SB762: Bill Text

The bill requires primary spinal care practitioners to maintain specific levels of malpractice liability insurance coverage and establishes various requirements with respect to fee splitting and billing for services. Those malpractice insurance, fee splitting, and billing requirements, as well as other requirements in the bill, are substantially similar to the requirements for podiatrists under current law.

The bill also treats primary spinal care practitioners similar to chiropractors in some respects. For example, the bill requires primary spinal care practitioners to refer a patient to a physician if the primary spinal care practitioner determines that the patient's condition is beyond the scope of the practice of spinal medicine. Also, the bill includes insurance coverage parity requirements that closely track the coverage requirements for treatment provided by chiropractors.

The bill requires the affiliated credentialing board and the Chiropractic Examining Board each to refer to the other board for investigation an allegation of a violation by a primary spinal care practitioner of the laws administered by that other board. If the alleged conduct involves a violation both of the laws applicable to primary spinal care practitioners and of the laws applicable to chiropractors, the bill requires the two boards to consult concerning the investigation of that alleged conduct. Otherwise, the affiliated credentialing board's authority to investigate misconduct and discipline licensed primary spinal care practitioners is typical of that for other similar boards, especially the Podiatry Affiliated Credentialing Board.

For further information see the state and local fiscal estimate, which will be printed as an appendix to this bill.

The people of the state of Wisconsin, represented in senate and assembly, do enact as follows:

SB762,1 Section 1. 15.085 (1m) (b) of the statutes is amended to read:

SB762,4,5 15.085 (1m) (b) The public members of the podiatry affiliated credentialing board, spinal medicine affiliated credentialing board, or occupational therapists affiliated credentialing board shall not be engaged in any profession or occupation concerned with the delivery of physical or mental health care.

SB762,2 Section 2. 15.406 (4) (a) of the statutes is amended to read:

SB762,4,10 15.406 (4) (a) Four athletic trainers who are licensed under subch. VI of ch. 448 and who have not been issued a credential in athletic training by a governmental authority in a jurisdiction outside this state. One of the athletic trainer members may also be licensed under ch. 446 or 447 or subch. II, III or, IV, or VIII of ch. 448.

SB762,3 Section 3. 15.406 (7) of the statutes is created to read:

SB762,4,15 15.406 (7) Spinal medicine affiliated credentialing board. There is created in the department of safety and professional services, attached to the medical examining board, a spinal medicine affiliated credentialing board consisting of the following members appointed for 4-year terms:

SB762,4,17 (a) Three primary spinal care practitioners who are licensed under subch. VIII of ch. 448.

SB762,4,18 (b) A physician, as defined in s. 448.01 (5).

SB762,4,19 (c) One public member.

SB762,4 Section 4. 29.193 (1m) (a) 2. (intro.) of the statutes, as affected by 2015 Wisconsin Act 97, is amended to read:

SB762,5,5 29.193 (1m) (a) 2. (intro.) Has a permanent substantial loss of function in one or both arms or one or both hands and fails to meet the minimum standards of any one of the following standard tests, administered under the direction of a licensed physician, a licensed physician assistant, a licensed primary spinal care practitioner, a licensed chiropractor, or a certified advanced practice nurse prescriber:

SB762,5 Section 5. 29.193 (2) (b) 2. of the statutes, as affected by 2015 Wisconsin Act 97, is amended to read:

SB762,5,14 29.193 (2) (b) 2. An applicant shall submit an application on a form prepared and furnished by the department, which shall include a written statement or report prepared and signed by a licensed physician, a licensed physician assistant, a licensed chiropractor, a licensed podiatrist, a licensed primary spinal care practitioner, or a certified advanced practice nurse prescriber prepared no more than 6 months preceding the application and verifying that the applicant is physically disabled.

SB762,6 Section 6. 29.193 (2) (c) 3. of the statutes, as affected by 2015 Wisconsin Act 97, is amended to read:

SB762,6,3 29.193 (2) (c) 3. The department may issue a Class B permit to an applicant who is ineligible for a permit under subd. 1., 2. or 2m. or who is denied a permit under subd. 1., 2. or 2m. if, upon review and after considering the physical condition of the applicant and the recommendation of a licensed physician, a licensed physician assistant, a licensed chiropractor, a licensed podiatrist, a licensed primary spinal care practitioner, or a certified advanced practice nurse prescriber selected by the applicant from a list of licensed physicians, licensed physician assistants, licensed chiropractors, licensed podiatrists, licensed primary spinal care practitioners, and certified advanced practice nurse prescribers compiled by the department, the department finds that issuance of a permit complies with the intent of this subsection. The use of this review procedure is discretionary with the department and all costs of the review procedure shall be paid by the applicant.

