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1 the georgia chiropractor conference coverage! summer 2014 Gluten: Bad for all guts PQRS & Meaningful Use: Prepare for Fee Reductions a publication of the Georgia Chiropractic Association

2 2014 presidential sponsor of the Georgia Chiropractic Association Now Offering Direct Deposit! Contact ActivHealthCare at or to sign up. NEW Visit our website at Your Network * for more network information. *ActivHealthCare is owned by the Georgia Chiropractic Association 2 summer 2014 the Georgia Chiropractor

3 summer feature 2014 features P. 10 Case Study Lumbar pain and sciatica, complicated by shingles outbreak. P. 12 Albany D.C.s, Physicians Form Urgent Care Clinic Doctors focus on treating the whole patient. P. 14 Spring Conference Draws Big Crowd Beachside location a hit with attendees. P. 16 Gluten: Bad for All Guts Causes inflammation that may lead to leaky gut syndrome. P. 18 PQRS and Meaningful Use: Prepare for Fee Reductions D.C.s who are not participating will face fee cuts in P. 20 Show Your Spirit! Make plans to attend GCA s Fall Conference & Trade Show. departments P. 21 The Way We Were Dr. Joel Margolies gave up music for chiropractic. P. 22 C.A. Corner Lessons to be learned by building castles in the sand. P. 23 Insightful Imaging DISH complicated by OPLL. P. 26 Member Spotlight Dr. Troy Alderman provides expanded health care as an F.N.P. P. 27 Funny Bones Never a borrower nor lender be. P. 28 Practice Building 101 New doctors: Get your NPI number! In Each Issue P. 5 Letter from the President A Time of Change. P. 7 Executive Insights The Summer of Discontent. How Will You Respond? P. 8 National News ACA Presses HHS to Implement Non- Discrimination Clause; McAulay Joins F4CP Board; Medicare Fees to Increase July 1 P. 24 Association News Two New Directors Join GCA Board; Member Participates in Medical Legal Roundtable; Join GCA s Online Communities

4 World s First 3D Imaging : BREAKTHROUGH System from Foot Levelers Foot Levelers has done it! We have developed the world s first 3D Imaging Device for Chiropractic 3D BodyView. V7+ Body Assessment Patient Compliance Software First-ever Pronation Stability Index Know Their Number Embedded videos explain the Why Height mapping accurate up to 300 microns Captures 900,000 data points When patients know why, they comply. Order your 3D imaging device today! FootLevelers.com Let us help you build your practice. We guarantee you will be happy. Chairman & CEO, Foot Levelers, Inc. The Posture Specialists 2013 Foot Levelers, Inc. FLA GCA_breakthrough.indd 1 12/12/12 11:26 AM Reach Maximize your company s impact on Georgia s chiropractic community with GCA: Georgia Chiropractic Association hc cirhoirporparcatcotror WINTER Advertise in The Georgia Chiropractor, distributed to 3,000 licensed chiropractors co N co fer ve EN Ra ce ge! re Lice ne wa nse LY ea r rgia the geo rgia the geo Exhibit at GCA s spring and fall conferences! Sponsor GCA conference events and seminars 2014 spring 2014 tors top Doact Fall D e r o n o h rencoetes, cogn CaFeProm Cts 4 Georgia s Chiropractors! PrePare-10 QsD r ic 0 Fa icd-1fo Start connecting with Georgia chiropractors TODAY! Contact Valerie Smith at or call for more information. te grmoader ic inp Breath oea PsrieaCt Chir apitol at the C.oRg achiro summer 2014 the Georgia Chiropractor ubl hociation onracwticitass iatirop rn hegeo rgia chi hesis DinsC of the icatio Dylolist.org achiro ion

