August 2003 Concerns of a pending US House Bill for Medicare Payments to a DC From: Daryl D Wills, DC - ACA President > James D Edwards, DC - ACA Chairman of the Board > > Re: HR2560 > > The following is an ACA response to a recent email by Dr. Terry Rondberg > pertaining to HR2560. The ACA believes it is important for the profession > to review the positions laid out by the opponents and proponents of this > far-reaching revamping of chiropractic services under Medicare. > > Before responding to each item raised in Dr. Rondberg's e-mail message of > August 11, 2003, the ACA would identify a point that there is agreement > between the proponents and opponents of HR2560. The original e- mail is in > black and ACA responses are in red and underscored. > > The e-mail exchanges between the proponents of HR 2560 and the ACA have > helped clarify the positions of both sides. There is agreement on one > critical issue - both sides believe that HR 2560 would lead to lower > relative value units for chiropractic services. The ACA opposes such a > reduction because, in its view, chiropractors are already paid too little > for the important services they provide. WCA views such a reduction in > reimbursement as an important way in which chiropractic services may be > used by a broader segment of the chiropractic patient population. In his > e-mail message of July 30, 2003, Dr. Rondberg quotes Mr. Barry Pineles, > legislative counsel for the U.S. House of Representatives and primary > author of HR 2560. Mr. Pineles acknowledging that the legislation would > require separate chiropractic codes with lower relative values notes that > this "should be a plus" . Mr. Pineles states "Would you rather have codes > solely developed for chiropractors or ones that are developed for > chiropractors and physicians? It would seem to me that by simply limiting > the data to chiropractors, you would get more accurate data and > potentially lower relative value units, i.e., chiropractic services would > be cheaper and more readily used by Medicare patients." (emphasis added). > > Again, it is ACA's position that chiropractors are deserving of more > reimbursement for their valuable services, not less. It would also stress > that the Medicare relative value system is used by many third party > payers, such as Worker's Compensation programs, Blue Cross/Blue Shield > programs, insurance carriers, managed care organizations. A reduction in > the Medicare relative value units, as espoused by Mr. Pineles and the WCA, > will result in a reduction of payment under those programs as well. > > There are many rumors and untruths being spread throughout the profession > by Jim Edwards, Chairman of the ACA. I have received copies of all of the > ACA Confidential Memos attempting to undermine positive legislation. > > Jim Edward's trip to Washington this past Monday is regrettable. Perhaps > he can't stand the idea that our legislation would negate the need for the > ACA legislation and prove the five million dollar lawsuit was unnecessary. > > ACA response: ACA has already achieved a significant victory in its > Medicare lawsuit by denying physical therapists the ability to correct > subluxations because P.T. do not enjoy physician status and manual > manipulation of the spine to correct a subluxation is a physician service. > Something HR 2560 would quickly reverse. Also, the bulk of the money > expended in ACA's litigation has been in the Trigon/Anthem lawsuit. The > ACA is fighting against economic discrimination that seeks to deny payment > equity. The ACA is fighting for the proposition that chiropractors > deserve equity and deserve more for the valuable services they provide. > HR 2560 says to the health care industry that chiropractors deserve less > for these services. While the ACA aggressively fights this economic > discrimination, the WCA and ICA would run up the white flag and forever > surrender on the issue of payment parity with HR 2560. > > The typical personal attacks on me and my motives are pure Edwards > fantasy. Edwards can only resort to ad hominem attacks because his > arguments have no merit. The ACA fear tactics are tired and predictable. > Instead of uniting behind our profession and the Coalition, the ACA path > remains self destructive. > > The Coalition remains a positive force in the chiropractic profession. > Instead of defending myself, I will take the high road and present the > facts behind this legislation: > A) HR 2560 would create a new category for chiropractic services, and > provide that chiropractic services could only be provided by a D.C. M.D.s > and D.O.s would no longer be reimbursed for providing the chiropractic > benefit. This would not only render the ACA lawsuit against Medicare > unnecessary, but ensure that D.C.s do not suffer economic competition from > other individuals who would attempt to provide the "chiropractic" benefit. > > > ACA response: It may render ACA lawsuit against Medicare unnecessary but > it would do so at a devastating cost to the profession. Doctors would see > the reduction in reimbursement from all sources as the relative values for > their services are reduced and payments are reduced. The enactment of > HR2560 would be a classic example of a profession shooting itself in the > foot. > > As long as DCs are lumped in with MDs and DOs, our position in the > marketplace is precarious. MDs and DOs hold plenary licenses. DCs hold > limited licenses. It is not realistic to believe that a limited > "physician" will be able to prevent a physician with an unlimited license > from providing a service he/she is trained to provide. DOs are already > trained