Our 2019 chiropractic legislative agenda; plus attend Leg District meeting and earn 2 free CE hours


Dr. Dave Butters

In my last letter, I shared information about the historic legislative achievements in 2018 for the Washington State Chiropractic Association, the Washington State Chiropractic Trust and chiropractic as a whole, including passage of chiropractic Fair Pay and Prior Authorization bills.

Now, we must work to support those state legislators who supported us. This is a critical mid-term election year and all of us must work together to re-elect our supporters – those willing to fight for our issues.

You have probably received communications from the WSCA regarding hosted meetings in various legislative districts around the state explaining the passage and implementation of the Fair Pay and Prior Authorization bills for which 2 hours of CE is offered at no cost. There is a component of the meetings where legislators from the district are invited to attend. Maybe you have already attended one of these meetings. We still need chiropractors to host more of these meetings inviting the chiropractors and the legislators from your area to attend. Our lobbyist, Lori Grassi, speaks at the meeting and will help you to set it up, and to invite the chiropractors and the legislators. Contact Lori at 206-878-6055 or by email lgrassi@chirohealth.org.

While we did accomplish amazing legislative gains this year, there’s always more work to do. Here are the priorities for the 2019 legislative session, as outlined by the WSCA Board of Directors:

Emphasizing drugless services to combat the opioid crisis: This proposed legislation is modeled after legislation that passed in West Virginia this year. This bill is intended to do three things:
1) Require health plans to increase their visit limits to 20 for drugless services such as chiropractic, acupuncture, physical therapy, massage therapy and occupational therapy.
2) Require the copay for these drugless services to be the same as Primary Care services.
3) Require patients who seek opioid services/prescriptions to first visit for a trial of care at least one of the named drugless providers prior to receiving an opioid prescription.

Regulating benefits managers: Benefits managers like ASH, eviCore and others are hired by insurers to implement some, or all, of the following services; prior authorization, clinical review, billing, network creation and management. We are working to introduce legislation that would require them to be licensed by the Office of the Insurance Commissioner. This legislation would also include provisions that would require disclosure of the agreements between the benefits managing company and the insurer, exposing financial incentives to blocking access to care.

Ensuring chiropractors receive Primary Care Status: Chiropractors are the only physician-level
providers who are not statutorily defined as primary care. Our message to legislators is that a primary
care provider’s job is to triage, treat and/or make appropriate referrals, working within their scope of
practice. Legislators are not knowledgeable about and do not understand the chiropractic education,
we need doctors to help educate them about our training which includes differential diagnose and our
practice of triaging our patients and referring to other providers for conditions outside of the
chiropractic scope. The most common presenting complaints to a primary care provider’s office are
musculoskeletal in nature and physicians routinely prescribe a muscle relaxer and/or an opioid
We are always monitoring other legislation and opportunities for new ideas to present themselves
We may not achieve legislative wins every year but it is important to remember that over the past
many decades the chiropractic profession in Washington State has not endured losses of previous
accomplishments. Year after year we have defended and protected against legislative attempts to
undermine patient access to our services, especially yearly attempts to erode or eliminate the Every
Category of Provider law, which requires that all plans sold in Washington State provide chiropractic
benefits.

We have expended enormous political capital to achieve our latest legislative wins, and much will be
expected of us. I can’t stress enough how important it is to donate to the Trust, to help elect
those who support chiropractic.

If you have contributed recently and/or are a regular contributor to the WSCT, it is appreciated and
makes a difference. If you haven’t contributed, I urge you to do so today. Just click here
to make either a one-time or recurring donation.

Make a one-time contribution: $1000, $500, $250, $100

Sign up for monthly credit card withdrawals: $100, $50, $25 Monthly

P.S. Regarding the new Prior Authorization Bill, we have heard that some
doctors are having trouble with coverage under specific health plans. To help
the WSCA track this issue, ask your patient to request from their employer or
their insurance company the “Summary Plan Description.” Then scan and email
the following information to us: The name of the employer purchasing the plan,
the plan name (or number) and the group name (or number). Email
to wsca@chirohealth.org — put “Summary Plan Description” in the subject line

— Dr. David Butters, President
Washington State Chiropractic Trust

Learn how to implement new state chiropractic laws into your practice at these meetings


Dr. Dave Butters

With the passage of three bills during the last legislative session that will affect Washington state chiropractors, our lobbyist Lori Grassi is hosting a series of meetings statewide in upcoming weeks to answer questions about effective dates and implementation. In addition, you will have an opportunity to share issues and concerns that you may have about practice in Washington State. Legislators will be invited to attend a portion of the meeting so that you can also meet them and ask questions of them.