5 board A Time of Change a letter from the president Dr. Edward Cordovado President Dr. Charles Weiss President-Elect Dr. Edwin Davis Secretary Dr. Matthew Ryan Treasurer Dr. Douglas Giles Past President Dr. Richard Buchanan Director Dr. Winston Carhee, Jr. Director Dr. Leana Kart Director Dr. Kenneth Register Director Dr. G. Clark Stull Director Dr. Michael Vaughn Director GCA has undergone some major changes over the past year, most notably to our infrastructure to serve you better. In 2012, the whole GCA board got together for our annual board training and orientation meeting. This is the time we get to think big, or as our past president Dr Giles used to say, look at it from 50,000 feet. At this time the size of the board had become large and cumbersome. At 21 members, the speed at which the board could react to the ever changing health care environment was slow. This is the meeting where we changed the structure of the board to At-Large directors from all over the state. We also changed the way that we voted to keep up with modern times by going electronic. This is a great way to have the entire state be able to run for office and the entire state be able to vote, instead of voting being restricted only to those attending the annual meeting. I am happy to report that we have had many more people involved in the voting process and have a nice cross section of the entire state represented. As with all elections we have transitions of leadership for one reason or another. First of all congratulations to our new board and returning members: Dr. Richard Buchannan, Dr. Clark Stull, Dr. Ken Register, Dr. Leana Kart, Dr. Winston Carhee Jr. and Dr. Michael Vaughn. As the president I extend big thank you to those who are not returning to the board at this time, Dr. Krystal Tomlin and Dr. Bob Hayden. Your dedication and service to the board is always appreciated and your impact will live on beyond your term of service. Dr. Robert Bob Roll-Tide Hayden will truly be missed in the board meetings. His keen perspective and kind words have been thought provoking and inspirational to all of us on the board. His dedication and leadership from the role of director to the presidency have set the bar very high and give us all something to aspire to in our servitude with the GCA. Dr. Hayden is leaving our board to answer the call of the ACA leadership where he will chair one committee and vice- chair another at the national level. We are now in the second round of voting with the new system and it has proven to work well. Our goal was to increase representation across the state and increase the number of members that are able to participate even if they were unable to attend the annual business meeting in person. The next cycle of elections are upon us now at the executive level. These positions are for President-elect, Secretary and Treasurer. Any member in good standing is eligible to be nominated or self-nominate for these positions. If you are not willing to put your name on a ballot or volunteer to be on a committee I would ask you to vote. The more we hear from you, the better we can serve you. That is why the staff has implemented a new 21st century Web site. This site is set up to help you in all chiropractic areas. There are blog groups in many different areas for insurance to technique. There is an easy referral system for doctors and consumers, as well as special areas for members only. If you are not a member, only one new patient will pay for your membership, so if you have not considered being a part of the GCA this is a great reason to become one now. As always it is my pleasure and honor to serve as your president and please call me if there is something we can do better for all serving in the field. Yours in Health, Edward Cordovado, D.C. President

6 Anthony Chiropractic, P.C. 335 Hawthorne Lane Athens, GA Dr. Mark Anthony refer your uga students to us Chiropractic Debt Collection Simplify your day No placement fees Online access Chiropractic references available RTC FINANCIAL (888) ext summer 2014 the Georgia Chiropractor

7 Executive insights Georgia Chiropractic Association the georgia chiropractor Summer 2014 Volume 33, No. 3 Official Publication of the Georgia Chiropractic Association, Inc. Founded 1912 Michael T. Walsh, C.A.E. Executive Director & Editor in Chief RoseMarie Griffeth Business Manager Terrence Cherry Director of Member Services Valerie L. Smith Director of Membership and Communications Aubrey T. Villines, Jr. J.D. General Counsel Georgia Chiropractic Association, Inc Northlake Parkway, Suite 201 Tucker, Georgia P: F: Jennifer Campbell Graphic Designer For advertising, please call or The Summer of Discontent How Will You Respond? Summer is a time of year we devote to outdoor activity, enjoy vacation with friends and family and, of course, take care of our patients. In the even-numbered years, summer is also a busy time because various state and federal candidates for office vie for our attention and money, either during the just-completed primary and run-off primary season or leading up to the general election. This summer is especially busy with campaigning, fund raising and other political activity due to the number of important offices to be filled in November. Georgia will be electing a candidate for governor. For the first time in several years there will be an open seat for the U.S. Senate from Georgia. This particular race has, in turn, led to other open-seat elections, as well as the other elections for office that occur every two years. I m sure you have noticed all of the political noise for the past several weeks, including radio and television ads, phone calls and the inevitable accusations, denials and counter-accusations. Several of these candidates have told me that they will fight for me in Congress or tell me how pro-this and anti-that they are. They even try to convince me how conservative or liberal they or their opponents are, as if assigning a percentage to this will lead me to support them. This may be the best way to campaign and to dumb it down for the general electorate, but at least for me, it tells me very little except how ridiculous this campaigning is, trying to squeeze positions on issues into a 15 or 30 second sound bite. While this may have been going on for a long time, the results to this approach this year may be different. Already this summer, Virginia Republican and U.S. House Majority Leader Eric Cantor was defeated in the primary election by a college professor with little else but ideas and proposed solutions. Mr. Cantor s opponent raised less than a tenth of the campaign contributions of this long-time incumbent who was the second most powerful man in the U.S. House. Other surprise election outcomes may not turn out to be surprises at all. From an electorate that is tired of little being accomplished except finger-pointing and having to suffer for it, actual change may be in the wind. Voters are sophisticated enough to know that very little is getting done. For example, my congressman wrote to tell me that the Republican-controlled U.S. House passed two important tax relief bills and sent them along to the Democratic-controlled U.S. Senate. I responded to his correspondence with my own, stating that passing bills which have no chance of being taken up by the Senate or signed by the President amount to little more than political posturing, like voting 100 times to get rid of Obamacare. Regardless of your own personal opinion on the issue, it s not going to happen, at least until the Senate and the occupant of The White House change. So, are we willing to wait until this fall, and more than likely 2016, for any kind of progress on anything? I hope not. I vote for candidates because I support their positions on issues. But I also elect someone to go to Washington, DC or the Georgia State Capitol, for that matter, to legislate. It s easy to introduce bills; it s tough to legislate or work with those of differing views to craft and introduce bills that will actually pass and be signed into law. For isn t that what it is supposed to be about? Please take a break from your activities this summer and join me now and in the fall in electing legislators, not ideologues; doers, not finger-pointers. We will all benefit from it. Michael T. Walsh, C.A.E. Executive Director

