An audit of health products and services marketed on chiropractic websites in Alberta and consideration of these practices in the context of chiropractic codes of conduct and ethics

Abstract

Background

Chiropractic’s success as a health care profession is evidenced in part by the rising number of practitioners. Paradoxically, this success may start to cost the profession, as the number of consumers may not be increasing proportionally. Fewer patients mean less income for practitioners. Some chiropractors are responding to these pressures by marketing health products, and services

Objectives

To describe the extent to which Alberta chiropractors with websites sold health products and the extent to which fee discounts/service inducements were advertised. To consider these practices in the context of chiropractic codes of conduct and ethics.

Methods

Chiropractic websites in the province of Alberta were identified using the online Telus Business Finder and cross-referenced with the Yellow Pages print directories. The websites were searched and an inventory of the health products for sale was recorded. Fee discounts and service inducements were also recorded.

Results

56 websites were identified and reviewed. Just under two-thirds of the chiropractic websites surveyed contained information on health products for sale. Orthotics were sold most often (N = 29 practices; 51.8%), followed by pillows and supports (N = 15: 26.8%), vitamins/nutritional supplements (N = 15; 26.8%) and exercise/rehabilitation products (N = 10; 17.9%). Nine practices (16.1%) offered some type of inducement to potential customers. These included discounts on treatment packages (N = 2; 3.6%), free gait/ posture analyses (N = 2; 3.6%) and free general consultations with the chiropractors (N = 3; 5.4%)

Conclusions

The marketing of health care products and services by chiropractors in Alberta is common. Such practices raise ethical considerations for the profession. Professional guidelines vary on the acceptability of these practices. Consumer and practitioner perspectives and practices regarding retailing need to be further examined.

Introduction

Chiropractic is established as a health profession within the health care systems of many countries, evidenced by statutory regulation, reimbursement protocols, and consumer usage surveys.^1,2 Consumer satisfaction with chiropractic care has been high as demonstrated by surveys of patient groups.^3,4

The rising number of practitioners is another sign of the discipline’s success.^1,5 Paradoxically, this success may start to cost the profession, as the number of consumers may not be increasing proportionally to the number of providers. Further, in Canada, some provincial health insurance plans are reducing their coverage of chiropractic services, leaving consumers without third party coverage to pay directly out of pocket.^6,7 This in turn may reduce the number of people able to access care, and fewer patients might mean less income for practitioners. The dental profession has faced similar challenges in the last 20 years.⁸

Some chiropractors are responding to these pressures by marketing health products, devices and services,¹ a measure also taken by dentists as a means of promoting their practices.⁸ Annual surveys reported in the US trade magazine “Chiropractic Economist” have shown a steady rise in the proportion of responders who sell health products in their practices reaching a high of 92.1% in 2004.⁹

The Canadian chiropractic 1995–96 census survey collected information on the sale of nutritional supplements, orthotic devices and homeopathic/naturopathic remedies as sources of practice income.⁵ For responding chiropractors in active practice:

• nutritional supplements provided 1–5% of practice revenue for 27% and, 6–~20% of practice revenue for 7.2%

• orthotic/assistive devices provided 1–5% of practice revenue for 49.5%, and 6–~20% of practice revenue for 7.2%

• homeopathic/naturopathic remedies provided 1–5% of practice revenue for 12%, and 6–~20% of practice revenue for 2.9%

Finally, an investigation of the market for dietary supplements in the United States, indicated that 5% of $13.9 billion in sales was distributed through “health care practitioners such as chiropractors”.¹⁰ The authors expected the proportion of sales in this category would increase in coming years.

Recently, the Ontario Chiropractic Association (OCA) and the Canadian Chiropractic Association sponsored studies examining the public’s attitude toward chiropractic marketing practices. These survey results revealed that certain marketing practices used by chiropractors eroded consumer confidence in the profession. While the majority of consumers (close to 75%) surveyed indicated that offers for discounted or free services would have no effect on their decision to seek chiropractic care, 10% indicated such offers would make them less likely to seek such care.¹¹

In Canada, chiropractors are self-regulated provincially with each province having legislation for the practice of chiropractic including regulations for licensure, scope of practice and disciplinary procedures. In addition, many provincial organizations and the Canadian Chiropractic Association have codes of conduct and ethics, which are independent of the legislation and are intended to support the provincial regulations and guide members of the profession in their conduct. It is within these codes of conduct and ethics that the professional organizations offer guidance to practitioners with respect to the retailing of health products, and provision of fee incentives and service inducements.

