Proposed Excessive Treatment Admin. Rule

[Guest guest]

Vern et al

This is a good example of why we need to adopt Art Croft's treatment guidelines

in this state. They are based on SCIENCE, not " well, I think it is so,

therefore, it is so " . Consensus may have its place, but hard scientific data

wins hands-down everytime.

Ray, DC

THanks for reposting these comments from Minga. There is no clear measuring stick to determine excessive treatment nor "under-treatment." During my four years on Peer Review this is what we ran smack tab into, we had several of the well known IME colleagues in front of the committee but without a clear evidence based measuring stick (outcomes assessment tools) we were powerless to act.

In 1994 (I think this was the year) as I recall the OBCE attempted to act against Dr. Dick Tilden relative to an IME situation and because of this lack of a clear measuring stick of what constitutes reasonable and necessary care the OBCE lost the contested case. This cost the OBCE a huge amount of money, which since is only self funded by all lic DCs in the state, could ill afford. Hence the OBCE is finacially unwilling to act when there is no clear violation and there is no clear violation because we all have our own measuring sticks (opinions) as per the appropriate frequency and duration of care etc., etc., etc.

Evidence based outcomes assessment is the measuring stick and where the entire health care industry is headed and has been headed for quite some time.

I been thinking about all the valuable comments relative to this issue and it has come to me that these new proposed rules could be a real positive opportunity, and opportunity to lead the rest of the health care professions here in Oregon in the cost effective treatment of musculoskeletal problems. We are the musculoskeletal experts lets use this opportunity to validate that we are indeed the experts and own it.

Vern Saboe

Re: "Proposed Excessive Treatment Admin. Rule"

Ann,Oh if only I could just leave it all to peer review! however, the legislature makes the rules that govern this thing I've volunteered for: the OBCE. Sure we as a profession, can make suggestions to add rules or change rules. But as you can tell from this process on the listserv, it's no easy task to make a change. As it stands, when a complaint is made, The board must respond. We can send items to the peer review for their "expert advice". Once the advice is returned to us, we must make a determination and return an answer to whom ever is complaining. We are not allowed to say, we don't want to make a determination. We are not allowed to ask peer review to make a final determination. I think maybe a lot of doctors don't understand the job of the board. I know I didn't even fully understand it until I was neck deep. I'm still learning in my first year. Also, I have learned that even if the peer review committee thinks there is obvious over billing or treatment without proper exam, justification , excessive treatment, etc, there is often, NO clear rule to judge it. There is simply a small thing about not violating "professional conduct". The fact that professonal conduct is left open to very broad intrepretation, leaves no room to call it a clear "violation of statute". We've been advised time and again by our legal experts that we would lose a case if it were contested. We/ve been advised to rewrite the law. As I understand it, We choose not to file a case and spend lots of $ when we know we'll lose. So even if we do see a case that seems to be unfair to a patient, we have to rule "No Statutory Violation" NSV. The public (patients) are always calling and writing us back wondering how we could say such a thing. They are often upset. I've seen this happen 3-4 times already in less than a year. (MY time on the board.) Minga Guerrero DCIn a message dated 5/11/2004 9:33:17 PM Pacific Daylight Time, anngoldeen@... writes:

Minga: Why not just leave the whole issue to peer review? It sounds like their department. We already have a mechanism in place for complaints and disputes. Let's use it, instead of adding more bureaucracy. Ann Goldeen

----- Original OregonDCs rules:1. Keep correspondence professional; the purpose of the listserve is to foster communication and collegiality. No personal attacks on listserve members will be tolerated.2. Always sign your e-mails with your first and last name.3. The listserve is not secure; your e-mail could end up anywhere. However, it is against the rules of the listserve to copy, print, forward, or otherwise distribute correspondence written by another member without his or her consent, unless all personal identifiers have been removed.

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[Guest guest]

Doctors,

The attached statistics show the kinds of complaints that are received by the

OBCE. More information regarding the specific cases closed with board actions

may be found on the OBCE web page at www.obce.state.or.us under Public

Protection.

Dave McTeague, Ex. Dir., OBCE

503-378-5816 ext. 23

>>> " Ann " <anngoldeen@...> 05/12/04 10:53PM >>>

Minga: I think most people aren't aware of what you have written. I am CC it

to the list. It will provoke more responses and widen our understanding. Are

there lots of these cases? I thought most of the complaints were sexual or

gross mistreatment. Ann Goldeen

Re: " Proposed Excessive Treatment Admin. Rule "

Ann,

Oh if only I could just leave it all to peer review! however, the legislature

makes the rules that govern this thing I've volunteered for: the OBCE. Sure we

as a profession, can make suggestions to add rules or change rules. But as you

can tell from this process on the listserv, it's no easy task to make a change.

As it stands, when a complaint is made, The board must respond. We can send

items to the peer review for their " expert advice " . Once the advice is returned

to us, we must make a determination and return an answer to whom ever is

complaining. We are not allowed to say, we don't want to make a determination.

We are not allowed to ask peer review to make a final determination. I think

maybe a lot of doctors don't understand the job of the board. I know I didn't

even fully understand it until I was neck deep. I'm still learning in my first

year.

Also, I have learned that even if the peer review committee thinks there is

obvious over billing or treatment without proper exam, justification , excessive

treatment, etc, there is often, NO clear rule to judge it. There is simply a

small thing about not violating " professional conduct " . The fact that

professonal conduct is left open to very broad intrepretation, leaves no room to

call it a clear " violation of statute " . We've been advised time and again by our

legal experts that we would lose a case if it were contested. We/ve been advised

to rewrite the law. As I understand it, We choose not to file a case and spend

lots of $ when we know we'll lose. So even if we do see a case that seems to be

unfair to a patient, we have to rule " No Statutory Violation " NSV. The public

(patients) are always calling and writing us back wondering how we could say

such a thing. They are often upset. I've seen this happen 3-4 times already in

less than a year. (MY time on the board.)

Minga Guerrero DC

In a message dated 5/11/2004 9:33:17 PM Pacific Daylight Time,

anngoldeen@... writes:

Minga: Why not just leave the whole issue to peer review? It sounds like

their department. We already have a mechanism in place for complaints and

disputes. Let's use it, instead of adding more bureaucracy. Ann Goldeen

----- Original

[Guest guest]

Yep, correct the OBCE's current administrative rule language simply does not

adequately address inappropriate excessive treatment nor under treatment.

The existing language is simply not specific enough and as such the OBCE and

the Peer Review Committee both have difficulty determining/proving either

excessive our under treatment. In my opinion what's been missing is a

specific universal evidence base " measuring stick " by which all the

stakeholders can determine the reasonableness and necessity of chiropractic

care.

