CHP Provider ejournal News & Information from The CHP Group Volume 1, 2014

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1 CHP Provider ejournal News & Information from The CHP Group Volume 1, 2014 Coding for Acupuncture by Peter Martin, LAc, LMT The provision of acupuncture and Oriental medicine within the third-party payer system of American healthcare necessitates the use of codes which designate what is being treated and what procedures are being utilized. The codes used to designate diagnoses are listed in the International Classification of Disease, 9th Revision, commonly referred to as ICD-9. The codes that designate therapeutic procedures are listed in Current Procedural Terminology (CPT ), updated and published yearly by the American Medical Association. Until 1997 there were no CPT codes for acupuncture. The advent in that year of the CPT codes for acupuncture (97780) and acupuncture with electrical stimulation (97781) was a milestone for integration. A new milestone was reached with the doubling of the acupuncture code set as of January 1, 2005 when and were retired. In their place we have: 97810: Acupuncture, one or more needles, without electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient : Acupuncture, one or more needles, without electrical stimulation, each additional 15 minute increment of personal one-to-one contact with the patient, with reinsertion. (List separately in addition to code for primary procedure) 97813: Acupuncture, one or more needles, with electrical stimulation, initial 15 minutes of personal one-on-one contact with the patient : Acupuncture, one or more needles, with electrical stimulation, each additional 15 minute increment of personal one-on-one contact with the patient, with reinsertion. (List separately in addition to code for primary procedure) There cannot, of course, be milestones without obstacles and the path of development for these new codes has been less than smooth. One glaring example of this is found in the definition of the codes, which includes the word reinsertion. This is not a word that has meaning within the acupuncture community since we do not reuse needles or points within a single treatment. This word was added by the AMA Reimbursement Update Committee (see below) to connote an additional set of points that would demand a greater amount of work. A set is undefined but according to the code definition it could be a single point. It must, for documentation purposes, be distinctly separate in some fashion and in the process of code development it was implied that a set would require repositioning of the patient. The CPT codes are the property of the AMA and they serve as a significant source of income for that organization. The CPT codes are used nationwide and have become not only the de facto standard but also the only HIPAA compliant code set. HIPAA, amongst many other things, mandated that there be a consistent code set across the country, no longer would there be regional codes and individual payors would no longer be able to use their own codes. The Centers for Medicare and Medicaid Services (CMS) is responsible for contracting with the AMA and establishing what is essentially a government mandated monopoly. In this process the CPT codes have come up against some criticism for being incomplete. An alternative code set, the Advanced Billing Concept (ABC) codes has been developed specifically with complementary and alternative medicine in mind. This was certainly not the focus of CPT. When HIPAA became the law of the land there existed a certain amount of pressure on the CPT to expand the code set. Acupuncture was one area ripe for expansion. The CPT Committee formed a workgroup comprised of representatives from the professional organizations that have acupuncture in their scopes of practice. These included the American Chiropractic Association (ACA), the American Academy of Medical Continued on Page 3 1

2 CHP Provider ejournal From the Editor: Best Practices in Complementary & Alternative Medicine At CHP we talk about best practices in clinical care delivery as exemplified in the 48 CHP Clinical Pathways, in clinical record keeping as documented in CHP s Clinical Record Keeping Quality Standards, in our commitment to continuous quality improvement and, as discussed in this issue of the ejournal, best practices in acupuncture patient safety. While there is no universal definition of best practices, there are characteristics of them that aim to improve performance and patients outcomes. Best practices are fair, legal, replicable, and applicable 1 across an organization to improve the quality of the healthcare services in the CHP network. They include ethics, guidelines, recommendations and ideas that represent the most effective, prudent and efficient course of action. Best practices are assembled from a variety of sources including regulatory agencies (e.g. licensing boards, state and federal law), training institutions and programs, professional associations, and the best medical evidence. However, as is often the case, these sources fail to define adequately those practices that truly represent the best that complementary and alternative medicine has to offer. At that point, consensus of experienced high quality clinicians and therapists must be engaged to elaborate those best practices. Massage & Bodywork (NCBTMB). An ad hoc committee of CHP massage therapists will convene to review this evidence and draft recommendations for quality standards relevant