Note that there is no fee for the meetings but there are capacity limits for the locations. Please register at this link so that we know when the meeting is full and if we need to schedule an additional meeting at a future date. Continuing education certificates will be offered for up to 2 hours.

The scheduled meeting dates and times are as follows. More meetings are in the planning stages, so visit www.chirohealth.org/events/event_list.asp to check for updates.

Thursday, April 26, 2018
11:30 a.m.-1:30 p.m.
Meridian Valley Country Club
24830 136th Ave. S.E.
Kent, WA 98042
Meal available for purchase

Tuesday, May 1, 2018
1-3 p.m.
Stemp Clinic
7247 S Pine St, Ste. A
Tacoma, WA 98409-5900

No meal provided. Bring a snack if you’d like

Thursday, May 17, 2018
11:30 a.m.-1:30 p.m.
Mercato Ristorante
111 Market St. N.E
Olympia, WA 98501
Lunch is available to purchase at restaurant

Wednesday, May 30, 2018
6:30-8:30 p.m.
Bridge Chiropractic – Salmon Creek
13800 N.E. 20th Ave.
Vancouver, WA 98686
No meal provided. Bring a snack if you’d like

Thursday, May 31
8:30-10:30 a.m.
Bridge Chiropractic – Salmon Creek
13800 N.E. 20th Ave.
Vancouver, WA 98686
No meal provided. Bring a snack if you’d like

This is a great opportunity to learn more about our legislative victories and also to meet your local legislators. Remember that the midterm elections are this November, and it’s critical that we support those lawmakers who supported us. The goal is to re-elect our supporters – those willing to fight for our issues.
It is equally important that you donate to the Trust, to help elect those who support chiropractic.

If you have contributed recently and/or are a regular contributor to the WSCT, it is appreciated and makes a difference. If you haven’t contributed, I urge you to do so today. You donate online at the WSCT website. Or, if you prefer, you can mail your donation to PO Box 2163, Seattle, WA 98111.

Make a one-time contribution: $1,000, $500, $250, $100. Or sign up for monthly credit card withdrawals: $100, $50, $25 monthly.

— Dr. Dave Butters, President
Washington State Chiropractic Trust

Hard fight brings huge legislative wins for chiropractic in Washington state this year


Dr. Dave Butters

Governor Jay Inslee has signed into law the Chiropractic Fair Pay Bill ESB 5518, the Prior Authorization Bill ESSB 6157 and HB 2313 which gives the Chiropractic Quality Assurance Commission greater authority and independence in its budget and operational activities. Thanks to the skillful hard work and dedication of our lobbyist, Lori Grassi, the unwavering commitment and testimony of Dr. Austin McMillan, and others who took time from their practices and families to attend Legislative Day – including additional trips to Olympia to work this legislation through the process – we were able to prevail over 12 highly paid health insurance company lobbyists.

The Fair Pay Bill ESB 5518 ensures that chiropractors are paid no less than 90% of what osteopaths and naturopaths are paid for spinal manipulation services. Currently, they are paid up to 2 times, or 100% more, for the same services. A 10% variation in reimbursement between the chiropractic and osteopathic codes is due to the Resource Based Relative Value Scale (RBRVS) methodology. This methodology, which is used by Medicare, establishes fair fees for services and procedures on an annual basis and allows the 10% variation in pay for the difference in the facility overhead and malpractice insurance costs between the provider types. This calculation is known as the Relative Value Unit, or RVU. The initial Fair Pay Bill, passed by the WSCA nearly 10 years ago required that insurers pay chiropractors the same for Evaluation and Management and Physical Medicine/Rehabilitation services as paid to other medical providers. Following its passage, reimbursement to chiropractors for these services increased by up to 100% (doubled). When we passed the initial Fair Pay Bill we were not able to include spinal manipulation because the chiropractic and osteopathic spinal manipulation codes are different, even though the first three codes of both are substantially similar in their service descriptions. In the case of E&M and Rehab, all providers use the exact same codes.