For example during my four years (1993-1997) on the OBCE's Peer Review

Committee I experienced first hand the reality that an evidence based

" measuring stick " was missing as per determining what constituted reasonable

and necessary care and what did not. Everyone had/has their own convenient

notion of how much treatment was enough? With many times a huge disparity

between the folks doing IMEs/DMEs/Paper Reviews (can you say CMR NBC

Dateline " Paper Chase I & II?) for the insurance carriers or defense firms

vs. the treating doctors, duh! With no true accurate measuring stick guess

what...they were/are all right.

....and so what of Art Croft's treatment guidelines? I have the utmost

respect for Art who we have had speak at our state convention more than

once, who I've listen to on other occasions, and one of these days will

indeed take his " Masters course " of study....ok well I said one of these

days...ok well then maybe online from the Capitol building...hey it could

work! Seriously though Art's landmark work in the realm of low impact

injuries blowing away the carriers mantra " no crash, no cash " referring of

course to the idiocy " hey how can you be hurt when there is little or no

damage to your car, gosh darn it! "

With that said the reality is Art is but one expert, one individual who has

generated HIS treatment guidelines which where originally published in the

ACA's trade journal (Jan. 1993). Dr. Croft's original 1993 article

" Treatment Paradigm for Cervical Acceleration/Deceleration Injuries

(Whiplash), was a valiant first attempt to answer the concerns of the

insurance industry, examing boards, and the profession as per what is

reasonable and necessary care in AUTO CRASH INJURIES. However Art's

treatment frequency and duration treatment guidelines were based on limited

evidence but more about that momentarily.

I have found Dr. Croft's prognostic section in his book very helpful in

determining the probability on the initial visit of injury severity,

likelihood of a protracted length of curative care, impairment, and

subsequent disability. However in my opinion there is a problem with his

subsequent rather " canned " recommendations as per the frequency and duration

of care as they are not based on that particular unique patient's response

to care? But rather Art's treatment guidelines are based on " common

complicating prognostic factors " which he has gleaned from a somewhat

limited body of medical research. Apparently Dr. Croft has also

been " surveying " chiropractic colleagues who visit his webb page

www.srisd.com as per the average number of visits for his various categories

of injury and it may interest you " list-serve heads " that in a ChiroWeb.com

2001 article Dr. Croft found that the average number of visits for " CAD "

injuries was 21 to 30 treatments and that the majority of these were what

Art coins as " grade II injuries? " ...Sherm.......can you hear the PIP

carriers building that " box! "

Ok so some of the problems I see with using, adopting whatever, Art's auto

injury treatment guidelines is that in my opinion it is a HUGE leap of faith

jumping from these general prognostic complicating factors to very specific

(one size can almost fit all) numbers of treatments and length of care.

This approach leaves no room for individualized responses to care which BTW

is exactly what outcomes management does do. By utilizing outcomes

assessment each case, each individual's unique life situation, response to

treatment etc., etc., etc. is allowed to be unique and run it's own course.

Conversely Dr. Croft's

somewhat arbitrary guidelines leave little room for individuality relative

to treatment responses. In reality folks currently there is a considerable

and ever growing disparity between scientific evidence that supports

outcomes management to determine treatments results and as such the most

cost-effective treatment vs. something like Dr. Croft's " CAD Guidelines. "

Simply put outcomes management is were the entire world of health care is

headed and where it's been headed for sometime now.

Only appropriate measurement of a patient's treatment results (outcomes

assessment) can determine the most cost-effective treatment Especially in

our realm of musculoskeletal problems objective assessments of a patient's

deficits in biomechanical function such as ranges of motion, muscle strength

& endurance, and cardiovascular fitness are critical. Colleagues we are the

musculoskeletal experts (BTW this is a $100 Billion industry...just thought

I'd mention it!) at least for

now (did I mention the " Doctor of Physical Therapy " is coming) and as such

in addition to my obvious " chicken little " mentality, I've been thinking

long and hard about this issue and I believe there is a real opportunity for

the profession. I think this could be a real opportunity for the profession

here in Oregon to take the lead role among the health care professions in

being the first (I think would be the first?) in adopting evidence based

outcomes assessment as our profession's determinate of treatment results,

what constitutes reasonable and necessary care, and as such provide the most

cost-effective treatment in this $100 billion dollar industry!! Along this

same thought unlike Art Croft's " CAD " treatment guidelines which are very

limited to auto crash injuries, outcomes management can be applied to any

form of musculoskeletal problem/injury. I believe that this will become

critical to our profession when we lobby (successfully!) for what we have

always dreamed of for our patients and our profession, stuff like a return

of full attending physician status to DCs in Worker's Comp (yep Willard I'm

going to go round-up your other plow horse!), " insurance equality, " " any

willing provider " etc.

On June 10 I've put a meeting together of two top OHSU " alternative care "

researchers, Mitch Haas, DC.,PhD of WSCC, Tony Rosner, PhD of the FCER,

Mitch (now State Representative) Greenlick, PhD ex-professor of epidemiology

OHSU, and our colleague Freeman, DC.,MPH.,PhD about my proposed

Worker's Compensation study. My intent is to produce the first in the

nation Prospective Randomized Cost Comparison Study Comparing Standard

Medical vs. Chiropractic Treatment of Common Musculoskeletal Injuries within

the Oregon Worker's Compensation System. The goal of this meeting of

" brainiacs " (yours truly excluded from the label of " brainiac " for obvious

reasons!) is to begin to pound out the studies design, cause the last thing

the profession needs is a poorly designed study that renders a poor result

(aka proves Uncle Vern was wrong, yikes!). My point is these researchers

will all know exactly to what I speak when I refer to " outcomes management, "

it is a universal language that transcends professions...do you suppose I'd

get the same nods from these brainiacs if I cited the " CAD Guidelines? "

Outcomes Management/Assessment Defined again,

Outcomes management is divided into Subjective or patient-driven information

and Objective doctor-driven information. Examples of patient driven outcome

assessment tools would be things like the Revised Oswestry, Rolland-,

Neck Disability Index etc., etc. In short these are very simply quick forms

the patient fills out and which then provide a quantitative appraisal of

your patient's current level of activity intolerance or " Disabilities. "

Simply forms that measure your patient's current level of pain include

things like the Pain Drawing, Visual Analog Scale (VAS), and Numerical Pain

Rating Box. In my clinic we have a simple one page form that has the Pain

Drawing, VAS, Pain Rating Box, and under " office use only " boxes to note

their Oswestry and Neck Disability Scores. We simply give these self

reporting forms to the appropriate patients every month (1st Monday of each

month) to fill out.