to massage therapy practice and consistent with CHP goals to improve the quality of care delivered in network providers offices and clinics. Chuck Simpson, DC ejournal Editor Vice President, Clinical Affairs at The CHP Group CHP has used the collective wisdom of network providers to further define best practices around clinical practice, record keeping, quality improvement and patient safety. Currently efforts are underway at CHP to further develop best practices in massage therapy record keeping. Work began with a series of workshops in connection with Table of Contents Coding for Acupuncture 1, 3, 4 From the Editor: Best Practices in Complementary & Alternative Medicine 2 Clinical Pathway Focus: Pediatrics 5 Clinical Management in , 7 Patient Safety: Best Practices in Acupuncture 8 Dr. Rita Bettenburg Receives Living Legend Award from NCNM and OANP 9 About The CHP Group 10 CHP continuing education events. Evidence has been gathered from state massage therapy regulatory boards, massage therapy educational programs, and The National Certification Board for Therapeutic 1 Best-Practice.com. com/definition-of-best-practice/ 2

3 Best Practices Coding for Acupuncture continued from page 1 Acupuncture (AAMA), the American Association of Oriental Medicine (AAOM) and the Acupuncture and Oriental Medicine Alliance (AOMAlliance). This group of practitioners met for over a year to develop a rational system that allowed for greater variability in coding an acupuncture treatment and still stood up under the scrutiny of, and was understandable to, the CPT Committee, few of whom had any knowledge of acupuncture. Time-based codes are something that have many precedents in the framework of the CPT code set and the conclusion of the workgroup was that this was the best strategy for additional acupuncture codes. These codes were indeed accepted by the CPT Committee and were then sent to the Reimbursement Update Committee (RUC) for valuation. The valuation process is one that all CPT codes go through and is, as they say, where the rubber hits the road. Valuation of a code means establishing a number called a Relative Value Unit (RVU) for that code. The number of Units expresses a Value which is Relative to that of other procedures, whether they be a colonoscopy or a cold pack. The RVU is made up of three separate component values. (The process of arriving at these values is beyond the scope of this article and to some extent proprietary to the AMA. Suffice it to say that it tries to be scientific, or at least systematic.) The work value denotes the training, effort and intensity of the practitioner s effort. The malpractice value denotes the risk involved in the procedure. The practice expense value denotes the cost of the office and equipment needed to perform the procedure. These three values are added to arrive at the RVU for that particular code. The RVU is then multiplied by a conversion factor to arrive at a dollar value for each code. The conversion factor is a dollar amount that is established contractually by insurers or regionally by CMS regulations for Medicare and Medicaid services. So, RVU x Conversion Factor = Reimbursement. The 2014 RVU for all CPT codes are available online at: PhysicianFeeSched/PFS-Relative-Value-Files-Items/RVU14A.html You can determine your own conversion factor by dividing the dollar amount of your charge for a particular procedure by that procedure s RVU. Which begs the question: What is the RVU for acupuncture? When and were established there was disagreement amongst the practitioners consulted and since neither code was a Medicare/Medicaid reimbursable expense CMS did not feel it necessary to publish values. There do exist other RVU systems, which are published independently of CMS and the AMA. Relative Value Studies Inc. published values of 1.83 for and 1.96 for When CMS first published the values for they ranged from.53 to.68. This was due, through error or omission, to the cost of actually having an office being left out of the code value. Any use of those code values is a clear under-valuation of acupuncture services. Fortunately this error was corrected by CMS as of RVU for acupuncture as of 2014 are at: Code 2014 RVU Code 2014 RVU The understanding of the workgroup was that the most common level of service would be 30 minutes of patient contact time, therefore, if there is no electrical stimulation, and one unit of If there is electrical stimulation one would use or or both as appropriate. The CPT initially mandated that one cannot mix the acupuncture without electrical stimulation codes and acupuncture with electrical stimulation codes but has since changed that to reflect the clinical reality. There are, of course, other nuances to code use. One of these is the aforementioned reinsertion. Another involves evaluation and management (E&M). E&M codes are divided into a new and a returning patient series of five levels of increasing complexity, time and charge. New patient codes are through Established patient codes are through The difference between a new patient and an established patient is three years. If the patient has not been seen by anyone in your clinic in that amount of time they can be considered new. Specific definitions of these codes can be found in the CPT manual. The 2014 E&M RVU are: continued on page 4 3

