universities of the wellness focus of chiropractic practice.

4. Continuing education to foster wellness knowledge, attitudes and skills among practicing doctors of chiropractic and support personnel.

5. Integration and emphasis of the wellness care model in all chiropractic specialty councils. 6. Design and seek funding for research studies that assess the chiropractic wellness model.

487. Educate the public, government agencies, and third party payors about why and how to

integrate the chiropractic wellness model. 8. Increase the chiropractic profession’s involvement in the American Public Health Association,

(APHA). 9. Develop buy-in to the wellness model by all chiropractic organizations. 10. Use publications and the Internet to provide useful materials on wellness to chiropractic

practitioners and their patients. 11. ACA to evaluate endorsing or affiliating with the Health People 2010 initiative. 12. ACA Communications Department to develop a public relations campaign based upon the

wellness model (t-shirts and slogans, etc.) 13. Continuous assessment of trends in wellness-related fields leads to the on-going update of the

wellness model. 14. Following acceptance in the United States, pursue globalization of the chiropractic wellness

model. The ACA views this model as a living document for the purpose of responding to progress points and change in the health care delivery system. (Ratified by the House of Delegates, September 2001).

X-RAY Accreditation Program The current trend by third-party payors is to institute proprietary radiographic quality standards that are tied to provider reimbursement, the ACA Board of Governors has evaluated the voluntary American Chiropractic College of Radiology X-ray Accreditation Program and finds it is an objective and comprehensive radiographic quality control program. Chiropractors who voluntarily seek and receive accreditation through this program will produce radiographs of consistently high quality, affording an enhanced opportunity for early diagnosis of pathologies that afflict chiropractic patients while maintaining patient exposure doses according to ALARA (As Low As Reasonably Achievable) principles. Resolved, that the American Chiropractic Association House of Delegates endorses the voluntary American Chiropractic College of Radiology X-ray Accreditation Program for the benefit of all chiropractors and their patients. (Ratified by the House of Delegates, August 1999). Advertising Free Examinations Resolved, that the American Chiropractic Association strongly condemn as unethical and potentially dangerous, the advertising of free x-rays, or indiscriminate use of x-rays, without an accompanying statement that: to avoid needless health hazards associated with ionizing radiation, no such free x-rays shall be undertaken unless there is prior demonstrated clinical need. (Ratified by the House of Delegates, July 1993). Certification of Chiropractic X-Ray Technologists Since the public interest would be served by the certification of qualified chiropractic radiologic technologists, ACA extends its recognition to the American Chiropractic Registry of Radiologic Technologists (ACRRT) as the only independent professional testing organization in this field. (Board approved, June 1983).

49Chiropractic Objectives It is recognized that roentgen rays are used by the health sciences for diagnostic or therapeutic purposes. The chiropractic profession utilizes x-ray only for diagnostic purposes and considers their use as one of the major diagnostic tools. The ACA Commission on Insurance holds that there are two facets to the responsibility of the chiropractic physician in the use of x-ray: (a) Medical necessity for the radiation exposure to the patient; and (b) Equality of studies consistent with scientific knowledge and acceptability. (Approved, July 1975). Diagnostic X-ray is one of the major diagnostic facets in the healing sciences and as utilized by chiropractic physicians is one of the major diagnostic tools of that science. Chiropractic does not use x-rays or radiology therapeutically. The ACA supports the position of the Council on Diagnostic Imaging that declares the importance of diagnostic x-ray in the practice of chiropractic and the position of the council that stresses the adherence to sound radiographic procedures. (Approved, July 1975). Lateral Bending Views of the Spine A trend in plain film radiography has been identified wherein multiple lateral bending views of the spine and its components have been performed. The American Chiropractic College of Radiology considers these procedures to be efficacious in only a limited number of circumstances. Certain guidelines of utilization are deemed necessary to safeguard the patient population from unnecessary ionizing radiation. Therefore, be it resolved that the ACA House of Delegates adopt and approve the ACCR position statement on lateral bending radiographic study, which states: The American Chiropractic College of Radiology considers the utilization of lateral bending views of the spine be a procedure only to be utilized in limited circumstances and adopts the following guidelines to their production: a. Are reserved additional views, not considered as part of the initial radiographic examination,

unless specific trauma or biomechanical dysfunction is documented by history or clinical evaluation, which suggest findings unobtainable by other means.

b. Are performed initially only in those patients where prior treatment has been unsuccessful or

where objective clinical findings or treatment resistive symptom expression suggests an as yet undiscovered occult pathology.

c. Are performed only of the cervical or lumbar spine. d. Are to be performed sectionally only in the cervical and lumbar areas, unless used to demonstrate

flexion of a scoliosis.

