On Chiropractic Spring 2015

ON Chiropractic AN OCA MEMBER RESOURCESPRING 2015Diabetes: 6PAGE 8PAGEWhat to Watch For When the NervousSystem Panics 20Trends in ExtendedHealth Insurance PAGE

CONTENTSFEATURES WHEN THE NERVOUS SYSTEM PANICS Central Sensitization research is revealing exciting possibilities. 8PAGE EXTENDED HEALTH INSURANCE The future is coming. Are you ready? 20PAGE2 SPRING 2015

ON Chiropractic DEPARTMENTS5PAGE In This Issue  page 56PAGE Chiropractors are leaders. To keep ahead of the pack we need to be attuned to trends and ready to innovate. Clinical  page 6 With diabetes rates on the rise, chiropractors are in a position to help identify at-risk patients. Learn what to watch for in the clinic. Compliance  page 18 FSCO has begun the Service Provider Licence examination process. Learn strategies to ensure your clinic makes the grade. Business  page 26 HST rules for health care products and services are complex. Get a refresher on the basics.18PAGE ON Chiropractic26PAGE ON Chiropractic is a member resource of the Ontario Chiropractic Association. The purpose of this publication is to serve and inform our members through the combination of future-focused articles with actionable advice on a wide range of topics relevant to your practice today. Contact the OCA at [email protected] if you have any feedback. www.chiropractic.on.ca 3

OCA AdvantagesThe OCA Advantages Program is comprised of over two dozenpartnerships, each of which can help you save money, build your businessor upgrade your knowledge. Accounting & HR Information & Finance Research Our partners can Accounting, help you with your Reviews and bookkeeping, payroll and human information on investments and resources needs. cutting-edge loans are just some chiropractic topics. of the services Legal available to you and Leisure your business. Legal advice, Activities agreements and Insurance divorce are just Play time is here! some of the Enjoy discounts Home, auto, life services available offered by our and extended to protect your partners. health policies are business. all available from Technology our insurance partners. IT solutions, web design, email Marketing Member communication Assistance and much more are Find help with Program offered by these promotional select partners. campaigns, website Support services design, social media to assist you and Vehicle and much more your family with Services from our partners. resolving everyday challenges, Save money withTo learn more go to complex issues partners providing and everything in valuable offers to between. drivers and travellers.www.chiropractic.on.ca4 SPRING 2015 Practice Building: Quindell Health Services Network Quindell operates a nationwide network of multidisciplinary clinics and is seeking qualified chiropractors to join their network. This program provides members the opportunity to build their practices by receiving patients from Quindell Health Services on a fee-sharing basis. Only chiropractors who are members of the OCA will be able to join the Ontario Quindell Health Services network going forward. Learn more at www.chiropractic.on.ca/quindell

In This IssueLeadership ThroughInnovation“Innovation distinguishes between a leader and a follower,” said Steve Jobs. While his own leadership style was often controversial, the innovations made by Apple during his tenure are impressive. Today, Apple is the highest valued technology company in the world. At approximately $740 billion, Apple’s market capitalization is nearly double that of the second place finisher – Google.Why is this relevant to chiropractic? Because central to the innovation-driven growth ofApple has been a keen and finely honed sense of how the personal technology marketworks. Jobs understood trends — how to create them and how to leverage them.In this issue of ON Chiropractic we will take a look at trends in two areas that will havea significant impact on the profession in the years to come. From a clinical perspective,you will hear about the compelling interim findings of Dr. John Srbely, a chiropractor andresearcher at the University of Guelph. His work is at the leading edge of our understanding ofCentral Sensitization.You will also be invited to examine trends impacting the extended health insurance marketplace. In particular, you will learnmore about the economic drivers of extended health plans and the exciting role chiropractors can play in the future.ON Chiropractic’s standard departments offer an overview of FSCO’s examination process and the nitty-gritty details of HST andits impact on your practice. You will also get a refresher on the warning signs of diabetes and what to be on the lookout for inyour practice.We hope these stories inspire you to look anew at trends in your practice and, by channeling your inner Apple, help lead theprofession forward through innovation.We’re here for you. www.chiropractic.on.ca 5

ClinicalDIABETES: WHAT TO WATCH FOR IN YOUR CLINICMany chiropractors have patients with diabetes. You may also have patients who do not yet know that they are diabetic or who are at risk of developingdiabetes. Chiropractors can play a crucial role in helping these patients bykeeping an eye out for early indicators and risk factors, and making them aware ofcomplications when they are observed in your clinic.Diabetes in Ontario While it is commonly thought that (darkened patches of skin), psychiatric all people with type 1 diabetes were disorders (schizophrenia, depression,The prevalence of diagnosed diabetes born with it, the average age of onset is bipolar disorder), or obstructive sleepamong Ontarians has increased from between five and nine years old and it can apnea, and,3% in 1994 to 10.2% in 2012. Prevalence also develop in young adulthood. ∞∞ Having been prescribed ais increasing worldwide, but Ontario glucocorticoid medication by a doctor.is a particular hotspot. One reason Type 2 (Previously ‘Adult-Onsetfor this is that diabetes risk rises with Diabetes’) Management of type 2 diabetes mayage, and Ontario’s population is aging. or may not include insulin therapy. ItImprovements in diabetes treatment and 90% of the 1.1 million Ontarians with may also include a combination of oralthe resulting longer life expectancy have diabetes have type 2 diabetes. In this medications, weight regulation, nutrition,also contributed to these higher rates. type, the pancreas may not be producing exercise and stress management. enough insulin or the body may not be While the type 2 diabetes is usuallyTypes of Diabetes using the insulin properly. The latter is diagnosed in patients over age 40, it can known as insulin resistance. also be seen in children. A recent study inType 1 (Previously ‘Juvenile Vancouver noted a higher rate of type 2Diabetes’) Type 2 diabetes risk factors include: than type 1 among children with diabetes. ∞∞ Having a parent or sibling with This increase in type 2 diabetes in childrenType 1 diabetes is an auto-immune has not yet been seen in Ontario, but thisdisease where the pancreas stops diabetes, may be due to missed diagnoses.producing insulin. Insulin is a hormone ∞∞ Being of Aboriginal, Hispanic, Southwhich helps the body to regulate glucose Gestational Diabeteslevels in blood. Type 1 diabetes is not Asian, Asian, or African descent,caused by nutrition or lifestyle. It is not ∞∞ Having given birth to a baby that Hormones from the placenta may makecurrently preventable and its cause is pregnant women resistant to their ownunknown. weighed more than four kilograms insulin, mimicking type 2 diabetes. (nine pounds) at birth or having had Gestational diabetes affects up to 13% of People with type 1 diabetes require gestational diabetes (diabetes during pregnancies in Ontario.insulin therapy. Insulin was discovered by pregnancy),Frederick Banting in 1921 at the University ∞∞ Having been diagnosed with Diagnosis usually occurs at 24 to 28of Toronto and mass production began prediabetes (impaired glucose weeks of pregnancy, and 50% of patientsin 1922. His first patient, Elizabeth Evans tolerance or impaired fasting glucose), require insulin therapy. If a woman hasHughes, died in 1981 at the age of 73. ∞∞ Having high blood pressure, high delivered a baby that weighed over nineInsulin therapy has enabled many people cholesterol or other fats in the blood, pounds, this indicates that she may havewith type 1 diabetes to live long lives — ∞∞ Being overweight, especially if that had gestational diabetes.some of your senior patients may be weight is mostly carried around theamong them. stomach, 20% of women with gestational ∞∞ Having been diagnosed with polycystic diabetes will have developed type 2 ovary syndrome, Acanthosis nigricans6 SPRING 2015