4 Best Practices Coding for Acupuncture continued from page 3 Code 2014 E&M RVU Code 2014 E&M RVU Typically within this model one patient encounter would entail the use of one E&M code and one or more procedure codes. The new codes for acupuncture do have a small amount of E&M included but it is minimal. The time element of the new codes are divided into three segments: Pre-service: Greeting of the patient and a brief interval history. The code is based on this being 3 min. Intra-service: Everything connected with doing the procedure - washing your hands, positioning the patient, locating and cleaning the points, inserting and stimulating the needles, checking on the patient, removing the needles. The code is based on this being 15 minutes. This does not include needle retention time when you are not directly monitoring or communicating with the patient. Post-service: Charting and any instructions to the patient. The code is based on this being three minutes. If your pre- and post-service time substantially exceeds 6 minutes you could charge for a suitable level of E&M, but it is essential that you document that you have fulfilled the requirements of that E&M code per the CPT manual. You must also modify the E&M code with a -25 modifier to denote that this is a significant, separately identifiable level of service. Insurers will expect E&M to be billed with a new patient and on reevaluation or a new diagnosis of an established patient. It is inappropriate to bill an E&M for each visit. Everything you code for must be supported by your chart notes. Historically the profession of acupuncture has been based on a cash practice with little variation of charge from patient to patient. Moving towards integration into the reimbursement structure of American healthcare means adopting and adapting the standard practices of coding to what we do. Our professional responsibility is to charge with some consistency a reasonable amount for our services. Insurance is not a cash cow to be milked by the sophisticated practitioner but an expression of the shared risk of human suffering. CHP UM Resources and Contacts CHP s Utilization Management (UM) policies and procedures are available 24/7 on our website, behind the secure provider log-in. These policies and other information include: Criteria for Medical Necessity Determinations Evidence-Based Criteria CHP s UM Affirmation Statement, signed by CHP clinician reviewers, to assure providers that UM decisions are made objectively Record Standards Information on the Best Practices in Clinical Record Keeping, CHP s Clinical Record Quality Improvement Program and clinical tools to guide and assist CHP providers in maintaining clinical records that support high-quality patient care. Clinical Pathways Forty-eight Clinical Pathways offering providers suggested clinical approaches for specific conditions. CHP uses evidence-based standards of practice from a consensus of expert opinion and review of scientific clinical literature to develop clinical criteria, which is reviewed and updated on an ongoing basis. Additionally, The CHP Group Utilization Management Department is available by fax 24/7 at All CHP fax lines, including the UM Department, are dedicated fax lines. All lines accept non-urgent requests outside of business hours but are not monitored during non-business hours. Therefore receipt of faxes will be documented on the next business day. 4

5 Best Practices Clinical Pathway Focus: Pediatrics CAM Use in Children Pediatric complementary and alternative medicine (CAM) has become of increasing interest as data shows increasing numbers of children seeing CAM providers and using CAM at home. The 2007 National Health Information Survey (NHIS) asked selected adult respondents about CAM use for children in their households. Responses indicate that 12% of children in the U.S. use some form of CAM. This increases the need for discussion about the safety and appropriateness of CAM approaches to pediatric health. This pathway provides a brief overview of the current evidence concerning management, safety, and use of CAM in pediatric healthcare. Among the top 10 therapies reported are natural products and homeopathics, chiropractic (and osteopathic) manipulations and massage. Conditions most frequently reported for CAM treatment include asthma, cancer, cerebral palsy, cystic fibrosis, gastrointestinal conditions (inflammatory bowel disease), back and neck pain, other musculoskeletal pain, colds, and mental health conditions (anxiety, depression, insomnia, ADHD, autism). Most pediatric patients who use CAM also receive conventional care. Evidence-based CAM A 2002 review identified more than 1400 random controlled trials (RCTs) and 47 systematic reviews of pediatric CAM. Formal evaluation of these determined that the quality of RCTs of CAM is as good as that of RCTs of conventional medicine, and the quality of systematic reviews of CAM exceeds that of systematic reviews of conventional medicine. As most literature highlights, there is a paucity of controlled clinical data regarding side effects of CAM in the pediatric population. Despite limitations of CAM evidence, healthcare providers need to be aware of the current evidence that does exist with regard to CAM therapies and not to assume such evidence is lacking or is of inferior quality. That being said, there are very few published reports of serious adverse effects of CAM use in children and lawsuits alleging CAM as harmful are rare. concerned about their adverse effects. Many families reported that CAM was more congruent with their own values, beliefs, and philosophical orientations towards health and life. The fear of known side-effects of conventional