Website marketing is a common vehicle for reaching potential consumers. The purpose of this preliminary study was to describe the the extent to which chiropractors with websites sold health products and the extent to which fee and/or service inducements were offered on the websites. These practices were considered in light of guidelines provided by chiropractic codes of conduct and ethics.

Methods

Chiropractic websites in the province of Alberta were identified using an online directory, the Telus Business Finder. This online directory provides contact information for all chiropractors offering services in the province and occasionally, lists web addresses. Data from the Canadian Chiropractic Association indicate that there were 856 licensed chiropractors in the province in 2006.¹² Currently, 877 chiropractors have listings in the Telus online directory, suggesting most chiropractors are represented. The listings in the online directory were cross-referenced with the Yellow Pages print directories for Calgary, Edmonton, Lethbridge, Red Deer, Fort McMurray and Grande Prairie. Only clinics owned/directed by a chiropractor were included.

The websites were searched and an inventory of the health products and services offered for sale was recorded. Products sales were considered as direct if the products were clearly available either online from the website or from the chiropractors’ offices. They were considered indirect if the chiropractic site provided a link to a product site from which products could then be purchased.

The sites were also examined for information on clinic fees and incentives.

Consistent with the TriCouncil Policy Statement, this study did not require ethics review (Section 1.A., Article 1.1).¹³

Results

Twenty-six websites were identified in the Telus online business directory. Two of these websites provided information on clinics that were affiliated. The first had five clinic locations, with different practitioners at each site. Four of the five clinics were owned and directed by physiotherapists and were excluded. The fifth clinic was owned and directed by chiropractors and was included. The second of these websites was a central site that provided no general clinic information, but instead provided the web-sites of 6 additional practices. Therefore, websites for 31 practices were identified. Of the 31 websites, 2 were currently under construction and no content was available (N = 29 useable). Examination of the print phone directories revealed 34 additional web addresses. Of these, seven were not accessible (N = 27 useable). In total, 56 websites were reviewed between May and June of 2006.

Practice characteristics

Seventy-one chiropractors (50 male) provided services at these clinics. Forty-two practices (75.0%) were multidisciplinary, most often providing the services of registered massage therapists (N = 41 practices; 73.2%) in additon to chiropractic services. Other frequently affiliated practitioners included Doctors of Chinese Medicine (N = 10 practices; 17.9%) and naturopaths (N = 6 practices; 10.7%). Eight practices were solo, four were chiropractic partnerships and two could not be characterized.

Forty-six practices (82.1%) were in large cities (Calgary, Edmonton), eight (14.3%) were in smaller cities (Red Deer, Lethbridge, Fort McMurray) and 2 (3.6%) were in rural towns/centres (Camrose, Strathmore).

Product sales

Almost two thirds of the practice websites (N = 37: 64.9%) advertised health products for sale.

Orthotics

Twenty-nine practices (51.8%) prescribed custom-made orthotics following variously described foot and gait scans, and casting. Orthotic manufacturing is typically outsourced and then distributed by chiropractors. Six practices provided prices for orthotics ($250–$450.00) and two noted the cost of orthotics might be covered under insurance plans. One practice advertised a “June Orthotics Special,” but no further details were available.

Other health products

Twenty-three (41.2%) sold other health-related products. These are illustrated in Table 1.

Table 1.

Description of health products for sale directly from chiropractic practices as advertised on websites

Product	Practices N (%)
pillows/supports	15 (26.8%)
vitamins/nutritional supplements	15 (26.8%)
exercise/rehabilitation products	10 (17.9%)
hot/cold packs	9 (16.1%)
massage oils/creams	5 (8.9%)
herbals	4 (7.1%)
misc (e.g., bath/skin care, magnetic balls/magnets, juice extractors, laundry disks, CPR masks, mechanical massagers, meditation programs, weight loss program)	10 (17.9%)

These products were available from the chiropractors practices, although a few (N = 5; 8.9%) offered consumers the opportunity to purchase online and three practices were in the process of developing “online stores.” One of the latter sites encouraged customers to send an email if they did not see what they were looking for or would like to be able to purchase online in the future.

The stated goal of one site was “to provide the Internet consumer with quality online access to innovative and traditional health and wellness products” and offered an extensive range of products relating not only to health and wellness, but including toys, kitchen items (e.g., oven mitts, kettles) and alarms clocks. The chiropractor’s role was described as “Actively search(ing) for quality items to offer to customers and openly recommending well-researched Chiropractic products such as ...”. It was not clear whether the chiropractor who operated the site offered any clinical services.