8 national news ACA Presses HHS to Aggressively Enforce Provider Non-Discrimination Law Anthony Hamm, D.C. The American Chiropractic Association (ACA), in comments submitted to the Department of Health and Human Services (HHS), strongly defends provider non-discrimination language included in the 2010 Patient Protection and Affordable Care Act (PPACA) as essential to quality patient care and genuine reform. ACA maintains that Congress intent is clear in this matter and that states and insurers should be pressed to adhere to the law as written, which will improve patient access to quality care and reduce costs. The comments submitted by ACA are part of the profession s on-going campaign to ensure the proper enforcement and aggressive implementation of that part of the health reform law aimed at curbing discriminatory abuses against the chiropractic profession and other non-md health care professionals and they complement a series of targeted lobbying and grassroots activities that seeks a robust non-discrimination requirement enforceable in all 50 states. The ability for patients to actually take a role in choosing the provider of their choice is integral in the further implementation of PPACA. If improving the patient experience, value and positive outcomes are indeed the pillars of health reform, Section 2706(a) should be considered a linchpin to the Act s success, writes ACA President Dr. Anthony Hamm as part of ACA s formal comments. The comments received by HHS from ACA and other groups on PPACA s non-discrimination provision (Section 2706) will be used to devise further guidance for states as they continue to implement the federal health care reform law locally. Proper implementation of the law has been hampered in part by flawed information distributed last year by the HHS Center for Consumer Information and Insurance Oversight (CCIIO), which led some states to limit patient access to qualified health care providers, including chiropractic physicians, based solely on the providers licenses, in direct contradiction to the intent of Congress. ACA specifically urges HHS to repeal the flawed set of Frequently Asked Questions on Section 2706 prepared by the CCIIO, noting that it has caused nothing but confusion and chaos, especially at the state level. The Senate Committee on Appropriations issued similar language on July 11, 2013, in support of a revision of the FAQ on Section 2706, noting that the original document falsely gives insurers the impression that they can exclude whole categories of providers based on licensure. The goal of this provision is to ensure that patients have the right to access covered health care services from the full range of providers licensed and certified in their state, the Senate report states. The ability for patients to actually take a role in choosing the provider of their choice is integral in the further implementation of PPACA. If improving the patient experience, value and positive outcomes are indeed the pillars of health reform. Additionally, as a result of ACA lobbying efforts, more than three dozen House of Representatives Democrats recently submitted a letter to HHS Secretary Sylvia Burwell, urging 8 summer 2014 the Georgia Chiropractor

9 Discount for GCA members! Brian McAulay, Ph.D. her to implement Section 2706 appropriately. According to ACA officials, HHS will likely take some action to clarify and/or replace the flawed FAQ language issued in 2013, and they estimate potential corrective action will likely take place before the end of this year. Until or unless the issue is finalized in a manner acceptable to the ACA, and fully in keeping with the law s original intent, the ACA will continue its campaign to ensure the proper implementation of Section Foundation for Chiropractic Progress Welcomes McAulay to its Board of Directors The Foundation for Chiropractic Progress (F4CP), a not-for-profit organization dedicated to raising awareness about the value of chiropractic care, announced today the appointment of Brian J. McAulay, Ph.D., president, Parker University, to its board of directors. With over 30 years of experience in higher education and health care practice, McAulay will present the organization with excellent leadership skills. We are honored to welcome Dr. McAulay to our board of directors, says Kent S. Greenawalt, chairman, F4CP. He brings a wealth of knowledge about the chiropractic profession that will complement the activities of our organization. He is a valuable addition to our board of dedicated industry leaders, and his involvement will help to expand our campaign and achieve even greater levels of success. I am honored by this appointment to the board of directors for the F4CP, which continues to fulfill its successful mission of advancing the public s understanding of chiropractic and generating positive exposure. Call or for a quote today! In addition to his position with Parker University, McAulay serves on several community and professional boards and is the president of the Association of Chiropractic Colleges. McAulay is the first individual in chiropractic education to be awarded the American Council on Education (ACE) Fellowship. He completed his postgraduate work at the Institute for Educational Management at Harvard University s Graduate School of Education. Eager to assume his new position, McAulay said, I am honored by this appointment to the board of directors for the F4CP, which continues to fulfill its successful mission of advancing the public s understanding of chiropractic and generating positive exposure. Medicare Fees for CMT to Increased on July 1 The Centers for Medicare and Medicaid Services (CMS) issued notification June 6 regarding updates to the 2014 Medicare Physician Fee Schedule Database that went into effect on July 1, Included in the updates were new fees for Chiropractic Manipulative Treatment (CMT) codes 98940, and Following the completion of the Chiropractic Medicare Demonstration Project in March 2007, CMS determined that the costs of this demonstration were higher than expected, and they were required to recover $50 million over a five-year period by deducting two percent from payments for chiropractic services. CMS has now determined that the costs are fully recovered; therefore, effective for dates of service on or after July 1, 2014, the two percent reduction for CPT codes 98940, and have been eliminated.