ON Chiropracticdiabetes within nine years, so these and feet become damaged after extended from the Canadian Diabetes Associationpatients should be particularly mindful of exposure to high blood sugar levels. recommend both aerobic and resistancetheir diabetes risk factors. Symptoms commonly experienced in exercises. the toes and feet include sharp shootingSymptoms and Complications pains, burning, tingling, a feeling of Diabetes Education Programs andto Watch For in Your Clinic: being pricked with pins, throbbing and diabetes self-management programs numbness to pain, heat or cold. are available across the province.Patients with undiagnosed diabetes Chiropractors can refer patients to them,may present with some of the following Numbness in the foot can also lead or patients can refer themselves. You cangeneral signs and symptoms: to untreated foot problems including search online for a program near you: blisters, ulcers, damage from ill-fitting www.ontario.ca/locations/health.∞∞ Unusual thirst, footwear, deformities to the foot’s bony∞∞ Weight change (gain or loss), structure (Charcot foot syndrome) and The Diabetes Education Programs∞∞ Extreme fatigue or lack of energy, reduced range of motion. To learn more also offer outreach teams of nurses and∞∞ Frequent or recurring infections, and to see photos of what to watch out dieticians. If you have several patients∞∞ Cuts and bruises that are slow to heal, for, consult the Clinician’s Brochure on who are living with diabetes or at risk of Diabetes, Healthy Feet and Your Patients developing diabetes, you can request and, (http://guidelines.diabetes.ca/CDACPG/ an outreach team to do an education∞∞ Tingling or numbness in the hands or media/documents/patient-resources/ session in your clinic on nutrition and self- diabetes-healthy-feet-and-your- management of diabetes. This service is feet. patients-feb2014.pdf) by the Canadian available free of charge. Diabetes Association and the Canadian These signs may indicate that your Association of Wound Care. Craving Change (www.cravingpatient should see a physician or nurse change.ca) is a program which trainspractitioner for a diabetes assessment. Diabetes Management and health care professionals to use aThere are additional specific symptoms Resources for Your Patients cognitive-behavioural approach to helpto be on the lookout for when assessing patients change their eating habits.a patient: Regardless of the type of diabetes, Developed by a clinical psychologist the core recommendations for self- and a registered dietician, this programDarker Skin at the Back of the management are the same: can help patients make the nutritionalNeck changes required to prevent or manage ∞∞ Eat 3 meals a day with smaller diabetes.Acanthosis nigricans is a brown to black portions,hyperpigmentation of the skin usually Eat Right Ontario (www.eatrightfound in body folds on the neck and ∞∞ Eliminate juice, ontario.ca) has menu plans and manyarmpits. The edges are faded, rather ∞∞ Remain active, and, other nutrition resources available forthan clearly defined. This symptom can ∞∞ Monitor blood glucose. patients seeking to prevent or manageindicate insulin resistance and other diabetes. Their toll-free number isendocrine syndromes. If you notice it Clinical Practice Guidelines (guidelines. 1-877-510-5102.on one of your patients, they should diabetes.ca/healthcareprovidertools)see a physician or nurse practitioner forassessment. ON DEMAND WEBINARPeripheral Neuropathy and Foot DIABETES UPDATEProblems Patient CareIf your patient experiences numbness ortingling in their extremities, this can be a Get the latest on the Ontario Diabetes Strategy fromsign of developing diabetes. Debbie Hollahan, Director of the Waterloo Wellington LHIN Diabetes Central Intake Office. Diabetic peripheral neuropathy isa long-term complication of diabetes.Peripheral nerves in the arms, hands, legs www.chiropractic.on.ca 7

FEATURE STORYWHEN THE NERVOUSSYSTEM PANICS:CENTRAL SENSITIZATIONEven the smallest pain is a complicated process.Despite what your eyes may tell you, there areno black dots on the opposite page.Optical illusions reveal that what we see canbe transformed, added to or completelyignored.Pain can change before we become awareof it too. What happens when the nervoussystem is overloaded and sensitized?Can chiropractic calm it down? 8 SPRING 2015

BURN HURT TWINGERELAX THROB RELIEVECURE COMFORT PULSE SOOTHE

FEATURE STORY/ WHEN THE NERVOUS SYSTEM PANICSP ain is complicated. Even The Consequences of Central neurons not only exhibit higher response the weakest pain triggers a Sensitization frequencies but also show persistent complex process. You can activity after removal of the input think of pain perception Dr. John Srbely, DC, PhD, is a signal.\":, a bit like a relay race: You chiropractor and Assistant pinch your finger in a door. Nerves in Professor at the University Typically, C-Sens is triggered by an your finger bolt from the starting line of Guelph. He is studying central injury or disease within the axial tissue and carry pain signals — the baton sensitization — which he likes to call (for example, spinal arthritis) which sends — to the spinal cord. The next set “C-Sens” for short — and what it can persistent intense inflammatory pain of nerves grabs the baton and races tell us about the effects of spinal signals into the dorsal horn of the spinal to the thalamus, the central hub of manipulative therapy and possible cord. Overstimulated, the second- and information in the brain. A third team of future applications for chiropractic. As higher-order neurons become sensitized. nerves rush the baton to the cerebral mentioned previously in our article on They pass more pain signals than usual cortex and — ouch! You feel the pinch. osteoarthritis, C-Sens is characterized by up the chain, leading to a higher level of Most patients expect pain to be an overall state of heightened perception perceived pain from the same stimulus. always this straightforward. If my arm of and sensitivity to pain. hurts, then my arm must be damaged. If Most patients have experienced Joint Dysfunction I rated my pain as a 4/10 yesterday and peripheral sensitization, but might not now it feels like a 6/10, the damage must know its formal name. The sensation Of course, the CNS does not be increasing. The brain is expected to of lukewarm shower water feeling only communicate with the be a reliable narrator of what is going on excruciatingly hot on sunburnt skin is a brain. Dr. Srbely has recently in the body. And most of the time it is. common example. The peripheral ends submitted a study for publication where But chiropractors know that the of the pain receptors (nociceptors) in his team experimentally evoked C-Sens. relationship between perceived pain and that skin have become sensitized and are They found a significant change in structural damage is not always so clear, sending more pain input to the central the excitability of the motor unit pool particularly when pain becomes chronic. nervous system (CNS) than usual. It’s a in the sensitized segment and altered The whole system can be thrown off protective measure put in place while the recruitment patterns of motor units. kilter. Signals go awry. skin heals. Every muscle in the body contains many Many chiropractors have had Central sensitization, on the other motor units, which are sets of muscle patients who experience a vastly hand, is a damaging “neuradaptive fibers and neurons that contract the higher level of sustained pain than an response characterized by an increased muscle. examination would suggest. You may responsiveness to input stimuli of have wondered, “Why isn’t this patient neurons within the central nervous Dr. Srbely described the changes feeling better?” These stubborn cases system.” People with C-Sens experience observed within the affected motor unit can be perplexing…and frustrating. pain which is more intense and lasts pool as “disorganized.” Smaller motor On the other side of the coin, many longer than it usually would. They also units are normally the first to be recruited practitioners have seen patients with a have lower pain thresholds, causing during force production. In the sensitized complicated set of issues who find relief them to experience pain from things that state he observed that the large motor for more than just musculoskeletal pain usually wouldn’t hurt. Yesterday’s pain units were kicking in earlier than small after receiving care from a chiropractor. A rating of 4/10 becomes today’s 6/10. The motor units and that they had higher connection between spinal manipulative CNS continues to alert the brain about frequency responses than usual. therapy and gastrointestinal issues, pain even after the input has stopped. colic and a host of other conditions is “A comparison of response profiles These observations suggest that observed in the clinic, but this is not well from sensitized versus normal dorsal increasing C-Sens may have the potential documented in the literature. What’s the horn neurons in rats,” writes Dr. Srbely, to disrupt force production and the missing link? “reveals that sensitized dorsal horn coordination of muscle recruitment.10 SPRING 2015