Some practices posted the costs and brands of the products they sold, while others did not. Occasionally, sites explicitly endorsed listed products:

“Looking for good deals on the highest quality nutritional supplements, orthopedic supports, exercise equipment and much, much more? If so, you’re in the right place. Many of the products we sell are the highest of quality and only available through health care professionals”

“Available only through licensed healthcare practitioners, ___ products are made to the industry’s most exacting standards ... we firmly stand behind these products and have seen amazing results in many of our patients.”

Links

In addition to directly selling products, eleven websites (19.6%) provided links to various product sites (Table 2). For ten sites, the links appeared to be independent of the chiropractic practice. In one case, the linked site indicated on the product order form that the chiropractor was the “referring representative.”

Table 2.

Products websites linked to chiropractic websites

Link	Practices N (%)
vitamins/nutritional supplements	9 (16.1%)
exercise/rehabilitation products	3 (5.4%)
Orthotics	3 (5.4%)
ergonomic products	2 (3.6%)
misc (e.g., pillows/supports, hot/cold packs, massage oil/creams, herbals, aromatherapy, baby products)	3 (5.4%)

Some sites offered explicit product testomonials:

“The following products are used and recommended by our expert staff.”

“One of the best nutritional supplements I have come across”

Fees and inducements

Twenty-nine (51.8%) websites provided some information about the practice’s fee structure. Seventeen (30.4%) provided specific fee information (e.g., cost per visit, first visit and subsequent visits, costs with or without provincial coverage, regular/student/senior rates) while twelve practices (21.4%) gave general information on fees without providing explicit amounts.

Several practices (N = 10: 17.9%) offered inducements to potential customers. In addition to the previously described orthotics special (N = 1; 1.8%), three (5.4%) offered complimentary gait/posture scans, two (3.6 %) offered free general consulations, two offered prepayment/discount payment packages, one (1.8%) offered a monthly product service special and one (1.8%) offered a “Family Day” rate.

Discussion

These data suggest the marketing of health products and services by chiropractors in Alberta is common. Almost two-thirds of the chiropractic websites surveyed contained information on health products for sale. Orthotics were the products most often sold, followed by pillows and supports, and vitamins/natural supplements. Moreover, a small proportion of websites offered incentives including fee discounts and complimentary services.

Chiropractors, like other health care providers, accept certain roles and relationships in society as members of a profession. The responsibilities and boundaries of these relationships are typically defined in codes of ethics and conduct.

The College of Chiropractors of Alberta follows the Canadian Chiropractic Association’s (CCA) Code of Ethics and Conduct. The CCA’s Code of Conduct states the sale of health products is permissable, with certain constraints:¹⁴

Professional Fees (Item 21): It is not unethical to dispense items providing; it does not create a conflict of interest, they serve the best interests of the patient, clinical value has been demonstrated, and the item is available at fair market price.

and:

Consultation and Examination (Item 13): The chiropractor will recommend only those diagnostic procedures deemed necessary to assist in the care of the patient, and treatment considered essential for the well-being of the patient.

Conflict of interest and professionalism

In this context, conflict of interest occurs when professional judgement about patient care is unduly influenced by the potential for financial gain.^15,16 The CCA’s code of conduct offers no prohibition against chiropractors selling health products to their patients, providing there is no conflict of interest. Consistent with the foregoing definition, conflict of interest arises when practitioners’ interests in practice revenue exceed their interest in patient well-being.

On a patient-by-patient basis, it seems unlikely that chiropractors would be unduly influenced by the potential for profits generated by the sale of individual health products. Rather, the potential becomes significant within an overall practice philosophy. The potential for financial conflict of interest to arise is made obvious by trade publications encouraging chiropractors to “Help patients, add income with nutritional therapy”¹⁷ and “Increase revenue by $200K with nutritional and posture analysis”.¹⁸ Another article entitled “Liquid vitamins: the wave of the future” had as its subtitle “This doctor’s income doubled the first year of selling liquid nutritional products through his office. These are his secrets for success”.¹⁹ Although the focus of these publications is on nutritional supplements, the potential for profit generation extends to all manner of health products sold.