50e. Repeat utilization is rarely indicated save in those cases where appropriate response to

treatment is lacking or where re-injury or exacerbation has been clinically documented. (Ratified by the House of Delegates, June 1991).

Lumbar Oblique Radiographs While there is little evidence to support routine acquisition of oblique radiographs of the lumbar spine, there is ample evidence to support acquisition of these views if the frontal and lateral views fail to adequately demonstrate therapeutically significant pathology, which is clinically suspected, or where uncertainty exists about a reasonable potential for these diseases to be present. In other words, it is important to take obliques where frontal and lateral views do not confidently rule-in certain pathologies just as it is important to take obliques where frontal and lateral views do not confidently rule-out significant pathology which is reasonably suspected based on clinical examination and history. (The text printed above is an abstract of a policy statement ratified by the House of Delegates, May 1996. A copy of the complete policy statement can be obtained from ACA headquarters). Patient Safeguards The chiropractic profession recognizes that diagnostic x-ray examinations, while offering inestimable benefits to the knowledge that is made available, have risks and possible detriments, which must be weighed against those benefits. The ACA stands on record that there should always be clinical evidence of need for diagnostic x-ray examinations before such are performed. Use of x-ray as a routine procedure and from patients' self-referral is not good practice and is not condoned. Proper measures of patient radiological protection including adequate collimation, filtration, gonadal shielding (when applicable) etc., should always be utilized. ACA admonishes all doctors of chiropractic to use all known measures of proper x-ray protection including proper selection of patients with due reference to age, childbearing status, and other factors, surely including clinical indication of need. Continuing education programs in radiological health and x-ray safety are and have been offered through the chiropractic colleges, state and national chiropractic associations, and govern mental agencies. The chiropractic profession has been among the leaders in the healing arts in participation in such courses and all D.C.s are urged to avail themselves of these. (Ratified by the House of Delegates, 1967, reaffirmed, 1972). Videofluoroscopy With the publication of these guidelines and subsequent adherence to these tenets by operators/users, the American Chiropractic College of Radiology (ACCR) no longer considers Spinal Videofluoroscopy as investigational within the chiropractic profession. Caution and certain avoidances must nonetheless be observed with the use of Videofluoroscopy. Among these are those ill-advised practices, which include, but are not limited to, the following: 1. Spinal Videofluoroscopy is never appropriate in clinical practice to visualize the spinal

adjustment or manipulation, nor is it efficacious to employ Videofluoroscopy as a “pre and post” evaluation procedure in conjunction with an adjustment or joint manipulation.

2. Spinal Videofluoroscopy must never be performed without video taping of the procedure. This

ensures accurate recording of pertinent information and time of exposure.

513. Spinal Videofluoroscopy serves only as an ancillary diagnostic imaging procedure. 4. Spinal Videofluoroscopy shall never be utilized as a replacement for static radiographic

procedures. 5. Spinal Videofluoroscopy shall never be employed as a screening or cursory imaging device. Laboratories as well as referring practitioners are responsible for the necessary documentation and protocols as stated above, regardless of the source of referral for the examination. Practitioners utilizing Spinal Videofluoroscopy will adopt rigorous measures to ensure the radiation health and safety of both patient and operator. This includes limiting the examination to the area of clinical complaint, along with the application of appropriate radiation protective devices, inclusive of, but not limited to, lead gowning and filtration. Prior to the individual or institutional utilization of Spinal Videofluoroscopy equipment shall be adequately prepared by didactic training and practical experience to assure competency of application, and interpretation of both the technical and professional component of Spinal Videofluoroscopy. (Ratified by the House of Delegates, June 1991). Updated 9/2002