ON ChiropracticSegmental Inflammation: become amplified and sustained once injury would. If you continue applyingBeyond MSK it triggers C-Sens, this sensitization may pressure to this area, the clinician feels send altered signals to muscles and a relaxation response in that muscleC-Sens can also induce a response glands in the same segment “where and the patient actually desires more called neurogenic inflammation. they may initiate abnormal physiologic pressure. Initially it might be sore but In other words, if a spinal responses and, potentially, pathogenic if the pressure is maintained, patientssegment is centrally sensitized, the processes if allowed to persist.”: describe it as a ‘feel-good pain’.” Thismuscles and organs connected to thatsegment can also become inflamed. “You could have a simple disc herniation,”A research review from RRS Education Dr. Srbely says, “and if we allow the sensitizationdescribes this process: to remain, the neurogenic inflammatory response will kick in. It will augment the “This neurogenically mediated inflammation locally at the disc but then itinflammation refers to the discharge will begin to spread to other tissues that areof inflammatory mediators and segmentally linked.”neuropeptides (such as substance P orcalcitonin gene-related peptide) from Dr. John Srbelythe peripheral terminals of nociceptorsin tissues (both visceral and somatic) that Myofascial Pain Syndrome and was one of the first observations whichare neurologically linked to a primary Trigger Points suggested to Dr. Srbely that triggerpathology.b“ points may be the result of an underlying C-Sens may lead to myofascial neurogenic phenomenon rather than a The review continues, “Neurogenic pain syndrome, a condition local injury.inflammation has also been linked to commonly encountered byother non-musculoskeletal pathologies chiropractors. Dr. Srbely’s neurogenic In a 2010 journal article, Dr. Srbely(e.g., irritable bowel syndrome, cystitis hypothesis suggests that neurogenic covers several more indications of theand changes in both uterine and bladder inflammation is a primary mechanism neurogenic nature of myofascial triggercontractility).b” Dr. Srbely refers to a underlying the pathophysiology of points including:2007 rat study wherein distension of the myofascial trigger points and myofascialcolon led to an inflammatory response pain syndrome., Rather than being ∞∞ “Referred pain” which suggestsin the bladder.Q The colon and bladder caused by local overuse or chronic a centrally mediated network ofare neurologically linked and this study is injuries, emerging evidence suggests that sensitized trigger point circuits,an example of neurogenic inflammation trigger points may be a result of a centralspreading between organs. Given that mechanism. ∞∞ The way trigger point formationthe dorsal horn of the spinal cord is the follows segmental patterns, andlocation where somatic and visceral “Any clinician will tell you that onepathways converge, it is hypothesized of the key clinical differences between ∞∞ The previously mentioned “soothingthat C-Sens is a key mechanism linking a local injury and a myofascial trigger ache” of trigger point pain which isdisrupted musculoskeletal and organ point is the nature of tenderness,” Dr. differentiated from the sharp pain andhealth. Srbely says. “When a clinician presses on withdrawal reflex of local injuries. a myofascial trigger point, it does not “You could have a simple disc induce a withdrawal reflex like a local OCA members may also beherniation,” Dr. Srbely says, “and if we interested in reading RRS Education’sallow the sensitization to remain, the review of Dr. Srbely’s article on this topic.bneurogenic inflammatory response willkick in. It will augment the inflammationlocally at the disc but then it will beginto spread to other tissues that aresegmentally linked.” So, not only mightthe perceived pain of an MSK issue www.chiropractic.on.ca 11

FEATURE STORY/ WHEN THE NERVOUS SYSTEM PANICSModulating Central C-Sens and Trigger Points they had C-Sens.Sensitization Pressure pain sensitivity was In 2010, Dr. Srbely’s team studied theChronic degeneration or injury connection between C-Sens and monitored in trigger points within the to the spine is one of causes trigger point sensitivity. infraspinatus muscle (in the shoulder) of C-Sens, a maladaptive The C5 spinal segment supplies which is innervated by the C5 segment,process that may amplify disease and nerves to a number of areas, including and the gluteus medius muscle (in thespread discomfort. Could this serve as some skin on the elbow and the hip) which is not. Pain thresholds werea contemporary biomedical paradigm infraspinatus muscle in the shoulder. measured beforehand and then 10, 20supporting the spine’s key role in our This study experimentally evoked C-Sens and 30 minutes afterwards.overall health and how we heal from at the C5 spinal segment by exposingdisease? the linked area on the right elbow to Test subjects showed a significant 45 degree heat for 10 minutes. The test increase in pressure sensitivity in the A sensitized nervous system group then received a topical sensitizing segmentally-linked infraspinatus triggersends signals differently. “How these cream containing capsaicin, and the point compared to the non-segmentally-aberrant signals are processed,” control group received a topical placebo linked gluteus medius trigger point. Therewrites Dr. Srbely, “and what role spinal cream. was no difference between these pointsmanipulative therapy plays in modulating The participants who received the for control subjects.these signals, is an important area for capsaicin cream showed significantchiropractic research because these increases in brush allodynia, which These findings demonstrate aconcepts could form the foundation means that a harmless light brushing on strong segmental response in triggerfor the neurophysiologic paradigm of the skin felt painful. This indicated that point sensitivity, suggesting that C-Senschiropractic.”: may play an important role in the pathophysiology of myofascial trigger points. If trigger points are a product Like pain, what we see can be altered by the brain.12 SPRING 2015

ON Chiropracticof C-Sens, clinicians and researchers manipulation group received a bilateral SMT and Gate Controlcan use them as an easy-to-identify rotary manipulation targeting the C5-C6clinical indicator of sensitization and its segment. Those in the control group T he gate control theory proposesresolution. received a validated manual sham that a “gate” in the dorsal horn manipulation procedure which feels like of the spinal cord can allow orSpinal Manipulative Therapy a real manipulation but which does not prevent pain input to be transmitted to achieve intersegmental manipulation at the brain. Two kinds of fibers controlA2013 validated sham-controlled any cervical segment. this gate: large fibers which carry touch, trial investigated the ability of pressure, vibration and proprioception spinal manipulative therapy (SMT) Clinician A then left the room andto relieve pain in myofascial trigger pointswithin and across spinal segments. They “There must be a common mechanism thatdid this by monitoring trigger points in is linking all of these conditions,” Dr. Srbelythe infraspinatus (C5) and gluteus medius says. “When I started digging deeper into(not C5) muscles, as in the previous this, my hypothesis began to emerge: centralcapsaicin study. By performing real and sensitization.”“sham” SMT manipulations at C5-C6,they could measure the effect of SMT Dr. John Srbelyand whether this effect was observedwithin the local segment or extended Clinician B returned to record pain sensations, and small fibers which carrybeyond it. pressure threshold values again at 1, 5, temperature and pain sensations. When 10 and 15 minutes after the manipulation the gate receives more stimulus from the Two chiropractors were required for procedure while the patient rested on small fibers than the large fibers, it opensthe study. “Clinician A” was the “treating” the treatment table. to allow pain signals through. When itclinician, responsible for conducting receives more stimulus from the largethe history and physical assessment This study found that patients fibers, it closes.of participants and performing SMT. who received real SMT had statistically“Clinician B” was the “assessing” clinician, significant decreases in pressure pain This opens two pain relief options:responsible for identifying trigger points sensitivity in the infraspinatus muscle (1) reduce pain input from the smalland measuring pain pressure threshold at 1, 5, 10 and 15 minutes. Participants fibers, or (2) increase input from thevalues. This study was blinded so who received sham SMT experienced large fibers. SMT floods the gate withthat Clinician B was not aware which no relief, and neither set of participants large-fiber stimulus (touch and pressure),participants received real or sham SMT. experienced significant changes in the closing the gate. In order to overcome gluteus medius. the large-fiber stimulus, pain input needs Each participant lay face down while to increase. This theory explains theClinician B identified trigger points in These observations suggest that SMT relationship between SMT and higherthe right infraspinatus and right gluteus can decrease the pressure sensitivity of pain thresholds in trigger points observedmedius muscles. These trigger points myofascial trigger points within a spinal in this study. Pain input could only getwere marked on the skin and Clinician segment. One mechanism proposed through if it was more intense than theB recorded pain pressure threshold by the authors is that SMT may mitigate large-fiber stimulation of SMT.readings by applying increasing force on central sensitization by bombarding theeach trigger point until the participant spinal cord with mechanostimulation, Activity from descending fibers inreported a dull, achy discomfort or using the gate control mechanism to supraspinal regions could also closereferred pain. Clinician B then left the raise the pain threshold. the gate from above. “Based on thisroom, and Clinician A entered. rationale,” Dr. Srbely writes in the SMT Each participant now lay face upwith their head resting on a mechanicaldrop headpiece, ready to receiveSMT from Clinician A. Those in the www.chiropractic.on.ca 13