After many years of persistence in educating legislators and building relationships (grass roots politics) we finally got a strong majority to see the disparity and unfairness in our reimbursement for spinal manipulation. In addition, we were able to prove that we have not had a fee increase for our core service (spinal manipulation) in 15 years and that our provider contracts are take-it-or-leave-it: there is no opportunity for negotiation! ESSB 5518 takes effect January 1, 2019.

The obvious question: How will the insurers respond to the Fair Pay Bill come January 1, 2019? We don’t know! They could reduce the osteopaths and naturopaths to what they pay us, they could increase us to what they pay them, they could move us both towards the middle (all within the 10% variation) or they could use the RBRVS formula which factors in the variation and is federally recognized by CMS/Medicare. Legislators were moved by the disparity in pay and no cost of living increase in 15 years. I would suggest there was legislative intent behind the passage of ESSB 5518 and I would hope the insurers respond in good faith. We’ll just have to see!

The Prior Authorization Bill ESSB 6157 allows for up to 6 consecutive visits within an episode of care before prior authorization can be required. If the patient has not received treatment for the same or similar condition for a period of 90 days or longer it is, by definition, a new episode of care. Initially we had legislative support for 12 visits prior to requiring authorization for additional care but to move the bill out of the Senate and keep it alive we ultimately had to accept 6 visits. Those 12 health insurance lobbyists fought us aggressively every inch of the way. This legislation improves on our current situation but is still not a resolution that satisfies most of us. It’s an incremental process that never ends, I’ve come to learn and accept that challenge over 44 years of practice and political/legislative involvement nearly that long. ESSB 6157 takes effect June 6, 2018 (this year).

HB 2313 is the bill that allows our regulatory commission, the Chiropractic Quality Assurance Commission, to manage our licensing funds efficiently and independent of the Department of Health. It also allows the Commission to manage its staff and be more responsive to the needs of the public and the profession.

These are historic achievements for the Washington State Chiropractic Association, the Washington State Chiropractic Trust and chiropractic as a whole. To our knowledge, no other state in the USA has passed Fair Pay or Prior Authorization legislation of this nature. However, it’s important to remember that it takes persistence over years to educate 98 House members and 49 Senators.

As you can imagine, we have expended enormous political capital and much will be expected of us. The midterm elections are this November. It’s critical that we be there for those that were there for us. The Goal: re-elect our supporters – those willing to fight for your issues.

We need individual chiropractors to host meetings with other chiropractors from their area, inviting their legislators to attend. Lori Grassi is willing to help you set that up, and invite the legislators. Contact Lori at 206-878-6055 or by email lgrassi@chirohealth.org.

I am calling on you again to donate to the Trust, to help elect those who support chiropractic.

If you have contributed recently and/or are a regular contributor to the WSCT, it is appreciated and makes a difference.

If you haven’t contributed, I urge you to do so today.

You can make a one-time or recurring donation online here. Or, if you prefer, you can mail a check to P.O. Box 2163,
Seattle, WA 98111

Make a one-time contribution: $1000, $500, $250, $100 or sign up for monthly credit card withdrawals: $100, $50, $25.

 — By Dr. Dave Butters, President

Washington State Chiropractic Trust

 

 

Chiropractic Fair Pay bill passes House and Prior Authorization on its way to governor’s desk


Dr. Dave Butters

I have an an exciting update on our progress with ESSB 6157  (Prior Authorization) and ESB 5518 (Fair Pay).

ESSB 6157, the Prior Authorization bill that allows patients up to six consecutive visits of chiropractic care in a new episode of care without requiring prior authorization, passed the Washington State House 90-8. It’s now on its way to the Governor for signature. A new episode of care is treatment for a new or recurrent condition for which the enrollee has not been treated in the previous 90 days.

ESB 5518, the Chiropractic Fair Pay bill, passed the House 86-12 Wednesday, Feb. 28 and is back to the Senate for concurrence regarding a necessary technical language change in the House. We are cautiously confident and working on the Senate concurrence which must occur by Thursday March 8 at 5 p.m., after which ESB 5518 will also be sent to the Governor for signature.

Thank you to all of you who have called and or made trips to Olympia to meet with your legislators and who have worked the House and Senate Chamber doors with our lobbyist Lori Grassi.