in spinal manipulation. Courses are available in manipulation for > MDs. > By placing DCs in a unique category, and specifically prohibiting anyone > other than a licensed DC from providing the chiropractic benefit, our > interests are protected. > > ACA response: HR2560 would segregate chiropractic services making them > more susceptible to elimination, reduce their relative value and reduce > payment to chiropractors both in Medicare and other types of third party > payment. It was the intent of Congress to provide for manual manipulation > of the spine to correct a subluxation. There is no question that that is > specific to the chiropractic profession and that substitution of DC by an > MD or DO goes against the intent of Congress. > > B) HR 2560 includes x-rays, exams, and the use of chiropractic > instrumentation. The potential impact of this is significant. Barry > Pineles, Legislative Counsel for the US House of Representatives, early in > the process of crafting this legislation, stated, "I want to make sure you > get paid." Mr. Pineles spent many hours checking cross references to other > legislation to ensure that this would be so. Furthermore, Adam Magary, > Congressman Manzullo's Chief of Staff, indicated that it was clearly the > intent of the legislation that diagnosis of the subluxation be included. > The legislative language clearly and explicitly includes physical > examinations, radiological examinations, and specialized diagnostic > instruments used in the practice of chiropractic. > > ACA response: We question what are "specialized diagnostic instruments"? > And why are they specifically added to this legislation? Is there a > special interest involved? There is no explanation for this curious > inclusion. > > As a growing number of individuals become eligible for Medicare, the > potential economic benefits of HR 2560 are obvious. > > ACA response: While many hours have been spent on reviewing and > cross-referencing other legislation, it is clear that no time was spent by > the proponents of HR 2560 in assessing its effects on the CPT system, the > relative value system and the effects on private third party payment. > Only when ACA raised these considerations did the proponents of HR 2560 > comment that new codes and a reduction in the relative value for > chiropractic services may be a "plus". Lower relative values mean lower > payment to chiropractors and that in our view is not a "plus" but a > disaster. > > C) HR 2560 incorporates the widely accepted ACC definition of subluxation. > Perhaps the most important provision is the one which states that > objective evidence of subluxation is the basis for qualifying. No longer > would a patient need a musculoskeletal ache or pain to qualify. This would > make chiropractic care available to any Medicare beneficiary with > objective evidence of subluxation. > > ACA response: HR 2560 also eliminates the physician status recognized by > the CCE. All CCE schools train chiropractors to be physicians. Why would > the profession want to deny this training and education? > > The scare tactic used by those opposing the bill is the suggestion that > separating DCs from the MD and DO "physician" classification would > adversely affect third party pay, and the inference that this would > somehow affect state "physician" status. > > ACA response: The proponents of HR 2560 maintain that "Medicare coverage" > does not determine the scope of coverage in private insurance. They > either miss the point or intentionally chose to miss the point. The CPT > system and Medicare's RBRVS system are driving forces behind third party > reimbursement in private insurance and other third party payers. > Physician status under Medicare is currently central in chiropractors > maintaining physician status within CPT as it relates to the use of E&M > codes. The issue is not what services may be performed, the issue how > those services are to be described under the CPT system and how those > services are going to be valued under Medicare's relative value system. > Again, it is clear that the proponents of HR 2560 are resigned to seeing a > lower relative value for the services that chiropractors perform. We > insist that should not and cannot be the case. Chiropractors are already > suffering from reduction in reimbursement levels due to managed care > organizations, discrimination and unfair practices. Providing such > organizations with lower relative values for chiropractic services and the > basis to deny payment for physician level E&M Codes would invite them to > further deny coverage and reduce payments to doctors of chiropractic. > This would also render chiropractors to the status of technicians rather > than physicians. > > Medicare coverage does not determine the scope of chiropractic coverage in > private insurance. For example, although Medicare does not reimburse > chiropractors for x-rays, most private insurers that cover chiropractic > services do. > > This has nothing to do with limited "physician" status under Medicare. The > fact is despite the current classification of DCs under Medicare, only one > procedure is covered. Use or non-use of the term "physician" doesn't > change this. > ACA response: Again, this misses the point. The change in physician > status will a) result in the loss through the CPT process of the physician > level E&M code, with its higher relative value; b) result in a lower > relative value for any new chiropractic adjustment code; c) serve the > legislative goals of the AMA and serve as a jumping off point for > opponents of chiropractic to eliminate "physician" status in those states > that have it and