FEATURE STORY/ WHEN THE NERVOUS SYSTEM PANICSstudy’s discussion section, “we assumed This study showed a significant a right supraspinatus (C5) trigger pointthat SMT-evoked supraspinal effects difference in pain thresholds in the while control subjects received a shamwould impact pain sensitivity at both infraspinatus (as compared to the gluteus ultrasound exposure.trigger points comparably.” The study medius) at 3 and 5 minutes, suggestingonly showed significant changes at that dry needle stimulation can evoke Significant difference in painthe segmentally linked trigger point, short-term pain reduction within a thresholds were found in theindicating segmental rather than neurological segment. infraspinatus (as compared to thesupraspinal mechanisms. Researchers gluteus medius) at 1, 3 and 5 minutes,continue to examine whether SMT’s This was not a surprise to Dr. demonstrating that ultrasound caneffect is predominantly regional, general Srbely. He points out that the World evoke short-term pain reduction within aor a combination of the two. Health Organization’s list of diseases segment. and disorders that can be treated with acupuncture is multi-systemic in scope. And MoreIf SMT proves to be an effective modulator of If the above modalities are using gateC-Sens, this may open up a significant role in control to reduce C-Sens, it is veryour health care system for chiropractors as the possible that this same mechanismgate-keepers of clinical conditions associated may also be responsible for thewith C-Sens, such as myofascial pain syndrome. therapeutic effects observed with active release therapy, massage therapy, Other Manual Therapies Controlled trials have shown significant exercise, movement and more. scientific support for acupunctureSpinal manipulative therapy is not the treatment of conditions including colic, Remaining Research only mechanism proposed to ease headache, neck pain, low back pain, Questions C-Sens. Several other therapies stroke, morning sickness and depression. have also shown promise in this area. “There must be a common mechanism While there is now enough that is linking all of these conditions,” research data to begin Acupuncture Dr. Srbely says. “When I started digging connecting the dots, several deeper into this, my hypothesis began to outstanding areas of research stillDr. Srbely’s team performed a emerge: central sensitization.” remain. These questions will need to very similar study in 2010 that be understood in more depth before examined the effect of dry Ultrasound chiropractors can use this research to needle stimulation of myofascial trigger guide patient care or to make claims points, again by comparing trigger Dr. Srbely’s team performed for the effectiveness of SMT for specific points in the infraspinatus and gluteus a similar study in 2008 conditions. medius muscles. Rather than receiving which examined the effect of SMT, subjects in this study received ultrasound, again by comparing trigger Current research questions include: intramuscular dry needle puncture at a points in the infraspinatus and gluteus right supraspinatus trigger point which is medius muscles. Test subjects in this ∞∞ How should patients with C-Sens be neurologically linked to the infraspinatus study received low-dose ultrasound to identified in the clinic? How should muscle at C5. their care differ? Do sensitized patients require a gentler approach to avoid aggravating their sensitivity to pain input? ∞∞ Why might C-Sens affect some patients more than others? ∞∞ How can we measure the degree of central sensitization? This is important both for clinicians caring for patients14 SPRING 2015

and for researchers comparing the ON Chiropractic efficacy of various interventions. This is an active area of research in Dr. Recommended Reading Srbely’s lab.  OCA. “Osteoarthritis: Understanding pain and treatment.” ON Chiropractic∞∞ What is the cause-effect relationship (Winter 2015): 16-21. between C-Sens and other pathologies? C-Sens has been linked  Srbely, JZ. “Spinal manipulative therapy and its role in the prevention, to several conditions, but the causality treatment and management of chronic pain.” JCCA (2012): 56(1). has not yet been clearly established. : Srbely, JZ. “Chiropractic science: A contemporary neurophysiologic∞∞ How long does the effect of SMT last paradigm.” JCCA (2010) 54(3):144-146. when modulating C-Sens? How does it compare to other therapies?  Derjean, D et al. “Dynamic balance of metabotropic inputs causes dorsal horn neurons to switch functional states.” Nat Neurosci (2003 Mar) 6(3):274-81.∞∞ What is the nature of the relationship between C-Sens, myofascial trigger b Maguire, G. “Myofascial pain syndrome: Current concepts & management.” points and myofascial pain syndrome? RRS Education Research Reviews (2011). Online. This is an active research question. Q Ustinova, EE et al. “Sensitization of pelvic nerve afferents and mast cellPossibilities for the infiltration in the urinary bladder following chronic colonic irritationProfession is mediated by neuropeptides.” Am J Physiol Renal Physiol (2007) 292(1):F123-F130.While more research is needed, exciting possibilities for  Srbely, JZ et al. “Dry needle stimulation of myofascial trigger points evokes chiropractic science and segmental anti-nociceptive effects. J Rehabil Med. 2010; 42(5):463-8.practice are emerging.  Srbely, JZ. “New trends in the treatment and management of myofascial pain Consider a patient whose C-Sens syndrome.” Curr Pain Headache Rep (2010) 14:346–352.is triggered by something that ismusculoskeletal in nature (e.g., a muscle  Srbely, JZ et al. “Capsaicin-induced central sensitization evokes segmentalinjury or chronic joint degeneration). increases in trigger point sensitivity in humans.” J Pain (2010) 11(7):636-43.Resolving this injury may also resolvea series of secondary issues which  Srbely, JZ et al. “Immediate effects of spinal manipulative therapy onmay potentially stem from C-Sens regional antinociceptive effects in myofascial tissues in healthy young adults.”and neurogenic inflammation. For J Manipulative Physiol Ther (2013); 36:333–341.chiropractors who have observed thiseffect in the clinic, this research may  Moayedi, M and Davis, KD. “Theories of pain: From specificity to gate control.”offer a scientific explanation for these Journal of Neurophysiology (2012) 109:5-12.experiences.  World Health Organization. “Acupuncture: Review and analysis of reports on The primary cause of C-Sens can controlled clinical trials.” Geneva: World Health Organization (2002). Online:be non-musculoskeletal in nature (e.g., http://apps.who.int/iris/handle/10665/42414a tumour). While SMT cannot addressthese other causes, clinicians may be  Srbely, JZ et al. “Stimulation of myfascial trigger points with ultrasoundable to modulate C-Sens by “closing the induces segmental antinociceptive effects: A randomized controlled study.”gate” using SMT and other therapies. This Pain (2008) 139(2):260-6.way, clinicians could potentially halt ormitigate the establishment of secondary www.chiropractic.on.ca 15conditions of C-Sens and neurogenicinflammation.