Dr. Dave Butters, President
Washington State Chiropractic Trust

We need your help to pass bills on Chiropractic Fair Pay, Prior Authorization


On Tuesday, Feb. 20, in the House Health Care Committee, Washington State Chiropractic Association representatives testified before the House Health Care Committee regarding the Chiropractic Fair Pay Bill, ESB 5518. When you watch the video you will have a clear picture of how the insurers value chiropractors and chiropractic care. Following this hearing, on Wednesday, February 21, 2018, the committee passed the bill to the next step in the legislative process 12 in favor and 5 opposed. Even our “no” votes understand how unfair the insurers are being, they just don’t like putting this kind of thing in statute.

The committee also heard ESSB 6157, the bill allows access to up to 6 consecutive visits of chiropractic care (and other therapies) in the same episode of care without having to request prior authorization. An episode of care is definined by a period of 90 days or more without treatment for the same or similar conditon. This bill is scheduled for Executive Action Friday, February 23, 2018 and needs to move from committee to continue in the legislative process before the 5:00pm cut off on the same day. We need you to call your House members and ask them to vote YES on ESSB 6157.

Watching the Video: You can find the Fair Pay testimony from the 1:06:10 mark to the 1:29:27 mark. The Prior Authorization testimony runs from 0:00 to the 02:04, and again from 12:30 to 45.40.

It’s disturbing to see what health insurers are saying about chiropractors and the services we provide, and it’s critical for doctors to review their arguments. Find your legislative district and legislators and call them to urge their support for ESSB 5518 and ESSB 6157.

Talking points for the Fair Pay bill, ESB 5518:

• This bill gives insurers the option of:

A. Raising the pay UP to chiropractors to match what they pay others for spinal manipulation services (identified by the same or substantially similar code); or
B. Lowering others DOWN to the same rate they pay chiropractors for spinal manipulation services (identified by the same or substantially similar code); or, what we recommend-
C. Pay chiropractors using the appropriate payment methodology identified by CMS using the RVU formula to set fair payments for ALL providers.

Your contracts are not negotiated — they are “take-it-or-leave-it”.

Insurers haven’t raised your fee schedules for spinal manipulation in more than14 years! In fact, Regence pays chiropractors 14% less in 2018 than they did in 2003.

Talking point for Prior Authorization, ESB 6157:

• When patients are prevented from obtaining their benefits by obstructive prior authorization requirements, it drives them away from drugless providers into opioid prescriptions.
Every day non-drug treatment is delayed, another opioid prescription is provided.

CALL TO ACTION:

1. Come to Olympia. Your presence changes the outcome in a positive way! Once the bills pass through the Rules Committee they are eligible for Floor Action (a full House vote) and will need your help “at the doors” with Lori to help count votes. The bill must be heard by March 2, at 5:00pm. If you can come to Olympia email Lori at LGrassi@chirohealth.org or text her at 253-988-0500-be sure to put your name in the text message!
2. Call your State Representatives and ask for an appointment to meet with them. You can find your legislative district to know who to contact!

— By Dr. Dave Butters, President Washington State Chiropractic Trust

We need you in Olympia Jan. 25 for our 2018 Chiropractic Legislative Day


Join us at the State Capitol in Olympia Jan. 25.

It’s critical that you attend our 2018 Annual Legislative Day on Thursday, Jan. 25 in Olympia. It’s your opportunity to meet legislators who represent you, and to advocate for your profession and your patients.

Make appointments with your legislators now. You can find your legislators easily by using this link: http://app.leg.wa.gov/districtfinder. Once those meetings are confirmed, contact the WSCA with the time of the meeting, your legislator’s name and the room number. If you need assistance coordinating with your legislator, call the WSCA office at 206-878-6055.

Plan a carpool with other chiropractic colleagues from your legislative district. You can learn more about available parking options as well as shuttle service at this link.

We will meet in the Capitol Rotunda at 8 a.m. Jan. 25. Our lobbyist Lori Grassi will be briefing WSCA members on the association’s agenda before we set out on our day of public advocacy – both for our profession and for those who rely on us for their chiropractic care.

You can find our 2018 Chiropractic Legislative Agenda here.

If you cannot attend Jan. 25, you can still come any day during the legislative session. Just schedule your time in advance with Lori Grassi by calling the association office at 206-878-6055.

I look forward to seeing you in Olympia on Jan. 25.