be would serve to thwart efforts to obtain physician > status in those states that do not. > > Furthermore, state scope of practice has nothing to do with Medicare > reimbursement. IF LIMITED MEDICARE COVERAGE WOULD RESULT IN NARROWING > PRIVATE INSURANCE COVERAGE, IT WOULD HAVE HAPPENED LONG AGO. All states > have broader scopes of practice than the current Medicare program. The > fact that Medicare now pays only for manual manipulation of the spine HAS > NOT changed the scope of practice in any state. This has been the case for > three decades. > > Similarly, use of the title "physician" is a state law issue. It has > nothing to do with the list of reimbursable Medicare procedures. > > It should be noted that MDs and DOs are not reimbursed under Medicare for > all services they are permitted to render under state law. > > ACA response: Again, this misses the point, the issue is the relative > value for existing chiropractic services and how HR2560 would reduce these > values and payment to practicing chiropractors. > > D) The coding issue is another "straw man." Codes will be created, if > necessary, for statutorily mandated chiropractic services. This happened > in the earlier days of the program when there was no code for the > chiropractic benefit. One was created, A2000. > > ACA response: The proponents of HR 2560 do not directly address the ACA's > concern relative to the loss of the ability to utilize evaluation and > management codes due to the loss of the "physician" status. Rather, they > challenge the views of the chiropractic experts who currently serve on the > applicable CPT and Medicare Relative Value Update panels who have served > on these panels since 1996. However, they have offered nothing to > contradict the views of these individuals that the loss of physician > status under Medicare would result in chiropractors being assigned by the > AMA CPT to utilize non-physician level evaluation and assessment codes > with the resulting lower relative values and limited applicability. > Again, we note that the proponents of HR 2560 expect such lower relative > values and lower status as non-physician providers for chiropractors. We > again assert that without the federal status as physician, the > chiropractic profession would have to rely on the goodwill and kind > intentions of the AMA in order to retain the ability to use physician > level evaluation and management codes. To do so is not only naÔve, but > just plain irresponsible to the members of this profession. This is of no > concern to the proponents of HR 2560 since they have chosen not to address > that point. It, however, remains a central concern for the American > Chiropractic Association. > > We believe that chiropractors should be able to use physician level > evaluation and management codes and be reimbursed accordingly. We do not > believe that it is appropriate for chiropractors to utilize non- physician > level evaluation and assessment codes with their lower relative values and > lower reimbursement levels. > > Regulatory Counsel Mr. Pineles, who is one of the brightest and most > politically savvy men on the Hill (and who understands the intricacies of > chiropractic as well as he does the complexities of politics) put it this > way: > > 1. They would have to develop new codes for the new services provided by > chiropractors. That is nothing new. Whenever new services are added to > Medicare they would have to develop new codes. > > ACA response: What research for adjustment as opposed to manipulation > would the proponents utilize in developing the new codes? And, if the > profession abandons manipulation, is it prepared to permit the physical > therapists and M.D. fill the void? > > 2. Since the term "subluxation" is a term of art under the new > chiropractic definition, one would have to be paid to diagnose the > subluxation. That is the essence of the profession. Of course, if people > are concerned about that, report language can be added to explain that or > we can even amend the legislation to instruct them to include diagnosis. > That is not a big deal and people drop legislation and make corrections > adding new legislation all the time. > > 3. These e-mails back and forth are interesting but essentially > meaningless in the scheme of drafting legislation because it is easy to > ensure that chiropractors can do diagnosis. The philosophical gap will not > be bridged by a discussion of how the relative values for the codes are > developed because that is fundamentally a mechanical process that can be > easily dictated by legislation or report language. > > It is important to remember that we are relying not upon the opinions of > chiropractic politicians or outside attorneys. Mr. Pineles makes his > living writing legislation. Mr. Magary is Congressman Manzullo's Chief of > Staff, and must answer to the Congressman. He wants to ensure that the > legislation, as written, implements the intent of the Congressman. > > Congressman Manzullo himself is an attorney, and a long time, enthusiastic > patient and supporter of chiropractic. > > These men are committed to making sure that this is done right. > > There is agreement between the proponents and opponents that new codes for > the new services provided by chiropractors would have to be developed. > They claim that such a process is "not that big a deal" and corrections > could be made in the legislation or report language to address any of our > concerns. We again agree that new codes would be developed but > respectfully vehemently disagree that such a process is "no big deal". > The new codes would first go through the AMA CPT process and