FEATURE STORY/ WHEN THE NERVOUS SYSTEM PANICS If SMT proves to be an effective Canadian Chiropractic Association, Conclusionmodulator of C-Sens, this may open “the incidence of myofascial pain in theup a significant role in our health care elderly is reported as high as 85% and As a chiropractor, Dr. Srbelysystem for chiropractors as the gate- it is estimated that by the year 2050 hopes that this new paradigm willkeepers of clinical conditions associated the ratio of the elderly population to galvanize the different philosophieswith C-Sens, such as myofascial general population will double, making of chiropractic into one commonpain syndrome. As the connection myofascial pain syndrome one of health theme. From biomechanical sciencebetween central sensitization and care’s foremost challenges.”: to a holistic approach to health,myofascial trigger points becomes chiropractic has a lot to offer. Centralclearer and particularly as research and A number of non-musculoskeletal sensitization may scientifically validateclinical practice reveal more effective conditions such as Functional the therapeutic benefits of SMT andinterventions, chiropractors are well- Gastrointestinal Disorders (e.g., functional provide chiropractors an evidence-basedpositioned to become the go-to resource dyspepsia, irritable bowel syndrome) have role in the health care system far beyondfor patients suffering from this type of been linked to central sensitization as treating low back pain. ONpain. well. Chiropractic may have an important role to play in the management of these This is a big opportunity for the non-MSK conditions by moderatingprofession. As Dr. Srbely writes in a C-Sens.commentary for the Journal of theCCA | NATIONAL CONVENTION & TRADESHOW Featured Keynote Speaker John HerdmanAdvancing Excellence Head Coach of the Canadian Senior Women’s National Soccer Team;in Patient Care Analyst, CBC Sports: World CupJoin us September 18-20, 2015 REGISTER TODAY!@ Scotiabank Convention Centre ccaconvention2015.caNiagara Falls, Ontario, Canada Don’t miss the 16Full Registration Includes: early bird rate of CE $649 plus HST! • Food and non-alcoholic beverages • Intensive, Breakout and Keynote sessions ENDS JUNE 30TH • Kick-off Reception and Formal Gala Dinner at the AT MIDNIGHT world-famous Fallsview Casino Resort • Access to 80 of the best exhibitors in North America on our tradeshow floor • Special discounted hotel rates • Entry into draws for prizes16 SPRING 2015

Thank You VolunteersThe Ontario Chiropractic Association appreciates its volunteers and would like totake this opportunity to officially thank our 2014/2015 Community Engagement &Leadership Program (CELP) volunteers for their time, commitment and efforts inhelping to advance the understanding and use of chiropractic care over the past year. Dr. Carol Ann Weis at Dr. Anita Chopra MDrP.PSuTmeadn MChcaMkreeakbainrt&i the BabyTime Show Dr. Michelle Clarke Dr. Victoria Clarke Dr. Neil PatrickDr. CNaarsohl AatnnthWe eBisab&yTDimre. Jennifer Dr. Laura Clemenhagen Dr. Alexander Pessoa Show Dr. Michele Corriveau Dr. Sharon Peterkin Dr. David Dos Santos Alessandro PichiniDr. Corey Adler Dr. Jade Egonia Dr. Paulina ReibanDr. Jim Aru Dr. Jenny Elliott Dr. Robert RodineDr. Katherine Au Dr. Santo Fera Dr. Peter ScheuringDr. Dianna Bakalovski Dr. Kevin Finn Dr. Brian SchroederDr. Shayne Baylis Dr. Peter Fonti Dr. Christopher SmallDr. Andrew Bell Dr. Reginald Gates Dr. Kenneth StelsoeDr. Pierre Brunet Dr. Sasha Hamid Joseph TantiDr. Dale Chabot Dr. Elizabeth Hodgins Dr. Dean TapakDr. Sumon Chakrabarti Dr. Salima Ismail Dr. Katherine TiborDr. Ronnie Chan Dr. Roger Karam Dr. Navdeep Toor Dr. Tatyana Lachowich Dr. Murray Townsend Dr. Marissa Lee Dr. Gurvinder Virk Dr. Fabio Levi Dr. Joel Weisberg Dr. Melanie Locke Dr. Luke Winegard Dr. Jenna Macfarlane Dr. Keshena Malik Dr. Kevin Matheson Dr. Kelly McAllister Dr. Phil McAllister Christine Meckamalil Dr. Donald Millar Dr. Chris Myers Dr. Andrea Nalli Dr. Frank Nhan Dr. Paul Nolet Dr. David Orchard Dr. Rod OvertonInterested in volunteering? Dr. Corey Adler at theAll OCA members are invited to learn more and join CELP! Flowerton Senior Mens BonspielVisit the OCA website at www.chiropractic.on.ca.

CompliancePASSING YOUR FSCO EXAMINATIONS ince Service Provider Licensing was introduced in December 2014, FSCO’s Senior Compliance Officers have been performing random examinations(audits) at clinics across the province. How can your business be sure to receivea clean bill of compliance? We break it down by focusing on the five mostcommon examination results so far.Let’s Get Acquainted: The Officers understand what is happening 2 Lacking complete written policiesEducation Stage from the practitioner perspective. and procedures on billing practices.We are currently in the “education stage” If your clinic is examined this year and 3 O CF Forms lacking the healthof Service Provider Licensing. What does is found not to be compliant, the Senior professional’s signature or thecompliance look like? What kinds of Compliance Officer will spend time patient’s signature.records, policies and procedures will a encouraging industry-based solutionsSenior Compliance Officer check for? and best practices. FSCO’s main goal 4 Excellent compliance: No findings toWhat about patient confidentiality? FSCO at this point is to verify that you have report.is using these examinations to discuss business policies and procedures in placethese topics with practitioners across which address compliance with your 5 O ut-of-date information in thethe province so that expectations are Service Provider Licence. If not, they’ll Licensing Portal, especially contactclear and your specific questions are leave you with a list of recommended information.addressed. changes. Let’s Get Compliant This is also a chance for you to FSCO regulates many industries andeducate FSCO. From your perspective, has followed this process of educating Verifying Patient Identitywhat should they understand about new licensees in the mortgage industry,the insurers? Senior Compliance the pension industry and others. If Every health professional associatedOfficers have been hearing from FSCO continues to find a lack of with your Service Provider Licensepractitioners about late payments by compliance after this education phase who provides goods or services toinsurers (and not paying interest on from businesses that do understand the a patient must be able to verify thatthose late payments) and insurer misuse rules, then they will begin to escalate to this person was involved in a specificof Section 46.3 statutory declaration enforcement. motor vehicle accident. This should berequests. Practitioner feedback recently done before treating the patient, or ashelped to trigger a FSCO bulletin to Top Five Results of FSCO soon as possible after treatment. Someauto insurers (http://www.fsco.gov. Examinations verification methods you may consideron.ca/en/auto/autobulletins/2015a/ include:pages/a-03-15.aspx) reminding them FSCO has shared the top five results ofof their compliance requirements for the first 221 examinations performed as ∞∞ Requesting to view photo identifica-prompt payment. FSCO regulates both of March 2015, in order of frequency: tion (e.g., driver’s licence), andservice providers and auto insurers, andfeedback about your experiences with 1 N ot verifying patient identity (the top ∞∞ Reviewing the accident/police reportinsurers helps Senior Compliance result by far). or hospital records.18 SPRING 2015

