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October 2004 Table of Contents
CBP® Research Update • Conventional Wisdom • Don's Opinion • CBP® and Geriatrics: A Case Report • Enough of Chiropractic is for This Pain or That Pain • Chiropractic Passion • The Purpose Driven Practice • Three New and Important Whiplash Articles • You Hired Me To Do A Job • ACA Lawsuit Dismissed • CBP® Online Cyber Update • Harrisons' and Caillet • ICA Files 'Amicus' Brief • A Response to Dr Fuhr • Life University Achieves Financial Goal • Structural Rehab Tool • CBP®'s Chiropractor of the Year • CBP®'s Annual Awards
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A Response to Dr Fuhr
By Alan M. Immerman, DC
Alan M. Immerman, D.C., has been licensed in Arizona since 1980. He is responsible for the passage of four major insurance equality laws over the past seventeen years. Dr. Immerman is President of Independent Chiropractic Physicians, the largest and oldest state association in Arizona. He can be reached at 928.522.0600 or by email at amimmerman@direcpc.com
In a recent email posting, Dr. Fuhr provided comments on the article I wrote that was recently published (July 2004 issue) in the American Journal of Clinical Chiropractic regarding Activator Methods International’s (AMI) political involvement in Arizona. There are a few areas that require a response.
Dr. Fuhr noted: “Below you will find 11 short points providing additional information that Dr. Immerman chose to leave out of his article.” I will reprint each point below with comments.
“1. The problem and reason for the legislation initiated from a minority of Arizona chiropractic providers, out-of-network for United Healthcare, who were dramatically over-utilizing the system, costing millions of dollars.”
Comment: United Healthcare never produced a single medical necessity report documenting overutilization in even a single case. Therefore, no evidence exists to support Dr. Fuhr’s claim, This is a claim purely based on United statistics comparing Arizona to other states. It could just as easily be true that there is chiropractic under-utilization in the other states and that the utilization in Arizona is appropriate. There simply isn’t enough evidence to allow judgment to be passed.
“2. As stated by a prominent leader from the Arizona Association of Chiropractors (AAC), we would never have been in this position, fighting for the basic rights of all Arizona chiropractors and their patients, had it not been for a small population of unethical chiropractic providers. We need to come to terms with the fact that if we don’t keep our own laundry clean, someone else is going to do it and we won’t like how they do it to us.”
Comment: Again, there is absolutely no proof of overutilization in any single case. United should have, but didn’t, hire an expert chiropractor to review individual cases for evidence of overutilization.
“3. The legislation initiated by United Healthcare requested the ability to perform medical necessity reviews.”
Comment: The language that actually became law reads as follows: “A determination under this section of discrimination to the usual and customary procedures of any type of physician shall not be based on whether an insurer applies medical necessity review to a particular type of service or treatment.” This existing law, ARS 20-461, prohibits insurers from singling out any particular type of service or treatment such as spinal manipulation for medical necessity review. SB 1094 specifically states that it shall not be discriminatory to apply medical necessity review to a particular service such as spinal manipulation. United wanted the freedom to impose medical necessity review on chiropractic procedures without imposing the same on medical procedures for the identical condition. The new law has permitted a key form of discrimination that previously was outlawed.
As noted in my previous article, on February 12, 2004, ICP and the AAC, which are the two major associations in Arizona, both testified against SB 1094 while AMI testified in favor. A February 19, 2004 email from the AAC stated: “We WILL NOT support the proposed amendments by AMI and others to cut ‘diagnosis’ and ‘physician’ from the language. The proposed language authorizes discrimination in 3 ways: by physician, diagnosis, and type of service. This language gives United 300 percent of what they need to discriminate. Removing ‘physician’ still gives them all they need to discriminate by diagnosis (i.e. ‘subluxations’) or type of service (i.e. spinal manipulation). ‘Negotiating’ for the removal of ANY TWO of the three options but still leaving ANY ONE still gives United 100 percent of the authority they need to discriminate. There is nothing to be gained by negotiating along these lines and we will not do it. United will not allow their bill to be completely neutered by eliminating all three.”
“4. The legislation was written with the assistance of the department of insurance. The legislation was supported not only by the majority of the legislators, but also by the MDs, DOs, and PTs. Basically every healthcare provider group except chiropractic.” Comment: This bill was strenuously opposed by both ICP and the AAC throughout the session. Only AMI was in favor on behalf of chiropractors.
“5. While the AAC put up a valiant fight against the bill, the association did not have the votes in the senate or house committees to stop the United Healthcare bill. United Healthcare HAD THE VOTES TO PASS THE BILL AS WRITTEN.”