10 Case study Lumbar Pain and Sciatica, Complicated by Shingles Outbreak By Robert Hayden, D.C., Ph.D, F.I.C.C. Robert Hayden, D.C., Ph.D, F.I.C.C. History and Presentation Mac first presented for care in August 2012 with a chief complaint of lumbar pain, radiating down the left lateral leg to the ankle. It was worse with weight-bearing, described as approximately 5/10 in intensity, without numbness or tingling. His pain was made worse with long periods of sitting (more than 30 minutes), and ameliorated some by walking, more by lying down. He worked in a place that sold auto parts, so lifting, bending, twisting and walking on concrete floors for long hours were part of his daily expectation. He is a 67-year-old Caucasian male who lives with his wife of 35 years. He had a pleasant disposition and appeared in no acute distress at the time of his first exam. He denied vices (smoking, alcohol abuse, recreational drug history). At 5 11 tall and 238 pounds, he was moderately heavy. His medical history was significant for hypothyroidism for the past 15 years, treated by Synthroid. He also took Hydrodiuril with a potassium supplement for mild hypertension with adequate control. He took Centrum Silver and glucosamine daily. His only trauma was an arm fracture in childhood. Surgical history included a hernia repair in February On exam, there was a positive Beckterew s and straight leg raiser test with Braggard s on the left side, radiating pain to the left L5 dermatome. Valsalva maneuver exacerbated the back pain, particularly in a seated position. Range of motion was unremarkable except slight antalgia to the left side. Lumbar X-ray (AP & lateral) revealed five normal lumbars, leaning to the right, with a high right ilium that tilted the pelvis to the left. Disc spaces were well preserved. Lumbar lordosis was reduced in a manner consistent with myospasm. No soft tissue anomalies were observed. It was concluded that he likely had an L4 disc bulge, posterolateral on the left. His lumbar pain was treated with flexion distraction successfully over the next four weeks. He did well for several months. Mac returned for care in early June with similar symptoms: lumbar pain at 4/10 with sciatic radiation to the left, this time more in the groin and left thigh than in the leg, although the left lateral leg also was involved. We began treatment with spinal decompression (using a Chattanooga digital traction table) in the first week of June. On 16 June, Mac said that sometime during the previous week, he believed that the traction belt around his waist may have been too tight. He stated that it had produced a rash that felt like a rope burn, radiating from his low back to his left groin. Inspection revealed a raised rash extending from midline of the spine near L4/L5 to the patient s left, wrapping laterally and inferiorly, then anteriorly and inferiorly into the groin. Upon questioning, Mac said he believed that the rash had raised white pustules when it first arose about four days earlier. He experienced itching and burning at the site of the rash and had treated it with calamine lotion, although he noted very little success in controlling the discomfort. He had no fever or other constitutional disturbances. Although the lesions roughly followed the path of the traction belt as applied when the patient is on a decompression table, there were no analogous lesions on the right side of the spine or groin. Diagnosis: Herpes Zoster/ Shingles The Virus: Almost every adult in America over the age of 40 has had chickenpox, even if they do not remember it. Once inside the body, this virus (varicella) waits patiently for an opportunity to manifest itself. Specifically, it is waiting for some weakness in the immune system or a slight biochemical environmental change that allows this virus to run rampant. About one in three people in America will have this disease in their lifetime, with about one million infected at any given time. The risk of an outbreak increases with age and concomitant decline of immunity, with about half of the cases in people over 60 years of age. Although it is usually mostly a painful interruption of health, a recent study implicates this virus 10 summer 2014 the Georgia Chiropractor