ON Chiropractic If you are the Principal Representative Updating Your Information in the ∞∞ The opening, closing, acquiring,for your Service Provider Licence, it is Licensing Portal amalgamating, or transfer of anyyour responsibility to ensure that this is If any of the following information other office that is open to the public,done. One step in this task is to develop a changes, you must notify FSCO withincomplete set of policies and procedures five business days: ∞∞ The business’s list of directors,for your colleagues to refer to. officers, or partners, and ∞∞ The business’s mailing address, email ∞∞ The business’s identified PrincipalPolicies and Procedures address, telephone number or fax Representative.FSCO recognizes that having written number, Principal Representatives can updatepolicies and procedures might be new ∞∞ The location of the principal place of this information by logging into theirfor your clinic. While informal policies business or any facility, branch, office FSCO Account.{and procedures may be acceptable at or location in Ontario,this stage of the examination process, LEARN MOREyou can expect your Senior ComplianceOfficer to ask you to formally document If you have questions about FSCO Service Providerthem. The OCA highly recommends Licensing, you can contact FSCO by email atthe Health Service Provider Licensing [email protected] or by telephone at 416-Toolkit for Examinations/Audits provided 250-7250 (toll-free at 1-800-668-0128).by the Coalition of Health ProfessionalAssociations in Ontario Automobile Online resources include:Insurance Services. This toolkit provides ∞∞ FSCO Guide to Service Provider Licensing: http://www.a complete set of sample policies andprocedures which you can use for your fsco.gov.on.ca/en/service-providers/etoolkitclinic. ∞∞ OCA information and webinars on Service ProviderSigned OCF FormsEnsure that your records include originalsigned documents. An OCF-21 submitted through HCAI is Licensing (including a link to the Health Service Providernot deemed to have been signed by the Licensing Toolkit): http://www.chiropractic.on.ca/fsco-regulated health professional. Your filesmust include either a paper copy or a service-provider-licensingPDF copy of the OCF-21 with an originalsignature (or an electronic signature)of the regulated health professionalproviding treatment or an authorizedsignatory in order to meet the HCAI ON DEMAND WEBINARGuideline’s recordkeeping requirements.An “Authorizing Officer” may be an Preparing for a FSCO Auditauthorized signatory if designated by theregulated health professional. Legal & Compliance For OCF-18s and OCF-23s, ensure Members are guided through developing thethat you keep a copy of the completed requisite policies for their clinic staff and theform with the insured patient’s procedures for FSCO compliance.signature. www.chiropractic.on.ca 19

FEATURE STORYEXTENDEDHEALTHINSURANCE

THE FUTURE IS COMING.ARE YOU READY?

FEATURE STORY / TRENDS IN EXTENDED HEALTH INSURANCENext to individual patients benefit of EHB plans that is increasingly are heavily incentivised to focus on (paying out of pocket), valued by employers and plan members employee health and well-being in Extended Health Benefits (employees) alike. Reducing short-term order to manage absenteeism and (EHB) account for the disability (STD) costs was also identified reduce the frequency and length of greatest sources of revenue as a priority by 39% of the companies STD claims. Chiropractors are extremely for chiropractors in the province. Morneau Shepell surveyed. The top two well suited to support employers in this Ontarians of all generations now expect causes of STD are mental health and effort, and many practitioners across the EHB plans to fill in the gaps and support musculoskeletal (MSK) conditions. province are forging paid and volunteer what public health system coverage relationships to support companies in this cannot. But with rising costs and an The interaction of these two effort. Chiropractors are able to provide aging population, what does the future concepts demonstrates the opportunity one-stop solutions to employers looking hold for EHB in Ontario? for chiropractic. What companies are for programs and advice on exercise It is impossible to know for sure, seeking are ways to keep their most and this is a source of great concern for many chiropractors. The good news is “Benefits Consultants and TPAs agree that that there are signals that chiropractors chiropractic is an integral and sustainable are well positioned to be a partner in component of employee benefits plans with a helping to meet the challenges facing continuing role in maintaining the health and EHB plans and the broader health care well-being of productive workforces.” system down the road. There are three key trends which Dwight Lacey speak to this potential: the need for chiropractic expertise within productive assets – their people – happy, programs, ergonomics, diet and nutrition the workplace and EHB plans, the healthy and engaged. While this makes and, most importantly, specific care for emerging reality of EHB economics, and intuitive sense, consider the business a wide range of neurological and MSK developments in how some specific impact of each STD claim. The employee conditions. health care services are delivered at the that eventually requires being on STD clinic level. Preferred Provider Networks leave is likely not performing their duties This is in addition to the reality that are a significant part of the latter trends to their utmost in the days and weeks chiropractors support EHB plan members and an opportunity for chiropractic to leading up to their leave. Then when the in a variety of ways as patients in their play a larger role in Ontarians' health in leave begins, a temporary replacement practices each and every day. This work the years to come. is often retained to fill the void. The is both keeping employees healthy and recruitment and onboarding process productive and helping them to return to The Role of Chiropractic in of a contract employee carries costs, work sooner when problems do arise. EHB Plans even if that process unfolds quickly and without significant interruption to business Dwight Lacey, a consultant withMorneau Shepell, a leading operations. Adding to those costs, while decades of deep and varied experience human resourcing consultancy an employee is on STD, the employer is in the insurance industry, recently and EHB plan broker, recently typically still paying some portion of their conducted a series of interviews with released a report that sheds important salary in addition to the full salary of the insurance industry stakeholders on behalf light on how companies are thinking temporary hire performing their duties. of the Ontario Chiropractic Association about the role of EHBs in meeting their (OCA). His findings illuminate a number of business objectives. 57% of employers So what does this mean? Employers sources of optimism for chiropractors. that Morneau Shepell surveyed said that a top priority for 2015 is improving “Chiropractic is a respected and health and well-being among employees. Managing absenteeism is one potential22 SPRING 2015