Objective Provider Outcome assessments include two main categories

" Provocative Exam Procedures " and " Physical Performance Testing. "

Provocative examination procedures may include things like static and

dynamic palpatory findings, ranges of motion via appropriate

instrumentation, functional radiographic findings, dynamic S-EMG, tissue

compliance meter findings, algometry, and our various functional

chiropractic signs, tests, and maneuvers the stuff we do everyday in

practice. " Physical Performance Testing " can include measuring of specific

muscle groups for strength and flexibility and then comparing our results

with normative data. These types of outcomes assessment become very useful

as the patient reaches the third phase of healing or the " Remodeling Phase "

which as you all know can last up to 12 months or more. In especially the

later portion of the remodeling phase of the healing process our normal

provocative chiropractic tests, signs, maneuvers, and functional X-rays

become less useful but the time when physical performance tests begin to

shine and give real continued value to re-examinations. Practical physical

performance testing at this point in care can better drive specific

treatment

decisions/approaches such as strengthening exercises for weak trunk muscles

etc., etc.

Low tech physical performance testing we can all do in our offices is the

best way to determine continued improvement in the later stages of these

musculoskeletal injuries, and the best determinate of whether restoration of

normal function has occurred in our patients. All of which as I'm sure you

have guessed is highly individualized and as such well beyond Art Croft's

" CAD

Guidelines. "

Sorry guys/gals for this very long winded post....Ha!... and you thought Dr.

Ray's post was long!

Vern Saboe, DC

Re: " Proposed Excessive Treatment Admin. Rule "

> Vern et al

> This is a good example of why we need to adopt Art Croft's treatment

guidelines in this state. They are based on SCIENCE, not " well, I think it

is so, therefore, it is so " . Consensus may have its place, but hard

scientific data wins hands-down everytime.

>

> Ray, DC

>

>

>

>

>

>

>

> OregonDCs rules:

> 1. Keep correspondence professional; the purpose of the listserve is to

foster communication and collegiality. No personal attacks on listserve

members will be tolerated.

> 2. Always sign your e-mails with your first and last name.

> 3. The listserve is not secure; your e-mail could end up anywhere.

However, it is against the rules of the listserve to copy, print, forward,

or otherwise distribute correspondence written by another member without his

or her consent, unless all personal identifiers have been removed.

>

[Guest guest]

Dear Colleagues,

I must agree with Ann. We already have in place a peer review process and if I am not mistaken, a practice and utilization review committee is already spending many hours defining appropriate guidelines. I strongly feel that this proposed rule is not warranted. As my friend and respected colleagure Les Feinberg so aptly stated: "Actions that can have lasting consequences should not be made in an effort to offer up appeasement to people whose self interest has never permitted fair treatment of our profession. It can be argued that we need to educate them, and I surely don’t argue against anyone who wants to bring an understanding of chiropractic to the insurance industry. "

Why doesn't the CAO and OBCE educate the legislators of our ongoing efforts already in progess of practice guidelines? It seems that we have already taken a proactive stance and any further "rules" are redundant at this point.

My two cents, if you will.

Knecht, DC

Knecht DC Namaste Chiropractic 1809 NW Portland, OR 97209 503-226-8010 >From: "Ann" <anngoldeen@...> >< >, <AboWoman@...> >Subject: Re: "Proposed Excessive Treatment Admin. Rule" >Date: Tue, 11 May 2004 21:30:31 -0700 > >Minga: Why not just leave the whole issue to peer review? It sounds like their department. We already have a mechanism in place for complaints and disputes. Let's use it, instead of adding more bureaucracy. Ann Goldeen > Re: "Proposed Excessive Treatment Admin. Rule" > > > Garreth, > Xs care is absolutely not defined by time alone. And I'm sure Vern didn't intend that message. I think the key parts of his email, as I remember, were that there were no re-exam or objective justifications for continued care. that picture combined with an inflated fee, will do harm to the patient's case. The patient you describe sounds like an easy exception to continued care. It could also justify more drastic measures to stabalize. Just document the exams, treatments and outcomes. I've seen poor documentation ruin a great case. It's so sad when a patient comes to your office after months of poorly documented care. The bill is incredibly high. PIP is nearly exhausted and the patient is still in significant pain. I've been in business for 20 years and have no idea how long you've been practicing. Please rest assured that the vast majority of chiropractors understand the need for continuing care when there are circumstances beyond normal. Diabetes, previous surgery, pre! gnancy, rheumatoid arthritis and age of patient just to name a few. I've never seen or heard any docs at the meetings in peer review or with rules advisory committee neglect to think of these possibilities. That said, I've also never heard of any plan to give exact weeks for care of a given condition. It can't be done. there are too many variables. I think the rules that are being suggested are simply for a group of peers to be able to evaluate our work and see if it's reasonable when a complaint is filed. BTW, I'm not speaking for Vern, just my very own opinion of what I percieve from the time I've volunteered. > Minga Guerrero DC > > OregonDCs rules: > 1. Keep correspondence professional; the purpose of the listserve is to foster communication and collegiality. No personal attacks on listserve members will be tolerated. > 2. Always sign your e-mails with your first and last name. > 3. The listserve is not secure; your e-mail could end up anywhere. However, it is against the rules of the listserve to copy, print, forward, or otherwise distribute correspondence written by another member without his or her consent, unless all personal identifiers have been removed. > > >

[Guest guest]

Good Post Matt!

Knecht DC Namaste Chiropractic 1809 NW Portland, OR 97209 503-226-8010 >From: "mattydread" <mattydread@...> >"" < > >Subject: Re: "Proposed Excessive Treatment Admin. Rule" >Date: Tue, 11 May 2004 21:31:09 -0700 > > Dear Docs, > > I can't emphasis enough that if you are doing PIP work to get educated beyond your general background. Several people are saying this now, and it's nice to know that docs are doing their homework. Check out Art Croft, Dan , Melton, and of course our own Freeman, DeShaw, and Bob Pfeiffer (I know there are others, but I can't write 'em all down). If you have never read Croft's book, and you think you know MVCs - think again. I have had the book almost two years and I'm still digesting it. (then again - I'm a little slow...) Melton has an excellent binder that has tremendous amounts of info in it that 1) comes with a CD ROM and 2) is updated every year. I provided a link for those of you interested. > I'm not preaching that "you don't know this, and you don't know that". What I'm saying is if more and more of us knew this stuff, it would be easier to dispute the "junk science". Just ask Freeman about "junk science" if you want to see him go off... > > Sincerely, > > Matt Terreri, DC > > PS: If you really want to get crazy, take Freeman's masters program soon to be offered at WSCC. The bottom line is one weekend seminar on this stuff ain't enough! (in my opinion). > Re: "Proposed Excessive Treatment Admin. Rule" > > > Garreth, > Xs care is absolutely not defined by time alone. And I'm sure Vern didn't intend that message. I think the key parts of his email, as I remember, were that there were no re-exam or objective justifications for continued care. that picture combined with an inflated fee, will do harm to the patient's case. The patient you describe sounds like an easy exception to continued care. It could also justify more drastic measures to stabalize. Just document the exams, treatments and outcomes. I've seen poor documentation ruin a great case. It's so sad when a patient comes to your office after months of poorly documented care. The bill is incredibly high. PIP is nearly exhausted and the patient is still in significant pain. I've been in business for 20 years and have no idea how long you've been practicing. Please rest assured that the vast majority of chiropractors understand the need for continuing care when there are circumstances beyond normal. Diabetes, previous surgery, pregnancy, rheumatoid arthritis and age of patient just to name a few. I've never seen or heard any docs at the meetings in peer review or with rules advisory committee neglect to think of these possibilities. That said, I've also never heard of any plan to give exact weeks for care of a given condition. It can't be done. there are too many variables. I think the rules that are being suggested are simply for a group of peers to be able to evaluate our work and see if it's reasonable when a complaint is filed. BTW, I'm not speaking for Vern, just my very own opinion of what I percieve from the time I've volunteered. > Minga Guerrero DC > > OregonDCs rules: > 1. Keep correspondence professional; the purpose of the listserve is to foster communication and collegiality. No personal attacks on listserve members will be tolerated. > 2. Always sign your e-mails with your first and last name. > 3. The listserve is not secure; your e-mail could end up anywhere. However, it is against the rules of the listserve to copy, print, forward, or otherwise distribute correspondence written by another member without his or her consent, unless all personal identifiers have been removed. > > > > > OregonDCs rules: > 1. Keep correspondence professional; the purpose of the listserve is to foster communication and collegiality. No personal attacks on listserve members will be tolerated. > 2. Always sign your e-mails with your first and last name. > 3. The listserve is not secure; your e-mail could end up anywhere. However, it is against the rules of the listserve to copy, print, forward, or otherwise distribute correspondence written by another member without his or her consent, unless all personal identifiers have been removed. > > >

[Guest guest]

Doctor,

Excellent post. can you sign please? Who are you? This is incredibly valuable information for me as a board member. I would love to call you or continue with email towards the goal of investigating how WSCC clinic trains the new docs in this area. Thanks so much for your post. As a 1984 grad, my training was so completely different in the arena. Not worth mentioning at this point...antiquated to say the least. The best training for us older grads is in the seminar market. BUT I would love to check out the school's current help in this area.I am going to present a bit of changes to the new doc orientation next week at the regular board meeting as per Dr. Medlin's suggestion.

Thanks again for your interest.

Minga Guerrero DC

[Guest guest]

Hey Sherm,

As an FYI. As a 2002 grad. at WSCC, I can say that we had only one lab in

which the Croft guidelines were taught. As I recall, 3 written sample

presentations, task was to grade the injury, give a prognosis, pick out the

risk factors for complication of that prognosis. Several of us listened to

the upper quarter students bemoaning the lack of training on managing PI

cases and did the Croft modules while in school. I had subsequent

disscussions with those who designed the WSCC curriculum, and the general

tone was that they felt that Croft's guidelines were important to be exposed

to, but that they were somewhat excessive in number.

As I recall, Art proposed those guidelines based on standards of practice,

not available clinical studies. Correct me if I am in error. If that is

true, it could be seen how those guidelines are self-serving, the old fox

minding the hen house. Perhaps that's why some favor the use of the Quebec

guidelines, which Dr. Croft will be quick to school you on the similarity

those guides have to his previously published ones.

At the outpatient clinic, training is highly variable, dependent on the AP.

In general, students are taught, and most adhere to, tracking VAS, NDI

and/or ROQ and ADLs on most patients, but especially in PI cases.

Typically, targets are set for release of patients when <2/10 VAS and <10%

NDI/ROQ scores are maintained for 30 days.

Oh yeah, we also had a special class in how to win friends and impress

people with the use of acronyms.

Again, that was the general training I experienced, others may have received

slightly different versions, due to different APs. I would be curious to

hear other recent grads or profs weigh in on the current curriculum.

>From: " Sherman " <tsherm@...>

> " Vern Saboe DC " <vas@...>,<mottray@...>

>CC: <Oregondcs >

>Subject: Re: " Proposed Excessive Treatment Admin. Rule "

>Date: Wed, 12 May 2004 06:56:41 -0700

>

>I would be interested in knowing how many Oregon DC's have a copy of Art

>Croft's book now I believe in the third edition. It should be required

>reading/.text in all Chiropractic Colleges . I also wonder how many Oregon

>DC's have attended the seminars listed in other posts, , etc. Dan

>Dock, puts on a good seminar and is around quite often, at a very

>reasonable cost I might add. I am interested particularly whether board

>members, peer review members, are up to date on the information provided in

>these specific courses, and don't rely on the local conventions, or WSCC

>annual homecomings for their con't ed hours. And of a very big concern

>are the field doctors who never participate in these discussions. As I

>stated in a previous post, specifics are essential if we are going to

>create

>this program. As Dr. Ray elaborated upon in detail, the guidelines

>published

>by Croft are just that and lend themselves to accomplish what well meaning

>DC's such as Vern intend, but lets face it , what the powers to be are

>after

>is not this at all but " 12 visits in thirty days " regardless of what is

>necessary, relevant, fair, justified by published literature. Let's not

>play

>into their hands.The funny thing is that " they " might not even be in

>influential positions currently but may show up down the road to interpret

>vague language any way they can to meet their end.

>

>I can only support movement toward these rules if guidelines which reflect

>the real world are incorporated.

>

>Have a good day. Sherm

> Re: " Proposed Excessive Treatment Admin. Rule "

>

>

> > Vern

> > There already exists a process for excessive treatment and costs in any

>third party payment system, including PIP. The OBCE has the authority to

>receive and investigate complaints against DC's that appear to charge or

>treat excessively. We also have in place a Peer Review Committee that can

>look at both sides of any issues (DC -vs. - Insurance carrier) on over

>treatment or over charging and make recommendations to the OBCE for action.

>Your " new " proposal for ANOTHER Administrative Rule on this issue is, in my

>opinion, an extreme over reaction to pressure from outside influences,

>whose

>only motive is to use the Chiropractic profession as its " whipping boy "

>again as it did in 1990.

> >

> > What we should be telling those who are pushing to " put us in our

>place " ,

>is that there are existing avenues to address over treatment or excessive

>charging. For BOTH sides of the equation.

> >

> > I also have concerns about " consensus " panels. I repeatedly get new

>patients that have already been to another or other DC's, and without any

>improvement are told they are " all well " , or they are released from care as

>soon as they feel a little better. Yet the patient tells me that they did

>not improve and they still have the same problems they started with. If

>you

>have ten DC's that only treat each patient 5 or 6 times and release them

>from care as have reached " MMI " , then their " consensus " is that all

>patients

>get " well " in 5-6 visits. This cannot be considered, by any measure,

>scientific, and at best is short sighted, and is an extremely subjective

>approach to a multi-faceted issue.