SB762,7 Section 7. 29.193 (2) (cd) 2. b. of the statutes, as affected by 2015 Wisconsin Act 97, is amended to read:

SB762,6,11 29.193 (2) (cd) 2. b. The person has a permanent substantial loss of function in one or both arms and fails to meet the minimum standards of the standard upper extremity pinch test, the standard grip test, or the standard nine-hole peg test, administered under the direction of a licensed physician, a licensed primary spinal care practitioner, a licensed physician assistant, a licensed chiropractor, or a certified advanced practice nurse prescriber.

SB762,8 Section 8. 29.193 (2) (cd) 2. c. of the statutes, as affected by 2015 Wisconsin Act 97, is amended to read:

SB762,6,18 29.193 (2) (cd) 2. c. The person has a permanent substantial loss of function in one or both shoulders and fails to meet the minimum standards of the standard shoulder strength test, administered under the direction of a licensed physician, a licensed primary spinal care practitioner, a licensed physician assistant, a licensed chiropractor, or a certified advanced practice nurse prescriber.

SB762,9 Section 9. 29.193 (2) (e) of the statutes, as affected by 2015 Wisconsin Act 97, is amended to read:

SB762,7,5 29.193 (2) (e) Review of decisions. An applicant denied a permit under this subsection, except a permit under par. (c) 3., may obtain a review of that decision by a licensed physician, a licensed physician assistant, a licensed chiropractor, a licensed podiatrist, a licensed primary spinal care practitioner, or a certified advanced practice nurse prescriber designated by the department and with an office located in the department district in which the applicant resides. The department shall pay for the cost of a review under this paragraph unless the denied application on its face fails to meet the standards set forth in par. (c) 1. or 2. A review under this paragraph is the only method of review of a decision to deny a permit under this subsection and is not subject to further review under ch. 227.

SB762,10 Section 10. 45.40 (1g) (a) of the statutes is amended to read:

SB762,7,11 45.40 (1g) (a) "Health care provider" means an advanced practice nurse prescriber certified under s. 441.16 (2), an audiologist licensed under ch. 459, a dentist licensed under ch. 447, an optometrist licensed under ch. 449, a physician licensed under s. 448.02, or a podiatrist licensed under s. 448.63, or a primary spinal care practitioner licensed under s. 448.9725.

SB762,11 Section 11. 48.981 (2) (a) 6m. of the statutes is created to read:

SB762,7,13 48.981 (2) (a) 6m. A primary spinal care practitioner.

SB762,12 Section 12. 49.45 (9) of the statutes is amended to read:

SB762,8,16 49.45 (9) Free choice. Any person eligible for medical assistance under s. 49.46, 49.468, 49.47, or 49.471 may use the physician, chiropractor, dentist, pharmacist, podiatrist, primary spinal care practitioner, hospital, skilled nursing home, health maintenance organization, limited service health organization, preferred provider plan or other licensed, registered or certified provider of health care of his or her choice, except that free choice of a provider may be limited by the department if the department's alternate arrangements are economical and the recipient has reasonable access to health care of adequate quality. The department may also require a recipient to designate, in any or all categories of health care providers, a primary health care provider of his or her choice. After such a designation is made, the recipient may not receive services from other health care providers in the same category as the primary health care provider unless such service is rendered in an emergency or through written referral by the primary health care provider. Alternate designations by the recipient may be made in accordance with guidelines established by the department. Nothing in this subsection shall vitiate the legal responsibility of the physician, chiropractor, dentist, pharmacist, podiatrist, primary spinal care practitioner, skilled nursing home, hospital, health maintenance organization, limited service health organization, preferred provider plan or other licensed, registered or certified provider of health care to patients. All contract and tort relationships with patients shall remain, notwithstanding a written referral under this section, as though dealings are direct between the physician, chiropractor, dentist, pharmacist, podiatrist, primary spinal care practitioner, skilled nursing home, hospital, health maintenance organization, limited service health organization, preferred provider plan or other licensed, registered or certified provider of health care and the patient. No physician, chiropractor, pharmacist, podiatrist, primary spinal care practitioner, or dentist may be required to practice exclusively in the medical assistance program.