ON Chiropracticclinically effective form of treatment, Cost Containment & the Download Now:especially for [MSK] disorders that impair Economics of EHB Plans Apple App Storemobility, work-readiness and productivity,”Mr. Lacey said, describing his findings on Recently, the concept of “cost Google Playthe perspectives of insurance industry containment” has received a greatstakeholders. Mr. Lacey interviewed deal of attention in the health there are several trends at play. One isa number of stakeholders, including care sector. Government is continually prescription drug pricing. The increasedBenefits Consultants and Third Party seeking to contain costs in the publicly availability of generic medications isAdministrators (TPAs), including key funded system. In auto insurance, the helping to contain costs. The adventpeople at organizations like Morneau scramble to reign in Ontario’s highest- of new drugs and new classes of drugsShepell. “Overall, chiropractors are in-the-nation premiums is a source of often pushes costs up. Biologics arerespected professionals recognized for debate, friction and new regulation. an example of a new kind of drug thattheir training, clinical expertise and ethical The term is used quite frequently in has insurers concerned. Biologics arebusiness practices,” he reported. relationship to EHB too. When we hear alternatives to “chemical” drugs that it we often think of it as code for “profit are developed from living cells. They A fundamental message from Mr. maximization”. In Canada, extended are more complicated to manufactureLacey’s analysis is that the sky is not falling health insurance is a profit-seeking and, thus, more costly. To make matterswhen it comes to chiropractors’ inclusion industry and there is a responsibility on worse, these complex manufacturingin the EHB plans. “Benefits Consultants insurers to provide suitable service while standards make the creation of genericand TPAs agree that chiropractic is an turning a profit. A notable exception to equivalents very, very challenging.integral and sustainable component of this rule is Green Shield Canada, which is Increasing utilization of paramedicalemployee benefits plans with a continuing a not-for-profit insurer. benefits for mental health and MSKrole in maintaining the health and well- Profit is not the only driver of EHB condition care is another current trend.being of productive workforces,” he said. plan economics, however. There areThe profession must remain vigilant, many factors that go into EHB plan Employer Requirements:in order to cement and build upon the composition and pricing. Here is a lookstrength of chiropractic’s reputation at the most impactful: Insurers have many stakeholdersamong these stakeholders. to manage. Individual plan members, Utilization Trends: shareholders and practitioners are Mr. Lacey also uncovered an among the most important. At the topinteresting thread of discussion in his How plans are being used, of the food chain, though, is a smallconversations that links to a broader individually and across the sector, is a and influential group of individuals whotrend of encouraging targeted wellness key economic driver. At the moment, are often thought of as the “client” insupport for plan members in the the sale of EHB plans. They are knownworkplace. Chiropractors are thought collectively as plan sponsors or planof as contributors to overall employee managers. These are the individualsproductivity and wellness. This suggests within companies who are responsiblea synergy with an observation reported for the composition and administrationin Benefits Canada last Septemberthat employers are moving to moretargeted health and wellness programswith measurable results. For example,consider a program to encourage betterposture, frequent stretching and exercisetargeted at employees whose rolesrequire long periods of time seated at acomputer workstation. Who better than achiropractor to help employers build thatprogram? www.chiropractic.on.ca 23

FEATURE STORY / TRENDS IN EXTENDED HEALTH INSURANCEof EHB plans. Often times these plans are an enormously important tool Market Trends:individuals can be found in a company’s for companies in the management ofhuman resources department. They are employee recruitment, retention and Market trends are linked in somewhere the rubber meets the road. They productivity. What’s more, employees ways to plan member requirementsare the ones who hear feedback from increasingly see EHB plans as a right. The and satisfaction. How a specific planplan members, combine those insights 2014 Sanofi Canada Health Care Survey, stacks up against the prevailing viewwith business realities and objectives a benchmarking report in the insurance of a standard (or even a premium)from their companies and then look world, points out that the newest crop plan is relevant data to plan membersfor a plan that meets as many of their of professionals — millennials — are the and sponsors. Does the plan haverequirements as possible — no easy feat. most likely to see EHB plans as a right of vision coverage? What hoops do planFrom this tension, however, innovative employees. 50% of millennials surveyed members have to jump through toideas are often born. Accordingly their saw it that way, the most of any other see a chiropractor or psychologist?perspectives and requirements are a generation. As a comparison, 76% of How big is the major dental coverage?very significant economic driver for the plan sponsors see health benefits as a These questions and many more likeextended health insurance industry. privilege, not a right. Put another way, them represent the way individual plan EHB plans are a major asset when it members and sponsors evaluate thePlan Member Requirements & comes to recruiting and retaining great quality of their plan against what otherSatisfaction: people. They also come in handy when people get. The more often the plan an employee is being recruited, as they stacks up well against plan members’ The views of individual plan navigate through a challenging time and expectations the better. One specificmembers are often thought to be considering a change in their career. example is a trend towards makingsecondary to economic considerations. paramedical coverage available forThat is likely an overstatement. EHBWHAT'S DRIVING EHB ECONOMICS?01 Plan Utilization Trends 03 Plan Member Satisfaction 04 Market Trends$77 paid to Canadians Plan Quality 67% of Canadians have in EHB benefits Expectations Extended Health Competition BenefitsBillion annually Major Dental Rx Costs vs. Biologics MSK Mental Health MSK Mental Health02 Employer Requirements Plan Managers reconcile 05 Fraud & Abuse competing priorities then establish57% of Employers called $1.6 improving health & and maintain the plan. well-being a priority Billion Employee Satisfaction Referral Payments Team Productivity Kickbacks Financial Pressures Unlicensed Practice24 SPRING 2015

ON Chiropracticpsychological services. This trend was Developments in Health Care “Preferred Provider Networks willdriven by growing societal awareness Delivery become a significant percentage of theof mental health challenges and plan health care market,” said Mr. Piller. “Thesemember expectations in recent years. Preferred Provider Networks networks reduce operational costsThis can work in both ways. Vision and (PPNs) are becoming increasingly through the use of advanced systemsorthodontic coverage are becoming prevalent in both the EHB and auto in customer relationship management,less common than in the past, perhaps insurance realms in Ontario. Just last billing, scheduling, charting, practicebecause plan members are no longer fall the OCA entered into a partnership management and contact centredemanding the coverage the way they with Quindell Health Services North telephony,” he added. Mr. Piller went ononce did. America (Quindell), the operator of a to point out that systems and automation PPN in Canada that serves both auto provide transparency in patient care andFraud & Abuse: and extended health insurers. Quindell, play a role in reducing abuse and fraud. a company with a long history in According to the Insurance Bureau Europe, entered this market through the The bottom line, though, is thatof Canada, 10 to 15% of insurance acquisition of a Canadian firm, PT Health, PPNs can be beneficial to all of theirpremiums go to paying fraudulent claims. which is now operating and expanding relevant stakeholders. “Patients enjoyKPMG tallies that up at approximately under the Quindell banner. an excellent, efficient care experience$1.6 billion dollars in fraud from auto The Chief Executive Officer of focused on recovery, while practitionersinsurance alone. Common types of fraud Quindell Health Services North America can focus on the patient rather thaninclude claims for services not actually is Glen Piller. Mr. Piller has worked in administrative tasks. Insurance carriersrendered, providers performing services the insurance industry for over two realize cost savings along with happyoutside of their scope of practice decades and has a clear, first-hand customers and pass their savings intoor licensing and kickbacks or illegal perspective on the value that PPNs bring premium reductions,” Mr. Piller said.referral payments. All told, fraud has a to the insurance industry. This includesmajor impact on premiums and on the benefits for patients, practitioners and Of course, not all PPNs are createdavailability of funds to pay out legitimate stakeholders. the same. That is why the OCA chose toclaims. Fraud is also factored into the The landscape of the auto insurance partner with Quindell, a company withpricing models of insurance plans. market in Ontario has changed a very strong team and focus on patient dramatically in recent years. Resulting care. Learn more at www.chiropractic. These economic drivers clarify from many factors, the increase in the on.ca/quindell.in some ways the opportunities for number of private, for-profit health carechiropractic to cement its place within clinics has been particularly striking. T hese and other trends are quietlyEHB plans. Direct advocacy to plan According to the Health Claims for Auto but significantly shifting thesponsors and managers is crucial. Insurance (HCAI) database, there are nature of the insurance industryThis has been a focus of the OCA for currently at least 9,500 clinics and over in Ontario. While the news is not alwayssome time and that effort will continue. 31,000 individual health care providers purely positive, chiropractors are wellCracking down on fraud is critical practicing in the province. positioned to play an increasinglytoo. Individual chiropractors can play At the same time, motor vehicle important role in the provision of EHBan important role as advocates for accident (MVA) related health care costs services in the years to come. Whatthe profession by clearly articulating have shot up, contributing to Ontario is most essential now is focusing onthe value and benefits of their care to having the highest auto insurance providing exceptional patient experiencespatients and encouraging them to speak premiums in the country. The average and encouraging those patients to reportto their EHB plan manager. While that is motorist in Ontario was paying about back to their EHB plan managers aboutunderway, the OCA and the Canadian $1,500 per year as of 2013, prompting the impact of the care you provide. That,Chiropractic Association will continue to the Ontario government to take further and continuing to build relationshipsadvocate to key stakeholders about the steps to try to tamp down premiums. with employers in your community, willrole chiropractors can play in helping Enter PPNs. help cement the partnership of EHBs andemployers cultivate a healthy workplace chiropractors in the advancements ofand a productive team of employees. Ontarians health. ON www.chiropractic.on.ca 25