— Dr. Dave Butters, President

Washington State Chiropractic Trust

Join us for X-ray panel discussion Jan. 20, Chiropractic Legislative Day Jan 25


Dr. Dave Butters

I hope you had a great holiday and are ready for the New Year – which means the start of the 2018 legislative session will be here before we know it. You’ll find more details below on our Jan. 25 Legislative Day, and I also want to alert you to a panel discussion on X-rays Jan. 20.

Please plan to attend our 2018 Annual Legislative Day, this year on Thursday, Jan. 25, 2018 in Olympia. It’s your opportunity to meet legislators who represent you, and to advocate for your profession and your patients. We will meet in the Capitol Rotunda at 8 a.m. for a briefing.

Contact your legislators in advance to set up an appointment for Jan. 25. You can find your state legislator at this link: http://app.leg.wa.gov/districtfinder. We are counting on a large chiropractic turnout for our Legislative Day to ensure that legislators are focused on our issues.

On the weekend before our Legislative Day – Saturday, Jan. 20 – I encourage you to attend a panel discussion regarding the American Chiropractic Association recommendation that chiropractors do not obtain X-rays for patients with acute low-back pain during the first six weeks after onset of pain.

You can learn more about that program on the back of this page.

Here is the 2018 Legislative Agenda as approved by the Washington State Chiropractic Association Board:

1) Remove Chiropractic access barriers and reinforce our alternative drugless approach to the opioid crisis.

2) Ensure that chiropractors are paid fairly for CMT services

3) Identify chiropractors as primary care providers within their scope of practice.

4) Secure a manipulation benefit for adult Medicaid recipients-who can only see an osteopath or naturopath for manipulative services.

5) Remove the sunset provision on the independent pilot for the Chiropractic Quality Assurance Commission.

If you cannot attend Jan. 25, you can still come any day during the legislative session. Just schedule your time in advance with our lobbyist Lori Grassi by calling the association office at 206-878-6055. More details on the legislative agenda are available here.

Finally, here’s an important reminder during this season of giving: If you are a regular WSCT contributor, it is appreciated. If you haven’t donated, please do so today. Click on the DONATE button to make either a one-time or recurring donation. Or, if you prefer, fill out and return the enclosed contribution envelope. You can make a one-time contribution of $1,000, $500, $250, $100 or you can sign up for monthly credit card withdrawals.

Happy New Year to you and yours!

— Dr. Dave Butters, President
Washington State Chiropractic Trust

With gratitude, as we prepare to advocate for chiropractic during 2018


We are almost at Thanksgiving, and I want to express my gratitude to those of you who have given so much to our profession. You volunteer for committees. You donate time and money. You engage in our mission of protecting and promoting patient access to chiropractic care.

The holiday season also means that we are getting closer to the start of yet another session of the Washington State Legislature, and our Legislative Day, set this year for Thursday, Jan. 25, 2018 in Olympia. It’s your opportunity to meet legislators who represent you, and to advocate for your profession and your patients. We are counting on a large chiropractic turn out for our Legislative Day to ensure that legislators are focused on our issues.

Your participation in the legislative process is critical to our outcomes and truly makes a difference. If you cannot attend the legislative day, you can still come any day during the session. Just schedule your time in advance with our lobbyist Lori Grassi, and she will make sure that you get a chance to share your issues.

Here is the 2018 Legislative Agenda as approved by the Washington State Chiropractic Association Board:

1) Reinforce the importance of chiropractic’s drugless approach to address the opioid crisis

The WSCT, in partnership with the Washington State Chiropractic Association’s Insurance Committee, has been working with legislators and insurers to educate them on how chiropractic can save money assisting in the decrease of opioids for pain management. Patients can see their MD as many times as they want in any health plan and their first plan of attack on pain is an opioid. We want insurers and legislators to encourage patients to engage in a drugless option first, by reconsidering their approach and removing the barriers to access, which include high copays and visit limits. Another concept we’re pursuing is no prior authorization for the initial 12 visits.

2) Identify chiropractors as primary care providers within their scope of practice.

Our message to legislators: Primary care providers aren’t expected to manage and treat every condition that enters their office, but they are expected to triage and work within their scope of practice and refer when appropriate. We are citing results of the Optum study, which demonstrated that the most common health conditions presenting in a PCP’s office are musculoskeletal. If chiropractors were included by definition as PCPs the insurance specialist classification would go away, copays would drop and the patient would have a greater incentive to seek their chiropractor first – thus reducing exposure to an opioid.

