DC: In Oregon are the accusations and the allegations made against specific chiropractors who have been charged, correct?
DC: To your knowledge, are there a significant number of chiropractors who have been abusing the Worker's Compensation privilege?
Dr. Tilden: Well, when we're talking about one's own profession, one abuser is a significant number but I'm not aware of the specific number who might have been abusing the system. To my knowledge, no one has speculated about an actual number.
Within the last few weeks another chiropractor has had his computer and software seized but, as yet, there hasn't been an indictment in that case.
DC: Why was SAIF so successful in almost eliminating virtually all worker's compensation privileges for DCs in Oregon?
Dr. Tilden: Well, it wasn't just SAIF. There was some very strong support for the elimination of chiropractic in the Worker's Compensation system by Associated Oregon Industries (AOI) and others. Some of the members of the AOI were very vocal in their opposition to chiropractic. I have talked to some of those people and their opposition was generated by specific encounters with chiropractors who, on an individual basis, had a profound influence on time loss and medical treatment costs for the industries that these people owned or managed. I heard one account of a sawmill with about 100 employees, and the allegation was, that at one point, chiropractors had almost one-third of those employees on time loss and/or treatment. I don't know specifically how true that story was, but obviously there was a major economic impact. The spokesman for that industry was mad and very vociferous in his opposition to chiropractic. By gathering enough horror stories it was possible to create quite a stir and make a pretty convincing argument against chiropractic. During the recent special session of our legislature, I was present when a representative of the National Federation of Independent Businesses testified in opposition to having chiropractors remain as "attending physicians."
DC: I know again you just answered this in part, but what has taken place in the state of Oregon that is causing all these events to occur?
Dr. Tilden: This is just my personal opinion, but it is based on 26 years of practice and observation in Oregon. It seems to me that since the middle 1970s when chiropractic practice management consultants made their appearance, there has been an increasing emphasis on patient visit averages (PVA), and there are some chiropractors in this state who manage their practice by the numbers. So what happens is that you have patients who are victims of some "patient retention" scheme that has been purchased by a chiropractor from a practice consultant and the clinical aspects of the case are not what is used to determine the length, frequency, and nature of care. Thus, the chiropractor is not able to justify significant amounts of care and it calls the validity of that into question. Let me add that there are many, many chiropractors in this state who haven't changed their practice methods over the years and who are still doing a very careful, conservative and cost effective job. Then there are others who consistently see their patients on an average of 30, 40, and 50 or more times. I think that treating patients based on some arbitrary average-visit goal is clinically dishonest. I feel similarly about those offices which employ far more modalities and procedures than are necessary to promote recovery. Simply put, it boils down to doing too much, too often, for too long.
DC: Do you think what has happened with workers' compensation in Oregon could happen in other states and if so, would you tell us what you think DCs could and should do to protect themselves?
Dr. Tilden: Yes, I think it is happening in other states. One only has to read the various publications that come to our offices to get the idea that there are many and frequent appeals to allow others to manage our offices. Often, it is easy to see that the procedures recommended for chiropractors are not based on clinical reality, but stress primarily increasing the doctor's income by some secret method or belief system. Many claim that the DCs are delivering better service to their patients and to their communities, but, in fact, they are just delivering more services. I do not know the degree to which chiropractors across the nation have availed themselves of this type of practice building procedure or the extent they may have modified or softened some of the hard sell approaches.
Some of these firms are obviously quite large and they seem to have quite a substantial number of disciples. That tells me that there is a problem throughout the profession. We need to base our practices on sound clinical judgement so that the observations we record in our chart notes justify the care which is given. We should be able to explain that to anyone who is interested and not rely on some secret or mystical formula.
Chiropractic has survived all of these years because of our positive influence on body physiology and we have the responsibility to document what we do and why we do it. When we don't provide that documentation, then we rightly can be challenged.
I am very concerned for what is happening in Oregon. I'm disappointed that my profession has not done more to govern itself and I feel a sense of personal responsibility for that. As I reflect back on what I have seen take place over the last few years, there have been a number of individuals and organizations who have tried to stem the tide of clinical practice by case average.
For whatever reason, we were not successful in doing that. Obviously we have to be very careful in leveling criticism at any individual or group because of the very real threat of litigation. I don't know how successful people or associations in other states can be in stopping this trend. I think that our profession needs to reaffirm a very strong commitment to clinical ethics and efficiency. If we do that, we won't be victimized by the type of practice management schemes which have gotten us into our recent difficulty. Please understand that I don't have any complaint about sound business practices at all. Our offices should be run by sound business principles and there certainly is a need for that type of education during our college years and afterward.
We need to realize that the responsibility of third party payors, workers' compensation or otherwise, is to attempt to return the patient to pre-injury status. In summary, the problems which have developed with the practices of some chiropractors, have been used to indict our entire profession.{ It is a shame that we have been placed in this position when there is so much good in chiropractic.
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