BusinessHST IN THE CLINICIn July 2010, Ontario implemented a major tax reform that harmonized the provincial sales tax (PST) with the federal GST under one single value added tax system called the harmonized sales tax (HST) at 13%. Most goods and services in or imported into Canada are subject to GST/HST. It is important for business operators to know which goods and services are taxable and which are exempt.Does the HST Apply to Health Does the HST Apply to Health The following are general examples ofCare Services? Care Supplies? products and services commonly supplied in a chiropractic practice which count Under the HST system, the services Most supplies are taxable. Certain towards a clinic’s total worldwide taxableof some health care professionals supplies are exempt from GST/HST while supplies of goods and services:are taxable and the services of others others are zero-rated . ∞∞ massage therapy clinical serviceare exempt. The list of health careprofessionals whose services are exempt Zero-rated supplies are taxable at the provided to patients by a chiropractorfrom GST/HST can be found in Part II rate of 0%. No GST/HST is charged on or any other non-medical practitioner,of Schedule V to the Excise Tax Act (the them, but GST/HST registrants can claim ∞∞ fees for non-clinical services (e.g.,ETA). If you provide only exempt goods an input tax credit for the GST/HST they medical-legal reports, return to work/and services, you cannot register for a pay on purchases and expenses made to school notes, copying of clinicalGST/HST account. provide them. Zero-rated medical supplies records), count towards your total worldwide ∞∞ fees paid by an associate for the use of The following is a partial list of health taxable supplies of goods and services. the principal’s facilities or administrativecare professionals whose services services (we strongly urge you toare listed as exempt: chiropractors, Custom-made orthotic and consult with your legal or tax adviserchiropodists, dieticians, podiatrists, orthopaedic devices are one example regarding your specific situation),physiotherapists, registered nurses, of a zero-rated supply. If these devices ∞∞ sale of most dietary supplementsregistered nursing assistants and licensed are not entirely custom-made, they are (except those which count as basicor registered practical nurses. zero-rated only when prescribed by a groceries and are therefore exempt), medical practitioner. See the CRA’s GST/ and, If a health care professional is not HST Memoranda Series Chapter 4-2, ∞∞ sale of most orthotics, cervical pillows,listed in Part II of Schedule V to the Medical and Assistive Devices for more and other orthopaedic supports.ETA , the services that they provide information.are usually taxable. The following is a Businesses which only provide exemptpartial list of therapists or health care Do I Need to Apply for a GST/ goods and services cannot:workers whose services are generally HST Account?considered by the Canada Revenue ∞∞ register for GST/HST,Agency (CRA) to be taxable for GST/ It is mandatory for businesses (except ∞∞ charge GST/HST, or,HST purposes: acupuncturists, health public service bodies) to register for a ∞∞ claim input tax credits (ITCs).care assistants (including physiotherapy GST/HST account if your total worldwideand occupational therapy assistants), taxable supplies of goods and services In general, businesses with GST/HSTkinesiologists, massage therapists, exceed $30,000 in a single calendar taxable sales of $30,000 or less in the lastnaturopaths and sports therapists. quarter or in four consecutive calendar year (“Small Suppliers”) are not required to quarters. This includes zero-rated register and collect the tax. supplies like custom-made orthotics and orthopaedic devices. If you are already registered but taxable sales are $30,000 or less, you still26 SPRING 2015

ON Chiropracticneed to charge, collect and remit GST/ 1-800-959-5525, send the CRA a letter Accountants or the CRA for confirmationHST on all taxable (except zero-rated) or a completed “Form RC145, Request when interpreting the rules on charginggoods and services you sell or provide to Close Business Number (BN) Program GST/HST for their specific services.in Canada since the date of registration. Accounts.”Ensure that you hold the GST/HST in trust SRJ Chartered Accountantsuntil you send it to the CRA for filing your How Often Do I Need to File? ∞∞ Telephone: 647-725-2537GST/HST return. ∞∞ Email: [email protected] Typically your total annual sales ∞∞ Website: http://www.srjca.comWhat is an Input Tax Credit? determine how many times in a year ∞∞ OCA Advantages partner profile: you have to file your GST/HST return. An input tax credit (ITC) is the amount Businesses which have annual taxable http://www.chiropractic.on.ca/srjcaof GST/HST you may recover from the supplies of $1,500,000 or less areGST/HST you paid or owed on purchases assigned an annual reporting period Canada Revenue Agencyand expenses related to your commercial but may also choose to file monthly or ∞∞ Tax information phone service:activities, so long as you are a GST/HST quarterly.registrant. 1-800-267-6999 If you are a monthly or quarterly filer, ∞∞ Businesses and self-employed The ITCs can be claimed in the same you have to file your GST/HST return andreporting period as when the purchases pay the amount owed no later than one individuals: 1-800-959-5525were made when you file your GST/HST month after the end of your reporting ∞∞ Website: http://www.cra-arc.gc.ca/return. If you have any ITCs that were period. If you are an annual filer, generallynot claimed when you filed the return for you have to file your GST/HST return Please note that this article is not athe corresponding period, you can claim and pay the amount owed no later than legal document. It is provided as a generalthose ITCs on a future GST/HST return as three months after the end of the fiscal overview and is not to be treated as legallong as it is filed by the due date of the year. If you are an individual with business or tax advice or relied on as the basisreturn for the last reporting period that income for income tax purposes who is for any decision-making with regards toends within four years after the end of the also an annual filer with a December 31 your practice. OCA members are stronglyreporting period in which the ITC could fiscal year-end, you have to file by June encouraged to seek independent advicehave first been claimed. 15. However, you still have to pay the from their legal or tax advisers regarding amount of GST/HST owed by April 30 to the application of HST to their practice.What if I No Longer Qualify? avoid penalties and interest.Can I Deregister? The OCA would like to thank Rishabh More Information Khamesra and Kevin Fok of SRJ Chartered If you decide to deregister for Accountants for their assistance in theHST, you can request to cancel your There are many exemptions to these preparation of this document. SRJCA is aregistration so long as you have been rules set by the CRA. If you are unsure full service chartered accounting firm andregistered for at least one year (unless whether you need to charge GST/HST on an OCA Advantages Partner.your business has already stopped the services and supplies provided in yoursupplying taxable goods and services and clinic(s), you can contact SRJ Charteredno longer needs to be registered for theGST/HST). However, you may have to ON DEMAND WEBINARremit GST/HST on capital property used inyour commercial activities, and on other HST: WHAT THE ONTARIOproperty you own when you cancel your CHIROPRACTOR NEEDS TO KNOWregistration. Financial Management When you cancel your registration,you will have to file all GST/HST returns Tune into this webinar to sort through the nitty-gritty detailsand remit any GST/HST that was charged of HST and chiropractic services and products.or collected while you were a registrant.To cancel your registration, you can call www.chiropractic.on.ca 27

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