In contrast to the CCA’s code, Nelson and colleagues (2005) believe that professional ethics in health care are simply incompatible with the ethics of ‘mercantilism,’ though the chiropractic practice is a business. Whereas professional ethics dictate the interests of the patient should be primary and recognize that patients place their trust in the professional, Nelson et al.’s view of mercantilism demands that financial interests prevail and that the buyer should beware.²⁰

Serve best interest of patient/clinical value demonstrated

Patients’ best interests can be defined by their rights to receive respectful, effective care that does not compromise them physically, psychologically or financially. Patients’ best interests cannot be served by the sale of products for which safety and efficacy data remain inconclusive, which describes a significant proportion of natural health products^21,22,23 and a number of other devices and products as well. The CCA’s statement recognizes this in part, indicating that, “clinical value be demonstrated.” However determination of “clinical value” is more ambiguously defined and less rigorous with regard to safety and efficacy demonstration than is a clear body of scientific evidence. Promoting or retailing products lacking an established evidence base can potentially discredit the profession and reinforce the perception by some that it is fringe medicine. Retailing of products that are only tangentially related to health and well-being such as bath/ skin care products or laundry disks, is harder to justify as either in patients’ best interests or essential for the well-being of the patient.

Patients’ best interests also require that their use of health products be fully informed, that they be advised of their risks and benefits, and that they take/use the products appropriately. Although all of the marketed products are available without a prescription and are over-the-counter products and devices, it is a reasonable expectation that health care professionals selling the products bear some fiduciary duty to advise patients on product use. This is not likely the case with products purchased online. Online sales may represent a significant proportion of consumers – as described by one practitioner “half of the people purchasing the product are not even my clients”.¹⁹

The other side of this argument is that chiropractors should sell products as part of their practices because, assuming they have expertise in the product area, they are in a position to properly advise patients who could otherwise pick these products up at the local mall. A recent survey indicates however that chiropractors themselves believe they do not have the necessary expertise to provide such information in some areas.²⁴ Considering nutritional counselling specifically, 90% of responding chiropractors provided nutritional counselling to their patients even though the majority believed they were inadequately trained in nutrition. The BC College of Chiropractors in Canada has restricted the extent to which chiropractors can engage in nutritional counselling in apparent recognition of professional limitations in this area of expertise.²⁵

From the public’s perspective, deviation from what is perceived to chiropractic’s area of expertise (i.e., spine care) has the potential to erode the perceived legitimacy of the profession and diminish the public’s trust.²⁰

Fees and inducements

The CCA’s recommended guideline concerning the provision of free services states:²⁶

It is unprofessional and inappropriate to advertise free services such as consultation/examination procedures, diagnostics or treatment (Clinical practice guidelines, item G, 17.11)

Nevertheless, such inducements were observed on some of the websites surveyed (N = 5; 8.9%). This raises the possibilities that some members of the profession are unaware of these guidelines, may not view such offers as inappropriate or simply choose to ignore them. In addition to such offers contravening professional standards, they may meet with public disapproval as well. As indicated by the OCA survey, a small proportion of the public perceive such marketing practices as unprofessional to the extent that it would deter them from seeking care form such professionals.¹¹

Codes in other Provinces

As previously stated, the College of Chiropractors of Alberta follows the guidance documents of the Canadian Chiropractic Association with respect to Codes of Ethics and Conduct, and as illustrated, these documents are permissive with respect to the sale of health products. Chiropractic associations in other provinces are more restrictive in their own codes of ethics and conduct.

The Code of the Ontario Chiropractic Association offers a detailed guideline, explicitly stating that product sales are a potential conflict of interest and that conflict is realized when the “purchase price to the patient does not have a reasonable relationship to the handling and overhead expenses of supplying the product.” The association attempts to minimize the potential for conflicts to arise by setting out a recommended fee schedule.²⁷ The code developed by the British Columbia College of Chiropractors goes further and explicitly prohibits the sale of vitamins and food supplements. In addition, the College prohibits chiropractors from receiving financial remuneration or other benefit from the supply or distribution of any vitamins or food supplements.²⁸

Conclusion

The variation in practice standards across provinces suggests that the profession itself is grappling with the ethics of retailing, as other professions have done.²⁹ In questioning fellow dentists about their views on retailing, Saunders reports that most were adamant in their belief that dental offices should not retail any products. Criticisms included that it was unethical, may alienate patients, and that dentists should sell service, not products. Conversely, some believed that providing products for sale may provide accessibility and convenience to patients, enhance patient compliance with treatments, and generate revenue. Similar arguments could be made on either side for retailing in chiropractic. Future research should focus on addressing in greater detail the perspectives and practices of both chiropractors and consumers on the retailing of health products.

This study looked at a sample of chiropractic practices in the province of Alberta, Canada that had developed and advertised websites. It is not a representative sample and the generalizability of the results is limited. The web-site review might not have captured all products sold in the practice and therefore the extent of sales here is likely an underestimate.