Comment: A February 19, 2004 email from the AAC stated: “1. We believe that the defeat at the Senate committee and the defeat at the House committee were caused by the same thing: our profession’s representatives ‘broke ranks’ and failed to present a unified front at the crucial moment when victory could have been won with a little more faith and intestinal fortitude. 2. We believe that it was United’s strategy from the beginning (as they did last year) to prey upon our profession’s internal divisiveness, divide us and conquer us. Their strategy to lure factions of our profession into ‘negotiations’ that have no hope of actually solving the problem under the guise of ‘damage control’ has proven to be successful and some of our chiropractic leaders have been seduced into being played by United as pawns.”
It is likely that if AMI had joined ICP and AAC in opposing SB 1094, there would have been no split in the ranks and we would have defeated this bill.
“6. At the 11th hour, Arizona legislators friendly to chiropractic personally contacted me in Hawaii while I was teaching a seminar. They requested my assistance to find some way to mitigate the bill’s language and effect on chiropractic. I had been the AAC’s legislative committee chair the past two sessions and had been successful in assisting the AAC in defeating two previous similar initiatives by United Healthcare. I HAVE NOT SPLIT FROM THE AAC. I am still a member in good standing. I also have not created a new political association.”
Comment: The AMI amendments were negotiated before the first Senate hearing on February 12, 2004. The bill did not pass the legislature until March 15, 2004. Dr. Fuhr’s involvement was definitely not “at the 11th hour” as he claims. AMI did register itself as a lobbying organization in Arizona, a fact that is easily proven by consulting the webpage of the Arizona Secretary of State. AMI did take a position in opposition to that of ICP and the AAC.
“7. I was able to get concessions from United Healthcare to modify and amend the language to mitigate the potential effects of this new legislation and to assist the chiropractors in Arizona. My work also provided additional time for the AAC lobbyist to create, negotiate and initiate other favorable modifications to the bill.”
Comment: As noted above, the United Healthcare bill, as amended by AMI, was rejected by both ICP and the AAC. On February 13, 2004, the day after AMI testified in favor of SB 1094 and ICP and the AAC opposed the bill, an AAC legislative leader wrote the following: “Well, I am sure that Debra (the ICP lobbyist) brought you up to speed on our interesting day yesterday, including the attempted ‘end run’ by Activator methods. It is unfortunate that we had both chiropractic associations (ICP and AAC) shoulder to shoulder only to have someone else break ranks and allow themselves to be duped as a pawn by the insurance business machine.
I wonder if the Activator practitioners across the nation know that their leadership is adopting this kind of strategy ‘on their behalf.’ I have spoken with Activator doctors since yesterday and so far not one, including AAC board members, was aware that Activator methods had any legislative agenda at all, let alone a position on this matter. Dynamic Chiropractic should do a survey of the Activator docs to find this out.”
“8. The purpose of the Senate testimony was to ENSURE THE AMENDMENTS WERE INCLUDED in the bill to assist in the protection of, not harm, Arizona chiropractors.”
Comment: The AMI testimony in the Arizona State Senate on February 12, 2004 was in favor of SB 1094, not just the amendments to the bill. This is shown by the official records of the Senate.
“9. The bill passed with the amendments included, which dramatically decreased the potential for isolation or bias by United Healthcare towards chiropractic claims.”
Comment: United Healthcare, because of this legislation, will be free as of January 1, 2005 to perform medical necessity review exclusively on spinal manipulation while not reviewing the necessity of drugs, surgery and PT for the same condition. SB 1094 allows a form of discrimination that is currently illegal and objectionable.
“10. After the bill was passed, I encouraged United Healthcare to initiate dialogue with the AAC leadership.”
Comment: While this is true it is not expected that the dialogue will result in any meaningful gain for the chiropractic profession.
“11. Please refer to the current AAC journal, page 4, which provides information that the relationship between United Healthcare and the chiropractors in Arizona AFTER the legislation passed has been positive. That the AAC has developed very positive dialogue with United
Healthcare leadership and are hopeful that all parties have come to realize that the newly passed legislation may never need to be enforced.”
Comment: United Healthcare has already begun to enforce the law even before it goes into effect. Scores of Arizona chiropractors have received calls and medical necessity reviews from United’s subsidiary, American Chiropractic Network (ACN).
Dr. Fuhr notes that “previous to this recent article, Dr. Immerman made false statements about me that forced me to sue him for slander and liable. I won that case.” The reader should know that my insurer, Farmers Insurance Company, settled this lawsuit for $1 with Dr. Fuhr without my written consent. I never admitted to making false statements about Dr. Fuhr and this contention was never proved in a court of law.
If you have any questions or comments, I invite you to contact me at 928.522.0600 or by email at amimmerman@direcpc.com.
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