11 feature Photos 1 & 2: Inspection revealed a raised rash extending from midline of the spine near L4/L5 to the patient s left, wrapping laterally and inferiorly, then anteriorly and inferiorly into the groin. Photo 3: Laser treatment in process: four-head, 635 nm infrared, applied minutes in each affected area, beginning at nerve root. Photos 4 & 5: On Thursday, following the third treatment, dramatic improvement was noted in his rash. in about 100 deaths per year among people whose compromised immunity leaves them open to attack. Because this viral infection attacks spinal nerves, the manifestation will roughly follow dermatomes unilaterally. About 20 percent of patients will have overlapping dermatomes affected. Initially there is frequently burning, itching or tingling, followed by a painful rash that scabs over within seven days. In Mac s case, the scabbing progressed rapidly, possibly because of his vigorous use of calamine lotion, and possibly because the rash occurred in a high friction area when wearing jeans. Although shingles cannot be transmitted from person to person, contact with someone in the early stage of the rash (before the scabbing) can transmit the virus that causes chickenpox in someone who has not already had it. Thus, it is prudent to keep the rash covered and use normal handwashing precautions. In our case, we cleaned our table and its accessories with 70 percent isopropanol, allowing it to dry overnight. The worst-case scenario is the development of post-herpetic neuralgia (PHN), an extended version of shingles pain that may last for months or years. Treatment is more difficult with such progression. Treatment: First, the implications of this condition were explained to the patient. An informed decision needed to be made. We could refer him to a primary care physician, but medical treatment has very limited effectiveness with this condition. We could treat conservatively with a modality that is potentially far more effective and safer than medical treatment, then refer if not successful within one week. After weighing these options, the patient opted for the latter. Medical treatment for shingles varies with the approach of the practitioner. Most will use antiviral drugs, such as acyclovir, to initially slow the progression of the virus. Topical antibiotics may be used to prevent secondary bacterial infection of the blisters. Topical anesthetics like benzocaine might be used to control the pain of the rash. Oral pain medication may include over-the-counter acetaminophen, ibuprofen or narcotics. Antidepressants are sometimes used to augment pain medication. Gabapentin, an anti-seizure drug, may be used to capitalize on its side effect of raising pain threshold. Steroids are sometimes administered. All of these, sadly, may be ineffective in addressing the condition or the sometimes horrendous pain it can produce. Can chiropractic help with an active shingles case? I know of no evidence that chiropractic can help with this condition, but the chiropractor can. There is a growing body of anecdotal evidence describing the positive effect of infrared laser on this condition. I can personally attest to the success of the application of laser with shingles, as we have now treated several with positive results. Low level laser therapy (LLLT) has been used in Asia and Europe for about 40 years. It was approved by the Food and Drug Administration (FDA) in 2002 for the reduction of pain and inflammation in musculoskeletal conditions. It is proposed by some that neural tissue may be photosensitive in such a way that LLLT may reduce pain sensitivity by interrupting fast pain fibers. LLLT is also believed to speed healing by accelerating protein synthesis and mitochondrial energy production. Mac was treated with a dual probe/4 diode infrared laser with a 635 nm wavelength. The laser was focused on his lesions for minute sessions, one on the back and one on the groin on Monday, Tuesday and Thursday of the week following his breakout. During this time, spinal decompression was discontinued to avoid any abrasion of the rash. He continued to use the calamine lotion at home. He wore loose fitting clothes to stay comfortable. On Thursday, following the third treatment, dramatic improvement was noted in his rash. He reported that by Wednesday, his burning pain was gone, leaving some mild sensitivity where the skin was damaged. He denied any further paresthesia or pain along the site of the rash. Discussion Chiropractors have used physiotherapeutic modalities for the last 100 years. Often maligned and defined as ineffective or quackery by organized medicine, many of these modalities have been found effective and are emulated by medicine and other disciplines. In this case, we see a dramatic clinical improvement with only the use of an adjunct therapy commonly used in a chiropractic context. Our medical colleagues throw very powerful drugs at this condition with limited success. The use of powerful drugs sometimes necessitates the use of other drugs to counteract side effects. A patient s body may become a toxic dump with tissues caught in a biochemical crossfire. The ideal drug acts only on the tissue it is designed to affect and no others. It only does what it is designed to do with no side effects. It does not harm the patient. Of course, no such drug exists. All the above makes it even the more exciting when a treatment is safe and effective without harmful side effects.

12 This clinic helps fill the gap of too few primary care physicians Albany D.C.s, Physicians Form Urgent Care Clinic By Valerie L. Smith With the many changes in health care precipitated by the Affordable Care Act, from increasing premiums and deductibles and the development of Medical Homes to newly insured patients, Dr. Davis Kinney thought demand for urgent care facilities would rise in Albany. Many patients are basically self-insured until they meet high deductibles, and I thought people would be looking for a place to go where they could pay a reasonable cash fee and have access to less expensive testing, he explained. Plus, the additional or new portal of entry of the urgent care concept, offering both traditional medical care for minor emergencies and chiropractic care, is exposing the option of chiropractic treatment to an entirely new group of patients who may not have considered chiropractic care previously or who may not have understood that chiropractic care was perhaps the most appropriate option for treating their condition. People usually call the doctor when they are in crisis, meaning they are sick or in pain. Being available to care for patients on an urgent care basis with a broad range of multidisciplinary services allows our providers to use these crisis encounters to educate them about other treatment options like chiropractic care. So with two other doctors of chiropractic, Dr. Dan Webb and Dr. Donnie Butler, a chiropractor/nurse practitioner, Dr. Troy Alderman, two emergency doctors, Dr. Allen Lee and Dr. Jonathan Williams and an internal medicine doctor, Dr. Jorge Pisarello, Kinney launched OneSource Healthcare in January. Our philosophy is chiropractic first, drugs second and surgery last. Williams was happy to join the team. In most emergency departments, patients are coming in with non-emergent problems because they have no access to care, so they come to the hospital. This clinic helps fill the gap of too few primary care physicians, which is a big problem, especially in rural America, he said. Kinney explained how the practice was formed. We combined two busy D.C. offices together to help create a walk-in base for emergency care. And we re working collaboratively with M.D.s and a D.O. to expand the range of services for our patients. For example, Kinney recently had a patient 12 summer 2014 the Georgia Chiropractor

13 feature with a history of kidney stones come in with acute back pain, and he was able to have lab tests done in-house to rule out kidney stones, instead of referring her. Likewise, the internist and emergency doctors refer back injuries to the D.C.s. Instead of just prescribing pain medication, the patient has the underlying problem corrected. Our philosophy is chiropractic first, drugs second and surgery last. Williams said co-managing patients works well. People with acute work injuries want to go back to work. If they go to the hospital, they then have to follow up with an orthopedist. Here, we diagnose them and put them on a treatment pathway the same day. The patients love it, and we re doing it in a cost effective way. And because two emergency physicians are on staff, the clinic is able to handle situations that primary care physicians may not be comfortable handling. We are able to treat asthma attacks and fractures at the office and know how to recognize acute disease that needs intervention right away at a hospital, like heart attacks or strokes, Williams said. Additionally, this business model allows doctors of chiropractic to share in revenue that they normally would have lost by referring to an outside doctor. Our physicians can order X-rays, exams and therapies for Medicare patients, which has allowed us to expand our base. Also, all of us are certified to perform Department of Transportation physicals, and in our area, only the hospital s Occupational Health Clinic was performing those, Kinney said. Plus, patients who do not have a primary care physician are referred to the clinic s internist. We determined three of our DOT physical patients had uncontrolled hypertension and didn t have a primary care physician, so we referred them to our internist to manage their blood pressure, Kinney said. Currently, between 60 and 70 percent of traffic to the clinic are chiropractic patients, but the number of urgent care patients is growing, with about patients a day walking in. It s been going fabulously well, Kinney said. The reputation of goodwill our chiropractors have built with our patients translates into trust of the other medical providers. While patient flow has been good, the clinic has faced some challenges, especially in billing. If a patient sees a D.C. and an M.D. in the same day, it has to be billed from the same facility under different provider numbers. It can get tricky when there are multiple EM codes. Also, we have a chiropractor who is also a nurse practitioner, so he sometimes bills as a nurse, other times as a chiropractor, Kinney said. Kinney believes the urgent care and chiropractic model is a good one. It s a great model for D.C.s with an established practice who see the market eroded. It allows us to provide the same services and add more services to combat eroded reimbursements, he said. Williams has enjoyed working with doctors of chiropractic. They re a different breed. They re more inventive and have outside the box thinking. They re not afraid to pull up their sleeves and get their hands dirty. The best thing has been getting several physicians in a room together to discuss how we can help more patients, more quickly and cost effectively. This is the direction medicine needs to go to work on patient wellness and prevention for less disease. Kinney said, The perceived conflict between M.D.s and D.C.s is in the mind of the D.C. We have experienced strong cooperation with the other physicians. They are appreciative of what we do, and are all for not using drugs. Those considering establishing a multi-disciplinary practice should proceed carefully. You can get in trouble with a multi-disciplinary practice. You need to find an attorney who specializes in health care law not a personal injury attorney to help set it up and ensure you are operating within legal parameters, Kinney said. OneSource Healthcare is set up as a true group practice. We have five physicians who spend at least 75 percent of their time at the clinic; we have central billing; everyone invested in the setup of the practice; and, we share income. Kinney hopes OneSource Healthcare is just the beginning. I hope this will be the first of several clinics, he said.

14 More than 20 vendors supported the conference 2014 s p r i n g conference a n d t r a d e s h o w Spring ConferencE Draws Big Crowd By Valerie L. Smith Nearly 160 doctors of chiropractic and chiropractic assistants hit the books and the beach during the Georgia Chiropractic Association s Spring Conference and Trade Show May 2 4 at the Omni Hilton Head Oceanfront Resort on Hilton Head Island, SC. Our Spring Conference is a great opportunity for the chiropractic community to come together to learn and share fellowship, explained GCA President Ed Cordovado, D.C. I was also excited to see a lot of doctors brought their families to enjoy the beach. More than 20 vendors supported the conference, and attendees enjoyed seminars on topics from setting care criteria and the effects of NSAIDs on the body to building interdisciplinary relationships and spinal case studies. Next year s Spring Conference and Trade Show will be May 15 17, 2015 at a new location, the Sonesta Resort on Hilton Head Island. p a r t n e r s p o n s o r s Myofascial Acoustic Compression Therapy (MyACT) for targeted, non-invasive pain relief E d u c a t i o n S p o n s o r s C o n f e r e n c e s p o n s o r s 14 summer 2014 the Georgia Chiropractor

15 feature

16 Those wishing to avoid gluten should read product labels carefully to ensure they do not accidentally ingest it. GLUTEN: Gluten: Bad for All Guts By Valerie L. Smith Dr. Lorraine Gravante, right, with Dr. Alessio Fasano. Gluten free products are popping up at grocery stores across the country, and according to one Georgia Chiropractic Association member, even those who don t suffer from celiac disease or gluten sensitivity should consider limiting gluten in the diet. According to research conducted by Dr. Alessio Fasano, gluten causes inflammation in the stomach that can lead to leaky gut, explained Dr. Lorraine Gravante. All of us have an inflammatory response to gluten. Gluten is commonly found in products made of wheat, barley and rye, and may be used as an additive to other foods. Fasano, a pediatric gastroenterologist, is the director of the Center for Celiac Research and Treatment at Massachusetts General Hospital for Children in Boston. Dr. Fasano also directs the Mucosal Immunology and Biology Research Center and is associate chief for Basic, Clinical and Translational Research. Under his leadership, investigators are studying the molecular mechanisms of autoimmune disorders including celiac disease and other gluten-related disorders. He has been named visiting professor of pediatrics at Harvard Medical School. He authored the groundbreaking study in 2003 that established the rate of celiac disease at one in 133 Americans. Through his research, he and his team discovered zonulin, a protein that controls leaky gut, also known as intestinal permeability. Leaky gut can be caused by many things, including: medication, antibiotics, junk food, poor diet, stress, excessive alcohol consumption and gluten, Gravante explained. When the intestine becomes permeable, bacteria, undigested food, toxins and waste can get into the blood stream, where the body sees it as an invader, which can trigger an allergic/autoimmune response. While some people may experience no symptoms of leaky gut, others have reported cramping, bloating, achy joints, food sensitivities and rashes. Additionally, leaky gut has been shown by Fasano to cause celiac disease and may be connected to other diseases, such as Type I diabetes, Crohn s disease, irritable bowel 16 summer 2014 the Georgia Chiropractor

17 In addition to obvious gluten-containing foods like breads, cereal, baked goods and pasta, the Celiac Disease Foundation (www.celiac.org) warns gluten may be an ingredient in other prepared foods such as: feature Gravy and cream sauces Beer Granola bars French fries Potato chips Processed lunch meats Candy Soup Salad dressings and marinades Starch or dextrin on a meat or poultry product Meat substitutes, such as vegetarian burgers or sausages and imitation bacon and seafood that are made with seitan Soy sauce Self-basting poultry syndrome and possibly some cancers. It s like if you give a group of eight-year-olds peanuts. Some will be fine, some may have digestive distress, some might get a rash and there will be one or two that may go into have anaphylactic shock, Gravante said. In addition to avoiding NSAIDs, antibiotics and junk food, Gravante recommends either minimizing gluten or cutting it out completely. Avoiding gluten can be challenging, as it is an additive to so many foods (even Kroger rotisserie chicken is not glutenfree). I only eat Ezekiel bread, and even my patients with celiac disease can eat a little of that. Other starches that can take the place of gluten-containing wheat, barley and rye products include quinoa, brown rice and sweet potatoes. But because starches are a polysaccharide, they are like sugar bombs. The starches breakdown quickly and the glucose goes right into the blood stream, which can cause insulin spikes. So eat starches sparingly to moderately, she said. In addition to preventing leaky gut, a low or gluten-free diet appears to alleviate some of the symptoms of children with autism. Once gluten has been eliminated from the diet, Gravante recommends patients with leaky gut or celiac disease take a good probiotic, immunoglobulin concentrate and l-glutamine to help rebuild gut mucosa along with restricting refined carbs and eating more nutrient dense organic fresh whole foods. Gravante, who is pursuing a master s degree in Metabolic Nutritional Medicine at the University of South Florida, School of Medicine and is completing her Fellowship in Anti-Aging Regenerative Medicine through the American Academy of Anti- Aging Medicine, feels chiropractic and functional medicine are a perfect union in natural healthcare. Both of these healing arts focus on the cause of the problem not just the symptom. Chiropractic s main focus is with the biomechanical function of the body while functional medicine focuses on the metabolic function. Together they are a powerful synergistic approach to wellness, she concluded.

18 From the Centers for Medicare and Medicaid Services and the American Chiropractic Association PQRS and Meaningful Use: Prepare for Fee Reductions The Georgia Chiropractic Association office has received a number of phone calls from members who are confused about the Physician Quality Reporting System (PQRS) and Meaningful Use requirements from Medicare. These are two separate programs that will become mandatory in 2015, and doctors who are not participating will be subject to reduced Medicare reimbursements. PQRS The Patient Protection and Affordable Care Act made participation in Medicare s Physician Quality Reporting System (PQRS) program mandatory beginning in 2015 (based on 2013 reporting). The PQRS is a reporting program that uses a combination of incentive payments and payment adjustments to promote reporting of quality information by eligible professionals (EPs). Incentive Payments: The 2014 reporting period (Jan. 1 Dec. 31, 2014) is the last opportunity providers have to earn an incentive payment for participating in the PQRS program. Providers who successfully perform and satisfactorily report data to the Centers for Medicare and Medicaid Services (CMS) regarding quality measures related to their Medicare Part B patients can qualify to earn an incentive payment equal to 0.5 percent of their total estimated Medicare Part B Physician Fee Schedule (PFS) allowed charges for covered professional services furnished during that same reporting period. Incentive bonuses are usually paid in the month of November. Payment Reductions: CMS finalized Calendar Year 2013 as the performance period for the 2015 PQRS penalties. Therefore, doctors of chiropractic who did NOT report quality measures data in 2013 will have their Medicare reimbursement decreased by 1.5 percent beginning in Further, Calendar Year 2014 is the performance period that will affect a provider s 2016 Medicare reimbursement. If CMS determines that an eligible professional has not successfully performed and satisfactorily reported on quality measures during the 2014 reporting period (Jan. 1 Dec. 31, 2014), the provider will not qualify for the 0.5 percent payment incentive AND they will see a payment decrease of two percent applied to their 2016 Medicare reimbursement. ACA said while D.C.s should 18 summer 2014 the Georgia Chiropractor