3) Ensure that chiropractors are paid fairly for CMT services

We are again submitting a bill that would require insurers to pay chiropractors fairly for CMT services. The bill also encourages carriers to use the nationally established Relative Value Unite (RVU) system and its conversion factors in paying all providers. Currently, most insurers overpay some provider types and underpay chiropractors for CMT. They should be following the national standards instead of paying others more than the formula and chiropractors less.

4) Secure a manipulation benefit for adult Medicaid recipients-who can only see an osteopath or naturopath for manipulative services.

For the fifth year, we are working to include chiropractors in the list of providers who can deliver manipulation benefits. While we recognize this benefit doesn’t pay well, we believe that under-served communities deserve to have access to drugless services too, and it will save the entire Medicaid system money if they see a chiropractor first. We are also working with the Governor and the State Health Care Authority on a pilot project that would direct Medicaid patients to drugless options for pain management.

5) Remove the sunset provision on the independent pilot for the Chiropractic Quality Assurance Commission.

The Chiropractic Quality Assurance Commission regulates the competency and quality of chiropractors to ensure they are delivering high quality services to state residents. For the past four years, the commission has participated in a pilot project under which it has assumed responsibility for several functions that were previously provided by the Department of Health – including budget, licensing and disciplinary compliance. The pilot is set to expire in mid-2018, and we are advocating that the 2018 legislature grant the commission permanent status as an independent body.

As we prepare for the 2018 legislative session, and for our Jan. 25, 2018 Chiropractic Legislative Day, it is critical that each of you get to know your local legislators. Invite them for coffee or a lunch at your clinic and get 4 or 5 of your colleagues to come as well. You can find your state legislator at this link: http://app.leg.wa.gov/districtfinder. If you would like help setting up meetings with your legislators, contact Lori Grassi, Lobbyist and Executive Director for the WSCA, at LGrassi@chirohealth.org or 206-878-6055.

Finally, I began this letter by expressing my gratitude for those chiropractors who give back to our profession. If you are a regular WSCT contributor, it is appreciated. If you haven’t donated, please do so today. Visit www.washingtonchirotrust.org and click on the DONATE button to make either a one-time or recurring donation. Or, if you prefer, fill out and return the enclosed contribution envelope.

You can make a one-time contribution of $1,000, $500, $250, $100 or you can sign up for monthly credit card withdrawals.

Wishing you and yours a wonderful Thanksgiving holiday.

Dr. Dave Butters

— Dr. Dave Butters, President
Washington State Chiropractic Trust

Engage: Don’t turn your back on your profession


Dr. Dave Butters

This month, as chiropractic turns 122 years old, I have an important question:

Have you turned your back on your profession?

There are 2,000 chiropractors in our state. Yet, when it comes to engaging with our legislators and fighting for what we believe in, most don’t engage. It’s always a small percentage of us working to ensure doctors of chiropractic are compensated fairly — and that our patients have unimpeded access to chiropractic services.

However, thank you to those who did respond to our July 2017 request for help; you got us over half way to where we need to be.

This fall, control of the State Senate will depend on a key race in the 45th District. How we participate financially in both the Democratic and Republican caucuses will not be unnoticed and likely impact our chiropractic issues. It’s critical that we raise another $40,000 in October, mostly for the state House and Senate soft money PACS. When we go to the state Legislature in January 2018 session our support now on both sides of the aisle is what opens the doors to our conversations and concerns.

We continue to have major legislative issues to tackle, including Fair Pay for our services and Prior Authorization obstacles to the care of our patients and the huge administrative burden it’s placing on our offices. Our state and nation are in the midst of an opioid crisis, and our legislators need to know that we are the viable solution. Restricting or impeding access to our services is unacceptable!If you’ve left this work to others in your profession, just couldn’t find the time – now is the time to engage! Do it for your Patients. Do it for your Family. Do it for Yourself.

Click on the DONATE button. Or, if you prefer, mail a check to PO Box 2163, Seattle, WA 98111. Make a one-time contribution: $1000, $500, $250, $100 or sign up for monthly credit card withdrawals of any amount.

— Dr. Dave Butters, President
Washington State Chiropractic Trust