then through > Medicare's relative update system. Our experience has shown that THIS IS > A VERY BIG DEAL indeed and that opening up the codes to the highly > competitive and intense review process that is the CPT and RUC process is > akin to opening up the state scope of practice law for open comment and > revision by hostile opponents. We have no doubt that the results would be > a lower relative value for chiropractic services. This seems to be the > intent of the entire process, since as noted above, the proponents of HR > 2560 seem reconciled to the fact that there would be a reduction in > relative value for chiropractic services. Again, we believe practicing > doctors of chiropractics and their families will pay the ultimate price of > such a reduction of relative values. > > In summary: > > 1. Medicare relates to what services are reimbursable under that program > only. It does not control private insurance contracts, state Worker's Comp > programs, or state PI laws. > > ACA response: But the AMA CPT system and the Medicare Relative Value > system do directly affect these plans. > > 2. State law, not Medicare, determines lawful scope of practice. > > ACA response: The negative influence of HR 2560 will serve to impact the > physician status on a state level. > > 3. State law, not Medicare, governs use of the title "physician." > > ACA response: But the loss of federal physician status will undermine the > status of physician on a state level and further the goals of the AMA and > opponents of chiropractic. > > 4. Contract law and controlling state law regulate private insurers. > Medicare has not, and does not, determine the scope of services provided > in private indemnity policies. > > ACA response: Again, the CPT process and the Medicare Relative Value > process drive the reimbursement systems for of these insurers. HR 2560 > would reduce relative values and deny the use of physician level E&M Codes > resulting in lower payments to chiropractors under these systems. > > 5. Codes will be created, if necessary, for statutorily mandated > chiropractic services. This happened in the earlier days of the program > when there was no code for the chiropractic benefit. One was created, > A2000. > HR 2560 would solve a longstanding problem. Chiropractic would be > recognized as a separate health profession, exams, x-rays, and > instrumentation would be included. The criteria for chiropractic care > would be objective indicators of subluxation. > > ACA response: The codes created and relative values assessed for these > new codes would devastate reimbursement both in Medicare and with third > party payers. When A2000 was created all chiropractic services were > included at a lower global reimbursement. That inaccuracy was not > corrected until ACA efforts resulted in the CMT codes and fair > reimbursement based upon the "cross walked" values with the DO's. > > This bill would benefit all chiropractors. It would not be limited to a > handful of demonstration sites. > > If you wish to read the bill, please visit: > docid=f:h2560ih.txt.pdf> > > We need your help to make this bill a reality. It will benefit you, your > patients, and your business. If you care to fax Senator Hatch a letter > about why you support this legislation and thank him for his help, his fax > number is 202-224-6331 > > Best wishes, > Terry A Rondberg, DC > > Final ACA Comment: With all due respect to the architects and proponents > of HR 2560, it is clear that sufficient time and study was not afforded in > the review of the potential impact of the proposal. The ACA steadfastly > supports the recognition of our profession as separate and distinct and > does not feel that we have to give up physician status and accept lower > reimbursements to maintain it. The position of the proponents, almost as > an after thought, that lower relative values and therefore lower payment > for chiropractic services would result and is a "plus" is in our view > shocking. The effect of HR 2560 is for the profession to forgo physician > status relegating us to a "technician" status while setting a horrible > precedent of lower reimbursement for third party payers. Although > proponents of HR 2560 say they support separate and distinct status, what > they are proposing is more similar to isolated and extinct. > > The proponents of HR 2560 have come forward with this risky and far > reaching legislation without any assessment of it's overall impact on the > system. The burden is on them to demonstrate that it would do more good > than harm. The ACA has little doubt, based on years of experience in > dealing with these issues, that HR 2560 will devastate payment to > chiropractors both within Medicare and with private payers. In the final > analysis, it is practicing doctors of chiropractic and their families that > will pay the price for the risky and untested proposals contained in HR > 2560. > > Daryl D Wills, DC, President > American Chiropractic Association > > James D Edwards, DC, Board Chairman > American Chiropractic Association Having just read the following excerpts to Dr. Rondberg: Mr. Manzullo has not received any substantive, non-philosophical criticisms of his legislation, and therefore has no reason to believe that abandoning H.R. 2560 is the right thing to do. And: And regarding the reimbursement that is lowered, does it seem right that a chiropractor would be reimbursed through Medicare for malpractice insurance at the same level as another provider whose malpractice insurance costs him $200,000 rather than $2,000? Sincerely, Adam J. Magary Chief of Staff Rep. Donald Manzullo And that below from , I think the ACA has a