19 feature have been reporting on quality measures all year to ensure successful and satisfactory reporting, they may still begin reporting in an effort to be eligible for the 0.5 percent payment incentive for 2015 and to avoid the 2016 payment decrease. D.C.s must report measures correctly for at least 50 percent of the eligible Medicare Part B fee-forservice claims. Measures with a zero percent performance rate will not be counted. D.C.s who begin reporting on quality measures NOW can avoid the 2016 payment adjustment, and if they successfully and satisfactorily report on all applicable measures in 2015, their reimbursement will revert to the standard Medicare fee in GCA and ACA urge D.C.s who have never reported quality measures to begin immediately. For D.C.s who are continuing their participation in PQRS, significant updates and revisions were made for 2014 that affect the number of PQRS measures applicable to chiropractic practices as well as the specific quality-data codes (G-codes) used to report these measures. To get started: First, no registration is required to begin participating in PQRS. The three (3) quality measures doctors of chiropractic need to report are: Measure #131: Pain Assessment and Follow-Up Measure #182: Functional Outcome Assessment Measure #317: Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented (NEW for 2014) 3) To receive an incentive bonus for participating in PQRS, and avoid the 2016 payment adjustment, you must report satisfactorily on all three measures applicable to DCs during the 12-month reporting period. For more information on how to begin PQRS reporting, visit Electronic Health Records and Meaningful Use The Medicare Electronic Health Record (EHR) Incentive Program started in 2011 and will continue through The program was designed in three steps (Stage 1, Stage 2 and Stage 3) with increasing requirements for participation. Originally, all Eligible Professionals (EPs) needed to begin participating by meeting the Stage 1 requirements for a continuous 90-day period in their first year of meaningful use (MU) and a full year in their second year of meaningful use. After meeting the Stage 1 requirements, providers will then have to meet Stage 2 requirements for two full calendar years. However, for 2014 only, the reporting periods have been revised. Due to delays in the publication of regulations that require EHR vendors to upgrade their systems to meet certified technology criteria, all providers are only required to demonstrate MU for a 90-day EHR reporting period. In short, doctors of chiropractic will only need to exhibit MU for three months in regardless of what stage you re in. It is important to note, however, that the 90-day reporting period selected for 2014 depends upon: if the D.C. is a first time participant in the program or if the D.C. began meaningful use prior to 2014; and the EHR vendor s readiness to meet the Office of the National Coordinator s (ONC s) 2014 certification criteria. CMS Designated 2014 Quarterly Reporting Periods for EPs Beyond One Year of MU Participation (choose only one) January 1 March 31 April 1 June 30 July 1 September 30 or October 1 December Reporting Periods For First Year MU Participants Any 90-day Reporting Period Note: D.C.s who begin reporting on or before July 3, 2014 and attest on or before October 1, 2014 can avoid the 2015 payment adjustment D.C.s who began their first year of reporting in 2011, 2012 or 2013 may report quarterly in CMS has designated dates for the 2014 EHR Incentive Program quarters, which are shown in the table above. ACA recommends that D.C.s contact their EHR vendor to confirm when their system will be fully upgraded to select which quarter of 2014 to begin reporting. First-year program participants should report on any 90-day period. D.C.s had until July 1, 2014, to begin reporting and should attest no later than by October 1, 2014, to avoid being penalized in D.C.s who began reporting after July 3, 2014, are still eligible to receive up to the 2014 EHR incentive payment of $24,000; however, they will also receive the 2015 program adjustment a one percent decrease in Medicare reimbursement for all claims submitted in D.C.s who begin using EHR between now and October 3 and prove they are meaningfully using their software by completing the attestation process by February 1, 2015 can still be eligible for incentive payments. Though they will still have the 1 percent decrease in 2015, normal Medicare fees will be restored in For a list of certified EHR software, meaningful use measures, how to attest and how to get started with electronic health records, visit

20 1 0 2 n d A n n u a l Georgia Chiropractic Association fall conference a n d t r a d e s h o w Show your spirit! Register Visit to register, or call for more details. Refresh your chiropractic spirit with new techniques, fellowship with other doctors and access to top vendors at the Georgia Chiropractic Association s 102nd Annual Fall Conference & Trade Show October 24 26, 2014 at the Crowne Plaza Ravinia in Atlanta. Receive all 20 Hours of Required CE for 2014, including: Jurisprudence Risk Management Clinical Sciences MRI, extremity adjusting, panel discussions and more! 20 summer 2014 the Georgia Chiropractor

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