medications is another reason why some families seek CAM. When patients choose to use CAM, general trends suggest that between 50-80% report clinical benefits and side effects were perceived to be few. Pediatric Patient Management With all therapies, especially pharmacological treatments, prescribing and dosing should be performed by a by Charles Simpson, DC Clinical Pathways Clinical pathways for treatment of common conditions encountered in complementary and alternative medicine practice have been developed in order to help clarify performance expectations and to reflect CHP s commitment to the delivery of evidenced-based quality care. The pathways are available to CHP providers at professional with professional training and expertise in the field. All clinicians should ensure that they have the appropriate skills to treat the patient while complying with regulatory and institutional policies, and are legally authorized to provide treatment in the jurisdiction in which they practice. All providers must recognize their limits and refer appropriately. Whether a treatment is conventional or CAM, healthcare providers must weigh the risks and benefits of all available treatment options, inform their patients of these, and respect their patients values, beliefs, and preferences. The Pediatrics Clinical Pathway complete with references, patient and clinician resources are at available behind the secure provider login. Patient Preference and Autonomy Confidence in and use of CAM is increasing by families for their children. Many use CAM because they are attracted to the CAM philosophies and health beliefs, dissatisfied with the process or results of conventional treatments, or 5

6 CHP Insights Clinical Management in Healthcare reform continues to challenge CHP to remain focused on initiatives that demonstrate our clinical expertise. Our partnership with our provider network our core asset is critical. CHP elicits provider leadership through committee involvement to ensure ongoing evaluation of CHP in regard to: Continuing education of clinically related projects, processes and procedures; Monitoring changes in the complementary and alternative medicine (CAM) community; Establishing requirements for ongoing patient safety; Nurturing ongoing provider relationships. Utilization & Quality Management Utilization and Quality Management policies and procedures are reviewed and approved annually by clinician committees. Policies are configured to reflect performance expectations specified by the National Committee for Quality Assurance (NCQA). CHP s excellence has been demonstrated in our 100% NCQA Utilization Management audit scores over the past five years. 100% 2009 through 2014 NCQA Utilization Management Audit Scores Quality Management Program Quality initiatives throughout our organization reflect our consistent efforts in quality improvement. CHP commits significant resources to assisting network providers to improve the quality of care delivered to members. Patient Satisfaction Survey CHP s Patient Satisfaction Survey is an integral part of our Quality Management program. We perform an annual Patient Satisfaction Survey to identify potential opportunities to assess and improve member satisfaction. Our survey utilizes questions from the Consumer Assessment of Healthcare Providers and Systems (CAHPS ) 2.0 survey tool developed by the U.S. Agency for Healthcare Research and Quality. The questions pertain to provider communication, knowledge of patients medical histories, assistance given to patients in managing and/ or improving their medical condition, time spent with patients, appointment accessibility and Rate your 96% 2009 through 2013 CHP Patient Satisfaction Survey Scores Practitioner. The aggregate CAHPS Patient Satisfaction score in 2013 was 96%. Since CHP began performing this survey in 2000, patients have rated their satisfaction of CHP providers greater than 95% each year. Since 2009, CHP has expanded this survey to include questions relating to treatment outcomes or benefits of provider recommendations and reduction in use of prescription drugs and other medical care. The excellent scores depict a high rate of satisfaction from patients who seek care from CHP providers Clinical Quality Improvement Initiative The CHP Combined Medical Directors (CMD) Committee developed a Clinical Quality Improvement Initiative launched in 2013 with completion targeted for the end of This CQI initiative is focused on preventive health (PH) measures as documented in providers clinical records. Similar to a CQI project in 2005, this initiative furthers the earlier work to measure performance around what interventions the provider initiates when there are gaps in a patients preventive health status. To date, baseline performance data on seven measures (tobacco use, alcohol use, exercise habits, stress level, weight/appropriateness, dietary habits, and known allergies) has been collected among naturopathic physicians, chiropractors, and acupuncturists. The CMD Committee has identified opportunities for performance improvement that has the potential to positively impact member health. An intervention continued on page 7 6