SB762,13 Section 13. 49.46 (2) (b) 11m. of the statutes is created to read:

SB762,8,18 49.46 (2) (b) 11m. The services of primary spinal care practitioners.

SB762,14 Section 14. 50.36 (3) (a) of the statutes is amended to read:

SB762,9,3 50.36 (3) (a) Any person licensed to practice medicine and surgery under subch. II of ch. 448 or, podiatry under subch. IV of ch. 448, or spinal medicine under subch. VIII of ch. 448 shall be afforded an equal opportunity to obtain hospital staff privileges and may not be denied hospital staff privileges solely for the reason that the person is an osteopathic physician and surgeon or , a podiatrist, or a primary spinal care practitioner. Each individual hospital shall retain the right to determine whether the applicant's training, experience and demonstrated competence is sufficient to justify the granting of hospital staff privileges or is sufficient to justify the granting of limited hospital staff privileges.

SB762,15 Section 15. 50.36 (3) (b) of the statutes is amended to read:

SB762,9,13 50.36 (3) (b) If, as a result of peer investigation or written notice thereof, a hospital staff member who is licensed by the medical examining board or, podiatry affiliated credentialing board, or spinal medicine affiliated credentialing board, for any reasons that include the quality of or ability to practice, loses his or her hospital staff privileges, has his or her hospital staff privileges reduced or resigns from the hospital staff, the hospital shall so notify the medical examining board or, podiatry affiliated credentialing board, or spinal medicine affiliated credentialing board, whichever is applicable, within 30 days after the loss, reduction or resignation takes effect. Temporary suspension due to incomplete records need not be reported.

SB762,16 Section 16. 50.36 (3) (c) of the statutes is amended to read:

SB762,9,24 50.36 (3) (c) If, as a result of peer investigation or written notice thereof, a hospital staff member who is licensed by the medical examining board or, podiatry affiliated credentialing board, or spinal medicine affiliated credentialing board, for reasons that do not include the quality of or ability to practice, loses his or her hospital staff privileges for 30 days or more, has his or her hospital staff privileges reduced for 30 days or more or resigns from the hospital staff for 30 days or more, the hospital shall so notify the medical examining board or , podiatry affiliated credentialing board, or spinal medicine affiliated credentialing board, whichever is applicable, within 30 days after the loss, reduction or resignation takes effect. Temporary suspension due to incomplete records need not be reported.

SB762,17 Section 17. 50.39 (3) of the statutes is amended to read:

SB762,10,10 50.39 (3) Facilities governed by ss. 45.50, 48.62, 49.70, 49.72, 50.02, 51.09, and 252.10, juvenile correctional facilities as defined in s. 938.02 (10p), correctional institutions governed by the department of corrections under s. 301.02, and the offices and clinics of persons licensed to treat the sick under chs. 446, 447, and 448 are exempt from ss. 50.32 to 50.39. Sections 50.32 to 50.39 do not abridge the rights of the medical examining board, physical therapy examining board, podiatry affiliated credentialing board, spinal medicine affiliated credentialing board, dentistry examining board, pharmacy examining board, chiropractic examining board, and board of nursing in carrying out their statutory duties and responsibilities.

SB762,18 Section 18. 77.54 (14) (b) of the statutes is amended to read:

SB762,10,14 77.54 (14) (b) Furnished by a licensed physician, surgeon, podiatrist, primary spinal care practitioner, or dentist to a patient who is a human being for treatment of the patient.

SB762,19 Section 19. 77.54 (14) (c) of the statutes is amended to read:

SB762,10,18 77.54 (14) (c) Furnished by a hospital for treatment of any person pursuant to the order of a licensed physician, surgeon, podiatrist, primary spinal care practitioner, or dentist.

SB762,20 Section 20. 77.54 (14) (d) of the statutes is amended to read:

SB762,10,21 77.54 (14) (d) Sold to a licensed physician, surgeon, podiatrist, primary spinal care practitioner, dentist, or hospital for the treatment of a human being.