big opportunity here. First, the ACA can come out and point out that the evidence is lacking concerning the ability to document the subluxation. To base the financing of a profession's services on processes that are not well supported is to fly in the face of the whole movement within health care to rely on EBM concepts. Concepts that are designed to reduce the cost of health care by actually improving quality of the resultant application of physician services. That is the technical of it. Second, no where in the economy is an argument that because you can control your cost better than your competitor in the market place you will be reimbursed less accepted! NO WHERE! It is the premise in our country, that those who do it better, or for less or a combination of both, will reap the financial rewards of their efforts. Not be punished for it. Infact, I believe most government contracting is theoretically based on this concept? Thus, it is time to educate these bright boys about the lack of free market controls in the system, to get off this "pay them less because they are cheaper" and start paying everyone equally based on the coded service provided so that the government does not have to keep spending regulatory money based on a segmented provider group structure of reimbursement. Can we saw "DUPLICATION" expenses? Consequently, saving government administrative costs. Read that: Reducing government waste! IWO, start pointing out how out of step with the movement with in health care this piece of legislation is. To put us outside of the system flies in the face of the movement to try to congel the current segmented system based on special treatment of each provider type. How do you get people to work together for the common good of the individual? Not by separating the people who make up the group. Dan Becker, DC, DABCN President, Chiropractic Society of RI Below please read a letter from Congressman Manzullo's Chief of Staff Adam Magary regarding HR 2560 (Separating Chiropractic from Medicine in Medicare) and their response to proponents and opponents. Below that is a list of states where thousands of chiropractors support this bill. I have previously sent 2 letters, one from chiropractors and one from patients that can be signed and faxed to your representatives should you see the value of supporting this legislation. If you don't have a copy of these letters and implementation instructions, email me and I will send it to you. Thank you for getting involved in improving the legislation for current and future chiropractic patients. Stephanie Grenier, DC DrSteph@QualityofLifeChiro.com -----Original Message----- From: Magary, Adam [mailto:Adam.Magary@mail.house.gov] Sent: Monday, August 18, 2003 6:05 PM To: 'Terry A Rondberg, DC' Subject: Re: HR 2560 Dr. Rondberg, Despite any rumors that may be circulating, Mr. Manzullo has absolutely no intention of withdrawing his legislation. While we have always been and continue to remain open to constructive suggestions for improvement, Mr. Manzullo has not seen any arguments against the bill that warrant any action beyond technical corrections. The differences that now exist between supporters of the legislation and opponents of the legislation are purely philosophical in nature. This legislation may inconvenience certain chiropractic philosophies, but it will not devastate chiropractic as a whole. Mr. Manzullo remains committed to the idea that chiropractors are equal, but unique. He remains committed to the idea that chiropractors who participate in Medicare should be reimbursed for the use of their chiropractic services-and that this reimbursement should go beyond just the manipulation procedure itself; chiropractors should be also be reimbursed for x-rays, examinations, and the use of instrumentation. Mr. Manzullo remains committed to the idea that a chiropractor and not an office-based bureaucrat is the best one to determine the necessity of the care. Mr. Manzullo remains committed to the idea that chiropractors should not have to fear reimbursement denials which are subject to the whims of office-based bureaucrats who deny claims based on financial necessity not medical necessity. He especially is outraged that it looks like little is being done within the federal government to correct the perception that if a carrier denies a claim for a service that was actually rendered (and necessary according to the chiropractor's documentation), the federal government still regards and treats that chiropractor as having committed fraud. Just two weeks ago, we discovered that chiropractors have popped up on the radar screen of the Office of Inspector General. The OIG has been randomly auditing chiropractors around the country with the hopes of determining how much "fraud" or maintenance care is being billed to Medicare. How much longer should chiropractors have to fight to get paid for claims that were denied without the carrier even reviewing the tests and documentation justifying the care? Does that not seem absurd to anyone (that they say the service is not medically necessary but they do not look at the x-rays that objectively demonstrate the existence of a subluxation)? In my seven years on Capitol Hill, I have found that few in the federal government even understand what chiropractic is. That is because there has never been a clear definition of what chiropractic is. Whenever Congress becomes convinced enough that chiropractic is a good thing and votes to expand it as a benefit to federal beneficiaries, a massive regulatory subluxation occurs because the few regulatory personnel with any background in health care come from a