> >

> > I also feel strongly that we should, as a group, be looking very closely

>at implementing the treatment guidelines for PIP cases that Dr. Art Croft

>developed, using the existing scientific literature on outcome studies.

>These studies already show that Chiropractic care is the ONLY treatment

>regimen that has any validity in improving and stabilizing those patients

>injured in motor vehicle collision, especially CADS and those that develop

> " Late Whiplash " issues. In the Croft guidelines (Grades I-V), a grade II

>whiplash injury (without neurological signs or other complicating factors)

>has a treatment longevity of up to 29 weeks and up to 34 treatments. We

>need to educate not only the insurance industry, but also our own

>colleagues. Dr. Croft's guidelines can be accessed through the Spine

>Research Institute of San Diego (SRISD) and through CRASH. Both are

>on-line.

> >

> > Your example of the case that cost $19K, is at best, extreme, and in the

>least inflammatory and reactionary. There are those cases where the injury

>sustained has caused structural and functional disability that requires

>years of treatment, not months, and over 10% of those injured in MVC's have

>permanent impairment and lifetime disability in one form or another. (When

>was the last time Allsnake of Snake Farm offered you that information?)

>Therefore, one must ask, was the $19K helpful to the patient in that it

>returned them to there pre-functional status? What was the diagnosis?

>Were

>there risk factors or other complicating factors, or other factors for a

>more serious injury or for a poor prognosis? If one looks at the existing

>scientific literature verifies the known risk factors for injury and for a

>poor prognosis, especially in Cervical Acceleration-Deceleration trauma

>(CADS). These include:

> > 1) Female gender

> > 2) History of prior spinal injury

> > 3) Poor head restraint geometry/tall occupant (80th percentile male)

> > 4) Rear vs. other vector impacts

> > 5) Use of seat belts/shoulder harness (standard three-point restraints)

> > 6) Body mass index/head neck index

> > 7) Out-of-position occupant (e.g., leaning forward/slumped)

> > 8) Non-failure of seat back

> > 9) Having the head turned at impact

> > 10) Non-awareness of impending impact.

> > 11) Increasing age (i.e., middle age and beyond)

> > 12) Front vs. rear seat position

> > 13) Impact by vehicle of greater mass (i.e., 25% greater)

> > 14) Crash speed under 10 mph

> >

> > Additionally, the literature points to known risk factors for late

>whiplash, including:

> > 1) Female gender

> > 2) Lower BMI (body mass index)

> > 3) Immediate/early onset of symptoms (i.e., within 12 hours) and/or

>severe

>initial symptoms

> > 4) Ligamentous instability on radiographs.

> > 5) Initial back pain

> > 6) Greater subjective cognitive impairment

> > 7) Greater number of initial symptoms

> > 8) Use of seat belt shoulder harness for neck (not back) pain; non-use

>had

>a protective effect.

> > 9) Initial physical findings of loss of ROM

> > 10) Initial neurological symptoms

> > 11) Past history of neck pain or headache

> > 12) Degenerative changes seen on radiographs

> > 13) Loss or reversal of cervical lordosis

> > 14) Increasing age (i.e., middle age and beyond)

> > 15) Front seat position

> >

> > Also, did you check to see if, in this particular case, whether there

>were

>complicating factors that lead to a poor prognosis and long term treatment

>or disability?, i.e.:

> > 1) Metabolic disorders, i.e. diabetes, etc.

> > 2) Lower BMI

> > 3) Immediate/early onset of symptoms (i.e., within 12 hours) and/or

>severe initial symptoms

> > 4) Initial back pain

> > 5) Spondylosis

> > 6) Use of seat belt and shoulder harness

> > 7) Facet arthrosis

> > 8) History of neck pain or headaches

> > 9) Rheumatoid arthritis or other arthritides

> > 10) Degenerative changes on radiographs of the spine

> > 11) Ankylosing spondylitis or other spondylarthropathy.

> > 12) Loss/reversal of cervical lordotic curve

> > 13) Scoliosis

> > 14) Increasing age (i.e., middle age and beyond

> > 15) Prior cervical spinal surgery

> > 16) Front seat position in car

> > 17) Prior lumbar spinal surgery

> > 18) Prior vertebral fracture

> > 19) Osteoporosis

> > 20) Osseous diseases

> > 21) Spinal stenosis and/or foraminal stenosis

> > 22) Paraplegia or quadriplegia

> > Of course, these factors must be documented in the patient history and

>the

>DC's chart notes, in an accurate and concise manner.

> >

> > Then, in closing, is the $19K truly excessive? Compared to what?

>Compared to spinal surgery, at a minimum of $80K? Compared to PT, MD,

>Radiology, long-term pharmacologic dependence, Occupational Therapy, ad

>nauseum, with their related costs of $100K+? In addition, what are the

>costs

>of lost time, loss of familial consort, loss of social function, premature

>death from the sequelae of the effects of the injury and the gradual, stead

>deterioration of the quality of life? Personally, it is about time that we

>tell the world the truth about how the insurance industry is duping the

>public. Our efforts will be better served to broadcast to the public that

>we are more effective, less costly, and more efficient than any other form

>of treatment and stop acting as if we are the poor cousins in the health

>care delivery field. Our treatment should be worth more than standard

>medical care. Our true value is the marked effect we have on the

>functionality we return to our patient's lives and the reduced long-term

>costs we actually save with our treatment.

> >

> > My advice: Stop crying that the sky is falling and tell those that

> " think " we treat or charge excessively to contact the OBCE and our Peer

>Review Committee.

> >

> > But, that's just my opinion. I could be wrong.

> >

> > G. Ray, DC

> >

> >

> >

> > OregonDCs rules:

> > 1. Keep correspondence professional; the purpose of the listserve is to

>foster communication and collegiality. No personal attacks on listserve

>members will be tolerated.

> > 2. Always sign your e-mails with your first and last name.

> > 3. The listserve is not secure; your e-mail could end up anywhere.

>However, it is against the rules of the listserve to copy, print, forward,

>or otherwise distribute correspondence written by another member without

>his

>or her consent, unless all personal identifiers have been removed.

> >

[Guest guest]

This obvious fact is what I believe to be

the true motivation for the creation of the OBCE Ed Manual, i.e., to establish

a written standard of care. I do object to the clandestine creation of such a

manual as such, but I have had repeated discussions that suggest otherwise.

Again for the recordbooks, you movers and shakers,

please reiterate that the Ed Manual will never be used to define chiropractic

practice in Oregon.

Willard Bertrand, D.C.

Re:

" Proposed Excessive Treatment Admin. Rule "

Listserv,

The excerpt below is from a post by Dan Beebe: I must have missed this when it

was posted some time ago. Sorry Dan. But I'd like to reply to it now. To clarify the ORS 684.100 areas Dan is

directing us to look as a tool to deal with excessive treatment:

Please everyone, open your " Regulations

for Chiropractors and Chiropractic Assistants " handbook to page

4. Or you can go on line to www.obce.state.or.us

for the entire rule. Dan,

you're partially correct, in that there are things we can do once we find a

violation. There's a whole list of things that can be used as 'punishment' for

the wrong behavior.

(A) Any conduct or practice contrary to

recognized standard of ethics of the chiropractic profession or any conduct or

practice that does or might constitute a danger to the health or safety of a

patient or the public or any conduct, practice or condition that does or might

impair a physician's ability safely and skillfuly to practice chiropractic.

( Willful ordering or

performance of unnecessary laboratory tests or studies; administration of

unnecessary treatment; failure to obtain consultations or perform referrals when

failing to do so is not consistent with the standard of care; or otherwise

ordering or performing any chiropractic servie, X-ray or treatment that is

contrary to recognized standards of practiace of the chiropractic profession.

Now comes the part

that Vern has been mentioning. In this rule, you will note that there is no

list or description that describes just what the 'standard of care' is. There

is no clear definition of exactly what excessive treatment is. So lets say one

of you averge Joes files a complaint with the board about an improperly done

IME. You feel the doctor has disregarded what appears to be 'standard' findings

indicating a need for continued care. The board is not able to rule a violation

has occured without a clear definition of exactly what standard has been

violated. If several docs give opinions as to what the standard is....we would

still lose. Our Legal tells us this will happen because the rule doesn't spell

out what the standard is. I do understand the need to be very careful in

creating a rule that might hurt us. I think Vern is being very careful in

writing this rule. He's very open to suggestions and welcomes help. It needs

more discussion. The rules advisory committee meets on Thursday, July 8 at 3PM

in Salem at the OBCE office for more discussion on this.

Thanks and please come if you can.

Minga Guerrero DC

In discussing this with some of the OBCE members it appears

as though

Judges

>are reluctant to prosecute those practitioners that the board has deemed

in

>violation of excessive tx/fee. As I read ORS 684.100-1-g-b is pretty darn

>clear that there are guidelines for excessive treatment and ORS 684.100

(9)

>allows the scope of actions which include license suspenstion, revocation

or

>probation, a civil penalty not to exceed 10K or to take disciplinary

action

>as the board in its discretion finds proper.

>

>My question remains that if the judicial branch of the government fails to

>prosecute should the Insurance industry be moreover looking at the

>government and pressuring the judges to follow laws already in place

rather

>than having us narrowly define ourselves into the proverbial corner? My

>attempt here is not to attack Verne but rather to further the discussion.

>

>Regards,

>

>Danno

>

>

> Re: " Proposed Excessive Treatment Admin.

Rule "

>>>

>>>

>>>>Yep, correct the OBCE's current

OregonDCs

rules:

1. Keep correspondence professional; the purpose

of the listserve is to foster communication and collegiality. No personal

attacks on listserve members will be tolerated.

2. Always sign your e-mails with your first and

last name.

3. The listserve is not secure; your e-mail could

end up anywhere. However, it is against the rules of the listserve to copy,

print, forward, or otherwise distribute correspondence written by another

member without his or her consent, unless all personal identifiers have been

removed.

[Guest guest]

Vern:

Yes, I agree that we need to self regulate, and regulate within the

profession. At the same time, we have to recognize that SAIF and the

DOJ were hell bent on finding chiropractors at fault despite doing

nothing wrong. So, were there really a " % of the profession that were

truly abusing the system of Worker's Compensation " in 1990 or were

there a bunch of people charged because they gave away 1 too many free

birthday adjustment cards in 10 years like the case I worked on?

Because the truth is, you can get accused of fraud when you didn't do

anything wrong, and in the end, if ten years later no one knows the

truth you can keep suggesting that it was fraud or abuse.

One of the key issues of the profession remains how will you meet your

ethical responsibility to provide pro bono care to indigent patients

while at the same time not setting up a dual rate structure for people

with insurance benefits. How will the new fee guidelines address that

issue? What is the legal affect of working within the fee guideline

for the insurance companies while giving away free care to others who

have no benefits? Do you think that provides protection against

rackateering charges mounted by insurers? How will they address the

issue of a doctor who wants to provide a certain percentage reduction

to people with AIDS, infertile couples, or people of a particular trade

group? What about the fact that by accepting a certain rate structure

for Auto cases, and a different one for an HMO/PPO doctors are agreeing

to a dual rate structure that could end up leading to fraud charges?

Maybe the legal ramifications of these things should be considered

before the profession consents to a set fee structure for any area of

practice.

Again, this assumes that the profession could get the legislature to

now drop its set pricing guide for auto cases in favor of one with only

a vague definition of what is excessive.

Begin forwarded message:

> From: " Vern Saboe DC " <vas@...>

> Date: Thu Jun 24, 2004 9:01:17 PM US/Pacific

> " DeShaw " <deshaw@...>

> Subject: Fw: " Proposed Excessive Treatment Admin. Rule "

>

>  

> " Proposed Excessive Treatment Admin. Rule "

>

> Dear Colleagues:

>  

> As per the need for an Administrative Rule that is specific in

> language so to act as a measuring stick (outcomes assessment tools)

> that all stakeholders can use in the realm of PIP in Oregon, to

> determine that chiropractic treatment frequency and duration of

> curative care has indeed been reasonable and necessary....

>  

> I just received a post from a colleague in another state who just

> reviewed a PIP case that ran right at 10 months of care and close to

> $19,000 in charges.  Yes, we have this same level of abuse here in

> Oregon, what % of colleagues?  I have no idea but it matters not as it

> will indeed be these cases that the PIP carriers will use to convince

> the legislators that change is needed.

>  

> In the late 80's we needed to do something about the % of the

> profession that were truly abusing the system of Worker's

> Compensation.  What was missing was a universal evidence based

> measuring stick to apply to these casualty (accident) insurance type

> cases, to help determine if curative treatment had been reasonable and

> necessary.

>  

> Bottom-line was I heard some of the same arguments then against not

> " boxing ourselves in, etc., "   so we did nothing and we lost nearly

> everything and colleagues history is about to repeat it's self in PIP

> if we again fail to act decisively and in a timely manner.

>  

> I would like your thoughtful comments?

>  

> Vern Saboe

>  

>  

[Guest guest]

Dear colleagues:

In response to DeShaw's comments and reference to the " Art Croft's "

guidelines and why simply adopting Art's treatment guidelines isn't the way

to go in my opinion please see my May 13 post to Dr. Ray on this issue.

Vern Saboe, DC., DACAN., FICC., DABFP

President Chiropractic Association of Oregon

Re: " Proposed Excessive Treatment Admin. Rule "

> >

> >

> > > Vern et al

> > > This is a good example of why we need to adopt Art Croft's treatment

> > guidelines in this state. They are based on SCIENCE, not " well, I think

> it

> > is so, therefore, it is so " . Consensus may have its place, but hard

> > scientific data wins hands-down everytime.

> > >

> > > Ray, DC

> > >

> > >

> > >

> > >

> > >

> > >

> > >

> > > OregonDCs rules:

> > > 1. Keep correspondence professional; the purpose of the listserve is

to

> > foster communication and collegiality. No personal attacks on listserve

> > members will be tolerated.

> > > 2. Always sign your e-mails with your first and last name.

> > > 3. The listserve is not secure; your e-mail could end up anywhere.

> > However, it is against the rules of the listserve to copy, print,

forward,

> > or otherwise distribute correspondence written by another member without

> his

> > or her consent, unless all personal identifiers have been removed.

> > >

[Guest guest]

Verne:

I have concerns regarding the process and language that you are proposing

here in the excessive rule. There seems to be an alternative that has been

useful in Washington with a proven track record. Are you aware of this and

if so your opinion.

I would also appreciate hearing from the other CAO board members concerning

the rule and whether this is a CAO proposal.

Don, , Steve, Sunny?

In discussing this with some of the OBCE members and realizing that Verne is

attempting to head off a crisis I realize that the issue needs to be

addressed. I believe that the proposal that Verne is putting forth sets yet

another standard that is not needed. We already have Mercy guidelines, State

guidelines and National guidelines. I have written to express the language

in Verne's proposal to at least be mollified in utilizing words like may vs

shall or must. There are too many folks out there who do not have our best

interests at heart. I see no need to give them a bullet and this is what

is attempting to alert us all to from his prospective as an attorney.

Probably a good idea to take some counsel. Especially concerning his

background.

I understand the argument for the excessive treatment rule and realize that

Verne is putting forth a concept that he seems willing to change. While

there has been discussion concerning the need for the rule other than

Verne's suggestion there has been no alternative put forth in this forum

Would someone please quote the Washington law and maybe give other

alternatives?

In discussing this with some of the OBCE members it appears as though Judges

are reluctant to prosecute those practitioners that the board has deemed in

violation of excessive tx/fee. As I read ORS 684.100-1-g-b is pretty darn

clear that there are guidelines for excessive treatment and ORS 684.100 (9)

allows the scope of actions which include license suspenstion, revocation or

probation, a civil penalty not to exceed 10K or to take disciplinary action

as the board in its discretion finds proper.

My question remains that if the judicial branch of the government fails to

prosecute should the Insurance industry be moreover looking at the

government and pressuring the judges to follow laws already in place rather

than having us narrowly define ourselves into the proverbial corner? My

attempt here is not to attack Verne but rather to further the discussion.

Regards,

Danno

Re: " Proposed Excessive Treatment Admin. Rule "

> > >

> > >

> > > > Vern et al

> > > > This is a good example of why we need to adopt Art Croft's treatment

> > > guidelines in this state. They are based on SCIENCE, not " well, I

think

> > it

> > > is so, therefore, it is so " . Consensus may have its place, but hard

> > > scientific data wins hands-down everytime.

> > > >

> > > > Ray, DC

> > > >

> > > >

> > > >

> > > >

> > > >

> > > >

> > > >

> > > > OregonDCs rules:

> > > > 1. Keep correspondence professional; the purpose of the listserve is

> to

> > > foster communication and collegiality. No personal attacks on

listserve

> > > members will be tolerated.

> > > > 2. Always sign your e-mails with your first and last name.

> > > > 3. The listserve is not secure; your e-mail could end up anywhere.

> > > However, it is against the rules of the listserve to copy, print,

> forward,

> > > or otherwise distribute correspondence written by another member

without

> > his

> > > or her consent, unless all personal identifiers have been removed.

> > > >

[Guest guest]

Dan and Board members:

First, I continue to appreciate your thoughtful input Dan and have never

considered any of your comments so form of attack on me personally.

Second, the Washington State Admin Rule language is what we copied for the

" Excessive Fee " rule with one minor change I suggested which was to add the

terms " Specialty Certification(s).

Utilization of " Outcomes Management " within the proposed " Excessive

Treatment " rule is from a guideline type document also out of Washington

State. I was first turned on to using Outcomes assessment tools and this

document by Kim Christenson who just happened to be seated next to me on the

way to Washington DC about four years ago.

So Dan to answer you question both rules are somewhat linked to Washington

State.

Outcomes Management is where the health care industry has been heading to

determine the most cost effective and clinically effective treatments for

various conditions.

Nonetheless this is still only draft language and though we came to an

unoffiical consensus on the Oregon listserve, it still needs to be approved

by the CAO membership, and I believe the entire state via a survey letter to

all DCs.

Vern

Re: " Proposed Excessive Treatment Admin. Rule "

> > > >

> > > >

> > > > > Vern et al

> > > > > This is a good example of why we need to adopt Art Croft's

treatment

> > > > guidelines in this state. They are based on SCIENCE, not " well, I

> think

> > > it

> > > > is so, therefore, it is so " . Consensus may have its place, but hard

> > > > scientific data wins hands-down everytime.

> > > > >

> > > > > Ray, DC

> > > > >

> > > > >

> > > > >

> > > > >

> > > > >

> > > > >

> > > > >

> > > > > OregonDCs rules:

> > > > > 1. Keep correspondence professional; the purpose of the listserve

is

> > to

> > > > foster communication and collegiality. No personal attacks on

> listserve

> > > > members will be tolerated.

> > > > > 2. Always sign your e-mails with your first and last name.

> > > > > 3. The listserve is not secure; your e-mail could end up anywhere.

> > > > However, it is against the rules of the listserve to copy, print,

> > forward,

> > > > or otherwise distribute correspondence written by another member

> without

> > > his

> > > > or her consent, unless all personal identifiers have been removed.

> > > > >

[Guest guest]

Does the Washington State Law as it is written fit our needs ?

Re: " Proposed Excessive Treatment Admin.

Rule "

> > > > >

> > > > >

> > > > > > Vern et al

> > > > > > This is a good example of why we need to adopt Art Croft's

> treatment

> > > > > guidelines in this state. They are based on SCIENCE, not " well, I

> > think

> > > > it

> > > > > is so, therefore, it is so " . Consensus may have its place, but

hard

> > > > > scientific data wins hands-down everytime.

> > > > > >

> > > > > > Ray, DC

> > > > > >

> > > > > >

> > > > > >

> > > > > >

> > > > > >

> > > > > >

> > > > > >

> > > > > > OregonDCs rules:

> > > > > > 1. Keep correspondence professional; the purpose of the

listserve

> is

> > > to

> > > > > foster communication and collegiality. No personal attacks on

> > listserve

> > > > > members will be tolerated.

> > > > > > 2. Always sign your e-mails with your first and last name.

> > > > > > 3. The listserve is not secure; your e-mail could end up

anywhere.

> > > > > However, it is against the rules of the listserve to copy, print,

> > > forward,

> > > > > or otherwise distribute correspondence written by another member

> > without

> > > > his

> > > > > or her consent, unless all personal identifiers have been removed.

> > > > > >

[Guest guest]

Listserv,

The excerpt below is from a post by Dan Beebe: I must have missed this when it was posted some time ago. Sorry Dan. But I'd like to reply to it now. To clarify the ORS 684.100 areas Dan is directing us to look as a tool to deal with excessive treatment:

Please everyone, open your "Regulations for Chiropractors and Chiropractic Assistants" handbook to page 4. Or you can go on line to www.obce.state.or.us for the entire rule. Dan, you're partially correct, in that there are things we can do once we find a violation. There's a whole list of things that can be used as 'punishment' for the wrong behavior.

(A) Any conduct or practice contrary to recognized standard of ethics of the chiropractic profession or any conduct or practice that does or might constitute a danger to the health or safety of a patient or the public or any conduct, practice or condition that does or might impair a physician's ability safely and skillfuly to practice chiropractic.

( Willful ordering or performance of unnecessary laboratory tests or studies; administration of unnecessary treatment; failure to obtain consultations or perform referrals when failing to do so is not consistent with the standard of care; or otherwise ordering or performing any chiropractic servie, X-ray or treatment that is contrary to recognized standards of practiace of the chiropractic profession.

Now comes the part that Vern has been mentioning. In this rule, you will note that there is no list or description that describes just what the 'standard of care' is. There is no clear definition of exactly what excessive treatment is. So lets say one of you averge Joes files a complaint with the board about an improperly done IME. You feel the doctor has disregarded what appears to be 'standard' findings indicating a need for continued care. The board is not able to rule a violation has occured without a clear definition of exactly what standard has been violated. If several docs give opinions as to what the standard is....we would still lose. Our Legal tells us this will happen because the rule doesn't spell out what the standard is. I do understand the need to be very careful in creating a rule that might hurt us. I think Vern is being very careful in writing this rule. He's very open to suggestions and welcomes help. It needs more discussion. The rules advisory committee meets on Thursday, July 8 at 3PM in Salem at the OBCE office for more discussion on this.

Thanks and please come if you can.

Minga Guerrero DC

In discussing this with some of the OBCE members it appears as though

Judges

>are reluctant to prosecute those practitioners that the board has deemed

in

>violation of excessive tx/fee. As I read ORS 684.100-1-g-b is pretty darn

>clear that there are guidelines for excessive treatment and ORS 684.100

(9)

>allows the scope of actions which include license suspenstion, revocation

or

>probation, a civil penalty not to exceed 10K or to take disciplinary

action

>as the board in its discretion finds proper.

>

>My question remains that if the judicial branch of the government fails to

>prosecute should the Insurance industry be moreover looking at the

>government and pressuring the judges to follow laws already in place

rather

>than having us narrowly define ourselves into the proverbial corner? My

>attempt here is not to attack Verne but rather to further the discussion.

>

>Regards,

>

>Danno

>

>

> Re: "Proposed Excessive Treatment Admin. Rule"

>>>

>>>

>>>>Yep, correct the OBCE's current

[Guest guest]

I have also recommended changes like that Dan and didn't hear anything back.

Probably lost in the shuffle BUT the 'shall' and probably some statement

that " Outcomes Measures are an important and often pivotal measure in cases

where question of Tx frequency exists " would allow the OBCE more freedom to

use the admin rule effectively.

Colwell, DC

Re: " Proposed Excessive Treatment Admin. Rule "

> > > >

> > > >

> > > > > Vern et al

> > > > > This is a good example of why we need to adopt Art Croft's

treatment

> > > > guidelines in this state. They are based on SCIENCE, not " well, I

> think

> > > it

> > > > is so, therefore, it is so " . Consensus may have its place, but hard

> > > > scientific data wins hands-down everytime.

> > > > >

> > > > > Ray, DC

> > > > >

> > > > >

> > > > >

> > > > >

> > > > >

> > > > >

> > > > >

> > > > > OregonDCs rules:

> > > > > 1. Keep correspondence professional; the purpose of the listserve

is

> > to

> > > > foster communication and collegiality. No personal attacks on

> listserve

> > > > members will be tolerated.

> > > > > 2. Always sign your e-mails with your first and last name.

> > > > > 3. The listserve is not secure; your e-mail could end up anywhere.

> > > > However, it is against the rules of the listserve to copy, print,

> > forward,

> > > > or otherwise distribute correspondence written by another member

> without

> > > his

> > > > or her consent, unless all personal identifiers have been removed.

> > > > >

[Guest guest]

The fee rule is an Admin Rule not statute or law and yes it does. The CAO

and ODOC Legislative Committee members jointly met again tonight and both

agree to support the Excessive Fee Language which is copied from Washington

state!

Vern

Re: " Proposed Excessive Treatment Admin.

> Rule "

> > > > > >

> > > > > >

> > > > > > > Vern et al

> > > > > > > This is a good example of why we need to adopt Art Croft's

> > treatment

> > > > > > guidelines in this state. They are based on SCIENCE, not " well,

I

> > > think

> > > > > it

> > > > > > is so, therefore, it is so " . Consensus may have its place, but

> hard

> > > > > > scientific data wins hands-down everytime.

> > > > > > >

> > > > > > > Ray, DC

> > > > > > >

> > > > > > >

> > > > > > >

> > > > > > >

> > > > > > >

> > > > > > >

> > > > > > >

> > > > > > > OregonDCs rules:

> > > > > > > 1. Keep correspondence professional; the purpose of the

> listserve

> > is

> > > > to

> > > > > > foster communication and collegiality. No personal attacks on

> > > listserve

> > > > > > members will be tolerated.

> > > > > > > 2. Always sign your e-mails with your first and last name.

> > > > > > > 3. The listserve is not secure; your e-mail could end up

> anywhere.

> > > > > > However, it is against the rules of the listserve to copy,

print,

> > > > forward,

> > > > > > or otherwise distribute correspondence written by another member

> > > without

> > > > > his

> > > > > > or her consent, unless all personal identifiers have been

removed.

> > > > > > >