SB762,21 Section 21. 77.54 (14) (f) 7. of the statutes is amended to read:

SB762,10,23 77.54 (14) (f) 7. A podiatrist who is licensed under subch. IV of ch. 448.

SB762,22 Section 22. 77.54 (14) (f) 7m. of the statutes is created to read:

SB762,11,2 77.54 (14) (f) 7m. A primary spinal care practitioner licensed under subch. VIII of ch. 448.

SB762,23 Section 23. 102.13 (1) (a) of the statutes is amended to read:

SB762,11,16 102.13 (1) (a) Except as provided in sub. (4), whenever compensation is claimed by an employee, the employee shall, upon the written request of the employee's employer or worker's compensation insurer, submit to reasonable examinations by physicians, chiropractors, psychologists, dentists, physician assistants, advanced practice nurse prescribers, or podiatrists, or primary spinal care practitioners provided and paid for by the employer or insurer. No employee who submits to an examination under this paragraph is a patient of the examining physician, chiropractor, psychologist, dentist, physician assistant, advanced practice nurse prescriber, or podiatrist, or primary spinal care practitioner for any purpose other than for the purpose of bringing an action under ch. 655, unless the employee specifically requests treatment from that physician, chiropractor, psychologist, dentist, physician assistant, advanced practice nurse prescriber, or podiatrist, or primary spinal care practitioner.

SB762,24 Section 24. 102.13 (1) (b) (intro.) of the statutes is amended to read:

SB762,12,7 102.13 (1) (b) (intro.) An employer or insurer who requests that an employee submit to reasonable examination under par. (a) or (am) shall tender to the employee, before the examination, all necessary expenses including transportation expenses. The employee is entitled to have a physician, chiropractor, psychologist, dentist, physician assistant, advanced practice nurse prescriber, or podiatrist, or primary spinal care practitioner provided by himself or herself present at the examination and to receive a copy of all reports of the examination that are prepared by the examining physician, chiropractor, psychologist, podiatrist, primary spinal care practitioner, dentist, physician assistant, advanced practice nurse prescriber, or vocational expert immediately upon receipt of those reports by the employer or worker's compensation insurer. The employee is also entitled to have a translator provided by himself or herself present at the examination if the employee has difficulty speaking or understanding the English language. The employer's or insurer's written request for examination shall notify the employee of all of the following:

SB762,25 Section 25. 102.13 (1) (b) 1. of the statutes is amended to read:

SB762,12,12 102.13 (1) (b) 1. The proposed date, time, and place of the examination and the identity and area of specialization of the examining physician, chiropractor, psychologist, dentist, podiatrist, primary spinal care practitioner, physician assistant, advanced practice nurse prescriber, or vocational expert.

SB762,26 Section 26. 102.13 (1) (b) 3. of the statutes is amended to read:

SB762,12,16 102.13 (1) (b) 3. The employee's right to have his or her physician, chiropractor, psychologist, dentist, physician assistant, advanced practice nurse prescriber, or podiatrist, or primary spinal care practitioner present at the examination.

SB762,27 Section 27. 102.13 (1) (b) 4. of the statutes is amended to read:

SB762,12,22 102.13 (1) (b) 4. The employee's right to receive a copy of all reports of the examination that are prepared by the examining physician, chiropractor, psychologist, dentist, podiatrist, primary spinal care practitioner, physician assistant, advanced practice nurse prescriber, or vocational expert immediately upon receipt of these reports by the employer or worker's compensation insurer.

SB762,28 Section 28. 102.13 (1) (d) 1. of the statutes is amended to read:

SB762,13,2 102.13 (1) (d) 1. Any physician, chiropractor, psychologist, dentist, podiatrist, primary spinal care practitioner, physician assistant, advanced practice nurse prescriber, or vocational expert who is present at any examination under par. (a) or (am) may be required to testify as to the results of the examination.

SB762,29 Section 29. 102.13 (1) (d) 2. of the statutes, as affected by 2015 Wisconsin Act 55, is amended to read:

SB762,13,10 102.13 (1) (d) 2. Any physician, chiropractor, psychologist, dentist, physician assistant, advanced practice nurse prescriber, or podiatrist, or primary spinal care practitioner who attended a worker's compensation claimant for any condition or complaint reasonably related to the condition for which the claimant claims compensation may be required to testify before the division when the division so directs.