medicine-based, chiropractic-suspicious education. The rest don't have a clue what chiropractic is and quite frankly, don't care what chiropractic is. To them, chiropractors are just another bunch of whiney doctors who only care about getting more cash-and unfortunately, there are those in the profession who help perpetuate that perception. This is the segment of the chiropractic profession who wants to have its cake (and everyone else's cake) and eat them both, too. They want to be able to seek reimbursement in other providers' backyards, but then sue the government to keep those same providers out of their own backyard. I don't see how you can have a generic and fully-blended definition (such as physician) and not have all services be up-for-grabs. Let me state emphatically, in no way is Mr. Manzullo in favor of lower reimbursements for chiropractors and disputes the claims of bill detractors that his legislation would do that. It may be true that reimbursements for some codes may be lowered because of non- physician status, but Mr. Manzullo's legislation adds reimbursement in areas that chiropractors never received reimbursement for before. And regarding the reimbursement that is lowered, does it seem right that a chiropractor would be reimbursed through Medicare for malpractice insurance at the same level as another provider whose malpractice insurance costs him $200,000 rather than $2,000? Mr. Manzullo's legislation eliminates the need for OIG's, CMS's, and WPS's to invade chiropractic practices to confiscate records that may contain maintenance care. Those chiropractors who have never had the pleasure of this experience better keep their fingers crossed that their number does not come up in the lottery. Mr. Manzullo's legislation eliminates the whole concept of maintenance care and instead establishes a clinical necessity standard. Objective clinical evidence provided by a chiropractor will be enough to justify the care. While CMS and OIG will still be and should be on the prowl for bad actors, the elimination of the maintenance care prohibition will provide another stream of reimbursement for chiropractors, and at the same time, remove the fear that the feds will park a "fraud patrol" van in front of your practice and send letters to all your patients informing them that you bill Medicare for medically unnecessary services. While Mr. Manzullo's legislation expands the reimbursement streams for chiropractors, he remains concerned that reimbursement-only strategies do not address any of the concerns I have described above. Reimbursement-only strategies do not get the federal government off the backs of honest chiropractors. If anything, they invite greater scrutiny. Reimbursement-only strategies do not address bureaucratic disputes over what care is necessary. Reimbursement-only strategies do not address medical specialties that claim similarity with chiropractic or those who wish to eliminate chiropractic all together. Reimbursement-only strategies fail to plan for the notion that what is given can readily be taken away. Formulas will always be adjusted to favor the payer. But once you determine that chiropractic includes x-rays, examination, and instrumentation, how easy is it to take that away? Those items are key pillars of the provision of chiropractic and not as easy to dismantle as a short-lived gain in a formula. That is why Mr. Manzullo felt it was necessary to finally create a section in the Medicare statute that actually reflects and protects what chiropractic is and what chiropractors do. Based upon the concerns that Mr. Manzullo has about the future of chiropractic (especially with the OIG preparing to launch on the profession), Mr. Manzullo believes his legislation is critical now more than ever. Mr. Manzullo has not received any substantive, non- philosophical criticisms of his legislation, and therefore has no reason to believe that abandoning H.R. 2560 is the right thing to do. While he recognizes that serious philosophical rifts occur within the chiropractic profession, his main objective is to see that his constituents continue to receive the services that were promised to them (chiropractic being one of them), and that chiropractors who volunteer to participate in federal programs are treated fairly by the federal government. A strong, clearly-defined chiropractic statute is vital to protecting both chiropractors and patients. H.R. 2560 may not be perfect, but it is a pretty solid foundation upon which to begin rebuilding and redefining chiropractic. As with all parties interested, please do not hesitate to pass along to me any concerns, suggestions, or questions about Mr. Manzullo or H.R. 2560. Sincerely, Adam J. Magary Chief of Staff Rep. Donald Manzullo I just received the latest data on HR 2560 supporters from the Coalition Headquarters. Terry --------------------------------------- The Chiropractic Coalition, founded in November 2002 by three major chiropractic organizations - the International Chiropractors Association (ICA), the World Chiropractic Alliance (WCA), and the Federation of Straight Chiropractors and Organizations (FSCO) represents thousands of Doctors of Chiropractic world wide. The Coalition is urging field doctors and other pro-chiropractic organizations to support Rep. Donald Manzullo's HR 2560. If you have not done so already, please fax a letter to Rep. Manzullo expressing support of his bill. If you need further information concerning the positive impact of HR 2650 on the chiropractic profession, please contact the Coalition. Thousands of Coalition members in the following states support HR 2560: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming