Ethics and Jurisprudence

Backending - Selling Stuff to Patients

Lots of chiropractors sell stuff to patients these days. Here's an article that I wrote for a recent issue of Straight from Sherman on the topic of backending.

Backending - Selling Stuff to Patients
By Leslie M. Wise, D.C.

A definition is always in order when a new term is being put forth, especially if that term may have diverse meanings in multiple contexts. “Backending” is used in the computer industry, to differentiate hidden, unseen parts of an application from the visible, user interface. It is used in demographics and data collection to distinguish intentionally collected information from information which must be secondarily gleaned from the original entries. In sales, it means selling someone something they didn’t come in to buy. It is in this latter context that we will consider the extremely common practice of chiropractic backending, which occurs when a patient comes in for chiropractic services and leaves with two sets of orthotics, six bottles of vitamins, a knee brace, a carpal tunnel strap, a $200 pillow and a lifetime subscription to Chiropractic Health magazine.

I can already hear my detractors: “But all those things are good for the patient. We’re doing them a great service!”  That was the excuse of the Myrtle Beach chiropractor busted by the board of examiners in the early 80s for running nude hot-tub encounter groups in his office. His logic was that the sessions reduced stress, and lower stress means better health. Whether or not things are good for people is not the issue here. We will come to the true issue shortly.

One of the differences between a hardware store owner and a doctor is that the store owner is a merchant and the doctor is a professional. The merchant subscribes to the mercantile ethic of “buyer beware,” and the doctor is beholden to the professional ethic of “let the buyer trust.” The mercantile ethic may consider fair and honest service, but is primarily concerned with a profit motive and the merchant’s best interests, whereas the professional ethic must consider altruistic service and the best interest of the patient always must be supreme. When a doctor starts selling merchandise in a professional office, an immediate potential conflict of interest is created, causing the schizophrenic doctor to choose between serving the patient’s best interests and selling those 10 cases of special feel-good vitamins before they expire next week. The patient is placed in the uncomfortable position of deciding whether to be compliant with the doctor’s recommendations, or buy his vitamins at Wal-mart. He risks the doctor’s displeasure while making an economic decision, and is obviously reluctant to alienate this person because of his authority position.

Professions have created codes of ethics that specifically address the subject of conflicts of interests. They generally advise that professionals, because of their adherence to higher ethical standards than the general public, should scrupulously avoid conflicts, and even avoid the appearance of conflicts by always taking the high road in matters of money and profit.

Just how common is the practice of backending among chiropractors? The 2007 Chiropractic Economics Salary Survey indicates that 88 percent of DCs answering their poll receive income from ancillary products, with pillows, nutritionals, and orthotics being the top sellers. We can see that mercantilism is alive and well in our profession, and these products have become associated with chiropractic in the minds of the public. Many chiropractors depend on product sales for a considerable additional revenue stream without which their total income would suffer. Given the fact that backending is a widespread practice, and that DCs do not see it as compromising their professional integrity, it is unlikely that a prohibitive pronouncement from a conservative chiropractic magazine is going to change matters, so what if I offer a few considerations for thought on the practice? (I feel like Moses offering Ten Suggestions for Consideration.)

• Items or products should be offered with an extremely soft- sell approach, respecting the autonomy of the patient
• Items or products should be related to the chiropractic mission and aimed at helping us accomplish our mission (no vinyl siding)
• Items or products should be of highest quality and offered with a modest profit margin. If alternative sources are available, disclose that fact.
• If you invented the product or own the company providing it, full disclosure should be offered concerning your interests
• If you enter the world of mercantilism, do it with the Sears Roebuck, no questions asked, 100% money back guarantee.

I would hope that chiropractors focus on providing chiropractic services in a manner that emphasizes the professional ethic, not the mercantile approach. Patients need to feel with certainty that we are absolutely concerned with their best interests in every situation, and that is a tricky matter when they get the feeling that we’re just pushing product and generating profit. Obviously we are not the only profession to deal with this sticky situation. The American Medical Association (2005) has issued policy statements on physicians who sell stuff. Their attitude is “Welllllll, if you must…….”

The AMA allows sale of health related products, but is not crazy about the idea. Don’t even think about selling non-health related items. But the fact is only 30 percent of physicians belong to the AMA so their pronouncements have little weight in the marketplace. The ACA and ICA are relatively quiet about this practice, with no specific rules covering the topic.

We live in a new world, and must adapt to new ways of doing things, but I hope that we can maintain our professional integrity while living in this new world.

References
American Medical Association. (2005). E-addendum III: council on ethical and judicial affairs clarification of sale of products from physicians’ offices (E-8.062 and E-8.063).