SB762,30 Section 30. 102.13 (1) (d) 3. of the statutes, as affected by 2015 Wisconsin Act 55, is amended to read:

SB762,13,19 102.13 (1) (d) 3. Notwithstanding any statutory provisions except par. (e), any physician, chiropractor, psychologist, dentist, physician assistant, advanced practice nurse prescriber, or podiatrist, or primary spinal care practitioner attending a worker's compensation claimant for any condition or complaint reasonably related to the condition for which the claimant claims compensation may furnish to the employee, employer, worker's compensation insurer, department, or division information and reports relative to a compensation claim.

SB762,31 Section 31. 102.13 (1) (d) 4. of the statutes is amended to read:

SB762,13,25 102.13 (1) (d) 4. The testimony of any physician, chiropractor, psychologist, dentist, physician assistant, advanced practice nurse prescriber, or podiatrist, or primary spinal care practitioner who is licensed to practice where he or she resides or practices in any state and the testimony of any vocational expert may be received in evidence in compensation proceedings.

SB762,32 Section 32. 102.13 (2) (a) of the statutes, as affected by 2015 Wisconsin Act 55, is amended to read:

SB762,14,13 102.13 (2) (a) An employee who reports an injury alleged to be work-related or files an application for hearing waives any physician-patient, psychologist-patient, or chiropractor-patient privilege with respect to any condition or complaint reasonably related to the condition for which the employee claims compensation. Notwithstanding ss. 51.30 and 146.82 and any other law, any physician, chiropractor, psychologist, dentist, podiatrist, primary spinal care practitioner, physician assistant, advanced practice nurse prescriber, hospital, or health care provider shall, within a reasonable time after written request by the employee, employer, worker's compensation insurer, department, or division, or its representative, provide that person with any information or written material reasonably related to any injury for which the employee claims compensation.

SB762,33 Section 33. 102.13 (2) (b) of the statutes is amended to read:

SB762,14,24 102.13 (2) (b) A physician, chiropractor, podiatrist, primary spinal care practitioner, psychologist, dentist, physician assistant, advanced practice nurse prescriber, hospital, or health service provider shall furnish a legible, certified duplicate of the written material requested under par. (a) upon payment of the actual costs of preparing the certified duplicate, not to exceed the greater of 45 cents per page or $7.50 per request, plus the actual costs of postage. Any person who refuses to provide certified duplicates of written material in the person's custody that is requested under par. (a) shall be liable for reasonable and necessary costs and, notwithstanding s. 814.04 (1), reasonable attorney fees incurred in enforcing the requester's right to the duplicates under par. (a).

SB762,34 Section 34. 102.13 (3) of the statutes, as affected by 2015 Wisconsin Act 55, is amended to read:

SB762,15,16 102.13 (3) If 2 or more physicians, chiropractors, psychologists, dentists, or podiatrists, or primary spinal care practitioners disagree as to the extent of an injured employee's temporary disability, the end of an employee's healing period, an employee's ability to return to work at suitable available employment or the necessity for further treatment or for a particular type of treatment, the department or the division may appoint another physician, chiropractor, psychologist, dentist, or podiatrist, or primary spinal care practitioner to examine the employee and render an opinion as soon as possible. The department or the division shall promptly notify the parties of this appointment. If the employee has not returned to work, payment for temporary disability shall continue until the department or the division receives the opinion. The employer or its insurance carrier, or both, shall pay for the examination and opinion. The employer or insurance carrier, or both, shall receive appropriate credit for any overpayment to the employee determined by the department or the division after receipt of the opinion.

SB762,35 Section 35. 102.16 (3) of the statutes is amended to read:

SB762,16,2 102.16 (3) No employer subject to this chapter may solicit, receive, or collect any money from an employee or any other person or make any deduction from their wages, either directly or indirectly, for the purpose of discharging any liability under this chapter or recovering premiums paid on a contract described under s. 102.31 (1) (a) or a policy described under s. 102.315 (3), (4), or (5) (a); nor may any employer subject to this chapter sell to an employee or other person, or solicit or require the employee or other person to purchase, medical, chiropractic, podiatric, spinal medicine, as defined in s. 448.971 (5), psychological, dental, or hospital tickets or contracts for medical, surgical, hospital, or other health care treatment that is required to be furnished by that employer.