7 CHP Insights Clinical Management in continued from page 6 group has been identified and interventions are currently being developed. Postintervention re-measure will be conducted by year-end. Clinical Record Quality High quality clinical record keeping is reflective of quality clinical care. CHP is committed to assisting providers in achieving the highest levels of competency with respect to clinical record keeping. The table below illustrates the outcomes of CHP s 2013 Clinical Record Quality Improvement Program. Clinical Record scores improved an average of 16 percentage points. Clinical Pathways CHP s Clinical Pathways are an important tool we use to deliver treatment guidelines to our provider network. We develop pathways with our provider committees and consultants to ensure Clinical Record Quality Improvement Program Scores Discipline Average Score at Enrollment Average Score at Completion Chiropractic 61% 83% Naturopathic 75% 87% Acupuncture 71% 86% accurate, relevant and current CAM clinical insight for treatment of common conditions encountered in complementary and alternative medicine practice. These pathways reflect CHP s commitment to the delivery of evidence-based quality care. In 2014, CHP developed or maintained 48 Clinical Pathways available via our website. These pathways cover an estimated 200 commonly encountered clinical diagnoses. Several pathways integrate guidelines across chiropractic and naturopathic medicine as well as acupuncture which provides a comprehensive approach that our providers find valuable. CHP Clinical Pathways Adhesive Capsulitis Asthma Atopic Dermatitis Autoimmune Disorders Behavioral Health Bell s Palsy Bronchitis Carpal Tunnel Syndrome Central Lumbar Stenosis Cervicogenic Headache Diabetes Type I Diabetes Type II Domestic Violence Dysmenorrhea* Fatigue Fibromyalgia GERD Hand/Wrist Strain/Sprain Headache Hyperlipidemia Hypertension Hypothyroidism Intervertebral Disc Syndrome Irritable Bowel Syndrome* Knee: ACL/PCL Tear Knee: Bursitis Knee: Meniscus Tear Knee: Patellar Tendonitis Knee: Patellofemoral Pain Lateral Lumbar Recess Stenosis Low Back Pain* Menopause Neck Pain* Orthopedic Red Flags Pediatrics Piriformis Syndrome Sacroiliac Joint Syndrome Scoliosis Sinusitis Shoulder Strain/Sprain Spondylosis Subluxation Trochanteric Bursitis (Hip) *These clinical pathways have a version for more than one discipline, for example, one pathway specifically for naturopathic medicine and one pathway for acupuncture. 7

8 Best Practices Patient Safety: Best Practices in Acupuncture by Lindsey Armstrong, LAc, MTOM Source material for this article originally published in the Pacific College publication, Oriental Medicine (OM) Newspaper. All health professions have different risks. The cases that have come to light of harm caused by acupuncture worldwide cover a range from infection control breaches to injury from needles. The percentage of harm caused in relation to the volume of treatments given is small in comparison to other medical practices, but taking steps to avoid harm should be a part of every treatment given. Malpractice In malpractice cases there are two ways to become liable: omissions (failing to do something we are supposed to do) and commissions (doing something to a patient that results in injury). So, being human, we need to realize that unintentional harm can result even when we have the best of intentions. Setting standards of care to protect our patients, such as needle counting and monitoring the patient during treatment, can become safeguards that should be fully integrated into our practice. Keeping Patients Safe In David Kailin s excellent book Acupuncture Risk Management, he suggests a list (see highlights below) of reminders for patient safety. It is a useful reminder of the excellent training we received in school and a review of the Clean Needle Technique. Best Practices: Acupuncture Needles Never give needles to patient for self-treatment or as samples. Whenever practical, position the patients in a reclined, supine or prone position. When needling a seated patient, be in constant attendance, elicit verbal feedback, and maintain visual assessment. Keep records of needle disposal through a licensed, regulated medical waste disposal company Wash hands before needle insertion, between each patient contact, after removing gloves, and immediately after any blood or OPIM (other potentially infectious material) exposure. Keep a bottle of bleach in the clinic to be available for clean-ups of any needle spills. Glove both hands for minor bloodletting procedures. Record needle count after insertion and on needle removal. Do not needle patients through their clothing. For points over the lungs, consider the horizontal and oblique needle placements to decrease vertical depth of penetration. Never use imbedded needles. Err on the side of caution. Acupuncture is safe, but we must still pay attention As with other CAM therapies, acupuncture has an enviable safety profile, particularly when compared to standard interventions in conventional medicine. Nonetheless, acupuncture needles, moxa, and heat Procedural Pause In an ideal world, prior to any important task we would do this procedural pause before locating points and inserting needles. However, being human, it is possible to rush, forget or simply space out on potential harms of our medicine. Since we are working with needles, moxa and heat lamps, it is important to keep safety in mind. lamps are not entirely risk free. Necessary regulation that requires adequate professional training and licensure can minimize risk across the profession. But it remains for each acupuncturist to attend constantly to those aspects of practice, such as taking a procedural pause before a treatment, that can assure that patients receive the full benefit of our medicine as safely as possible. 8