Chiropractic Economics. (2007). 10th annual salary and expense survey. 53(8).

Abandonment - Ethics in Action

Another topic in podcast form from the short series, "Ethics in Action."

Finances and the Chiropractic Patient

Here's an article I wrote for a recent issue of Straight from Sherman.

Ethics In Action
By Leslie M. Wise, D.C.

Pod/Vodcast:



In a recent workshop for faculty, Dr. Norman Ouzts, Chairman of the South Carolina Board of Chiropractic Examiners, indicated that complaints filed about D.C.s to the SC Board are heavily weighted in the category of financial misconduct, with sexual misconduct a distant second place. This gives rise to the important consideration of what chiropractors can do to assure that we are absolutely fastidious about the financial conduct of our practices, and avoid public sentiment that we are less than honest.

In our ethics and practice management classes at Sherman, we make the following suggestions regarding finacial interactions with patients:

• Always discuss fees very early in the doctor/ patient relationship, preferably on the first encounter. Be sure to deal with initial visit fees, such as exam and x-rays, as well as the fees for subsequent routine visits. Patients hate surprises. Be willing to state your fees when asked.

• Have a written policy on fees and collections. Include it in your practice brochure, and on your website. Transparency is best when it comes to money. Patients will appreciate your willingness to discuss finances, even when they are hesitant to open the discussion.

• If you use pre-paid plans of care, be especially scrupulous in your explanations of what a patient gets for their pre-paid fee. You must have a refund policy, if a patient decides to drop out. Some states require that you keep all funds collected in a special escrow account until the services are actually delivered. Put it in writing and answer all questions before taking payment.

• If a dispute over money arises, be willing to take the high road. Ask the patient what would make him happy, and do it, even if it involves writing a check for a refund to which you are not legally obligated.

As ethical chiropractors we have a fiduciary responsibility to our patients, which means that we are obligated to look out for their best interests first, and that includes their financial best interests. Absolute financial integrity, with no hint of shady dealings will help assure that our profession gains the esteem we rightfully deserve.

Who Really Controls Healthcare?

Sal Martingano, D.C. is a Sherman graduate and a great friend of the college. This is a fairly long, but insightful look at the "big picture" of healthcare in America. I hope you will take the time to read the article and digest the content. These are issues that we will be dealing with for generations.

Chiropractic in Los Angeles

We are all accustomed to stories about DCs who practice in small towns, or rural areas, or the ever popular suburbs. We don't seem to think a lot about chiropractors in the land of freeways, beaches and movie stars. Here's a nice reflection by Dr. Michael Dorausch on the ups and downs of practing in LA.

Ethics Resource Center

We tend to focus on ethical issues in our profession, sometimes taking a broader view of ethics in other professions, and society in general. This website is the Ethics Resource Center, a non- profit organization focusing on ethics in the broader sense of corporate and governmental issues. Take a look at the current issue of their magazine, and see the "Top 10 Ethics Stories of the Year".

Protection from Personal Liability

Professionals quickly learn that there is no shortage of people who would like to have your house, swimming pool, bank account and new Hummer. They are prepared to sue you in order to have access to your assets and make them their own. If it seems that we spend an inordinate amount of time conniving to keep our assets, it's true. We prefer to keep what we have, thank you. This article gives one slant on keeping what you've got.

What Women (and men) Want

No, this isn't a reference to the Mel Gibson movie of a couple of years ago. Instead, it's a good article by Angelica Redleaf, D.C.,in the form of a fairy tale, addressing issues that every health care provider must deal with(unless you're a woman, and already know the answer).

Angelica Redleaf, DC, has been in practice in Providence, R.I., since 1978. She is the author of Behind Closed Doors: Gender, Sexuality & Touch in the Doctor/Patient Relationship (1998)

Expert Witness

I have mentioned in class that I occasionally appear as an expert witness in malpractice cases involving chiropractors. This is one use that courts make of experts. Another, far more common use of an expert comes when you are asked (or ordered) to testify on behalf of a patient, concerning injuries and disability issues. As a factual witness you may state what the patient told you, what you found when you examined the patient, and how your course of chiropractic care objectively improved the patient's status. Very often you will then be asked to give your opinion on the patient's condition, and predict how they will fare in the future. Only experts may testify about their opinions, so your status immediately changes from factual witness to expert witness. Here is a thorough article dealing with expert testimony.

Boundary Issues

Dating and the young professional is always a hot topic for discussion. A boundary guideline that creates a lot of interest is the general prohibition on doctors dating patients. It is with good reason that these guidelines ware created and exist, however, it seems that young professionals are always looking for loopholes and exceptions. This is an article by an attorney on this particular boundary issue.