SB762,36 Section 36. 102.17 (1) (d) 1. of the statutes, as affected by 2015 Wisconsin Act 55, is amended to read:

SB762,17,2 102.17 (1) (d) 1. The contents of certified medical and surgical reports by physicians, podiatrists, primary spinal care practitioners, surgeons, dentists, psychologists, physician assistants, advanced practice nurse prescribers, and chiropractors licensed in and practicing in this state, and of certified reports by experts concerning loss of earning capacity under s. 102.44 (2) and (3), presented by a party for compensation constitute prima facie evidence as to the matter contained in those reports, subject to any rules and limitations the division prescribes. Certified reports of physicians, podiatrists, primary spinal care practitioners, surgeons, dentists, psychologists, physician assistants, advanced practice nurse prescribers, and chiropractors, wherever licensed and practicing, who have examined or treated the claimant, and of experts, if the practitioner or expert consents to being subjected to cross-examination, also constitute prima facie evidence as to the matter contained in those reports. Certified reports of physicians, podiatrists, primary spinal care practitioners, surgeons, psychologists, and chiropractors are admissible as evidence of the diagnosis, necessity of the treatment, and cause and extent of the disability. Certified reports by doctors of dentistry, physician assistants, and advanced practice nurse prescribers are admissible as evidence of the diagnosis and necessity of treatment but not of the cause and extent of disability. Any physician, podiatrist, primary spinal care practitioner, surgeon, dentist, psychologist, chiropractor, physician assistant, advanced practice nurse prescriber, or expert who knowingly makes a false statement of fact or opinion in a certified report may be fined or imprisoned, or both, under s. 943.395.

SB762,37 Section 37. 102.17 (1) (d) 2. of the statutes, as affected by 2015 Wisconsin Act 55, is amended to read:

SB762,17,13 102.17 (1) (d) 2. The record of a hospital or sanatorium in this state that is satisfactory to the division, established by certificate, affidavit, or testimony of the supervising officer of the hospital or sanitorium, any other person having charge of the record, or a physician, podiatrist, primary spinal care practitioner, surgeon, dentist, psychologist, physician assistant, advanced practice nurse prescriber, or chiropractor to be the record of the patient in question, and made in the regular course of examination or treatment of the patient, constitutes prima facie evidence as to the matter contained in the record, to the extent that the record is otherwise competent and relevant.

SB762,38 Section 38. 102.17 (1) (e) of the statutes, as affected by 2015 Wisconsin Act 55, is amended to read:

SB762,17,24 102.17 (1) (e) The division may, with or without notice to any party, cause testimony to be taken, an inspection of the premises where the injury occurred to be made, or the time books and payrolls of the employer to be examined by any examiner, and may direct any employee claiming compensation to be examined by a physician, chiropractor, psychologist, dentist, or podiatrist, or primary spinal care practitioner. The testimony so taken, and the results of any such inspection or examination, shall be reported to the division for its consideration upon final hearing. All ex parte testimony taken by the division shall be reduced to writing, and any party shall have opportunity to rebut that testimony on final hearing.

SB762,39 Section 39. 102.17 (1) (g) of the statutes, as affected by 2015 Wisconsin Act 55, is amended to read:

SB762,18,15 102.17 (1) (g) Whenever the testimony presented at any hearing indicates a dispute or creates a doubt as to the extent or cause of disability or death, the division may direct that the injured employee be examined, that an autopsy be performed, or that an opinion be obtained without examination or autopsy, by or from an impartial, competent physician, chiropractor, dentist, psychologist or, podiatrist, or primary spinal care practitioner designated by the division who is not under contract with or regularly employed by a compensation insurance carrier or self-insured employer. The expense of the examination, autopsy, or opinion shall be paid by the employer or, if the employee claims compensation under s. 102.81, from the uninsured employers fund. The report of the examination, autopsy, or opinion shall be transmitted in writing to the division and a copy of the report shall be furnished by the division to each party, who shall have an opportunity to rebut the report on further hearing.

SB762,40 Section 40. 102.29 (3) of the statutes is amended to read:

SB762,18,21 102.29 (3) Nothing in this chapter shall prevent an employee from taking the compensation that the employee may be entitled to under this chapter and also maintaining a civil action against any physician, chiropractor, psychologist, dentist, physician assistant, advanced practice nurse prescriber, or podiatrist, or primary spinal care practitioner for malpractice.