9 CAM Industry News Dr. Rita Bettenburg Receives Living Legend Award from NCNM and OANP Press release originally published at ncnm.edu/posts/ PORTLAND, Oregon (Dec. 12, 2014) National College of Natural Medicine (NCNM) and the Oregon Association of Naturopathic Physicians (OANP) honored Rita Bettenburg, ND, with the organizations highest honor, the 2014 Living Legend award. The award was conferred at a banquet held Dec. 6 at the Portland Marriott Downtown Waterfront Hotel. The award recognized Dr. Bettenburg s outstanding leadership, commitment to excellence and longstanding contributions toward the advancement of the naturopathic profession in Oregon. What distinguished Dr. Bettenburg from other nominees is the extraordinary breadth of how she has served the profession, commented Laura Culberson Farr, executive director of the OANP, during the presentation of the award. From teaching, to advocacy, to accreditation, at the state and the national level, Dr. Bettenburg has been there for 25 years. Bettenburg s dedication to deepen and expand the scope of practice of naturopathic medicine ran parallel to her commitment to raising the standards of medical education for naturopathic physicians. After earning a Master of Science in Medical Technology in 1974 from the University of Minnesota, Bettenburg launched what would become a nearly 40-year career in medical education by combining her love of healthcare with a passion for knowledge. After teaching immunology and clinical chemistry at a hospital in Minneapolis, she enrolled at NCNM. Bettenburg graduated from the naturopathic medicine program in 1989 and completed a residency in family practice. In 1990, she began her private practice while also rekindling her dedication to education as she accepted a teaching position at NCNM. In 2004 Bettenburg was appointed dean of the School of Naturopathic Medicine, where she was instrumental in establishing NCNM s national reputation for academic and clinical excellence until her retirement from NCNM in Her influence in advancing the naturopathic profession went well beyond NCNM and Portland. With a zeal for legislative advocacy on behalf of the naturopathic profession, Bettenburg was well suited to serve as president of the board of directors for the Oregon Association of Naturopathic Physicians, an organization she served in various capacities for almost 25 years. Nationally, she was a board member of the American Association of Naturopathic Physicians, and served as Speaker of the House of Delegates for the organization. Bettenburg served for 12 years on the Council on Naturopathic Medical Education (CNME) in a number of capacities, including president from The CNME is recognized by the U.S. Department of Education as the national accrediting agency for the naturopathic medicine profession. About NCNM Founded in Portland in 1956, NCNM is the oldest accredited naturopathic medical school in North America and an educational leader in classical Chinese medicine and CAM research. NCNM offers four-year graduate medical degree programs in naturopathic and classical Chinese medicine; a Master of Science in Integrative Medicine Research; Master of Science in Nutrition; Master of Science in Global Health; and soon will offer a Master of Science in Mental Health. Its community clinics provide low-cost medical care throughout the Portland metropolitan area. In addition to the campus-based NCNM Clinic, NCNM practitioners care for approximately 37,000 patient visits per year. Visit for more information. Dr. Bettenburg s contribution to CHP over the years has helped immeasurably in creating a partnership with the Naturopathic Medicine community. Charles Simpson, DC Vice President, Clinical Affairs at The CHP Group Rita is a veritable font of knowledge regarding Naturopathic Medicine and is always valued for her rigorous and balanced perspective. Peter Martin, LAc, LMT CHP Associate Medical Director CHP has been fortunate to have Dr. Rita Bettenburg as an invaluable and integral member of our team for the past 20 or so years. Her experience, knowledge, insight, and integrity have helped guide the course of naturopathic medicine in the state as well as nationally as she helped integrate naturopathic medicine into the healthcare services that CHP offers to its partners. Bruce Chaser, DC Chair, Board of About OANP Directors of The CHP Group Founded in 1909, the OANP is the oldest naturopathic association in North America. Its mission is to support naturopathic doctors and improve the health of Oregonians through the advancement of naturopathic medicine. # # # CONTACT: Marilynn Considine, Ofc: Cell: , [email protected] 9

10 About CHP About The CHP Group The CHP Group is a provider founded, provider focused network of chiropractors, acupuncturists, naturopathic physicians, and massage therapists. Our mission is to deliver accessible, high-quality CAM solutions that enable our partners to control costs while promoting member health and satisfation. If you are not already a member of our network, we invite you to contact us today to learn more about our unique, provider centric approach and to hear what your peers are saying about us. To request an application to join our network, please us at [email protected] ejournal Staff ejournal Editor Charles Simpson, DC [email protected] ejournal Design and Layout Jocelyn Bonebrake ejournal Editorial Committee Art Walker, DC Richard Tilden, DC Bruce Chaser, DC The CHP Group 6600 SW 105th Avenue, Suite 115 Beaverton, OR