Issue Four: Newt Gingrich's "Contract with America"
The "Contract with America" has in its text an item that will be debated again in Washington: the balanced budget amendment proposal.
Newt Gingrich (R-GA) did pledge his support for chiropractic to Sid Williams.15 But is he willing to pledge that support financially at the cost to the taxpayer in accordance with his "Contract with America"? There are no friends in Washington. President Truman once said, "If you want a friend in this town, get a dog."
Issue Five: State Governments Reaction to Defaults
State governments are starting to take this default rate into their own hands. On September 21, 1991, the Texas legislature enacted Section 57-491 of the Texas Education Code. It states:
"Holders of profession/occupational licenses in Texas who are identified as student loan defaulters on guaranteed student loans guaranteed by the Texas Guarantee Student Loan Corporation (TGSLC) will not be eligible for license renewal until they have entered into repayment agreements with TGSLC."16This single piece of legislation should have been seen as an early warning sign for the profession. What this law means to chiropractic is that situations such as "Acts of God" which can cause loss to a practice from natural disasters or other financial concerns could hurt an individual practitioner. Young chiropractors who struggle (they usually do) early on in their practice and default, won't be able to practice. If you can't practice, you can't pay your debts. Then the default dollars will stay on the credit report sheets. Then the chiropractor has to incur additional expense trying to set up and establish in another state.
Issue Six: What Does this Government Lingo Mean?
A high default rate in chiropractic leaves this profession vulnerable. But how are we vulnerable to government budget cutters when we have supposedly made such great strides? The formula is simple. The profession is not united; with fundamentally and internally diametrically opposed groups, and so many independent, internal, special-interest groups saying they are the voice of chiropractic, government officials in the melee of confusion could use that against us.
The AMA and AOA lobby could use the argument that chiropractic, using the out-dated straight vs. mixer argument that has proliferated and downtrodden the profession, is not worthy of government finances to continue education. One recommendation that has to be done is that the chiropractic schools are going to have to conduct the studies and understand the default rate of all chiropractic borrowers. It must also understand the effect of loan debt on all practicing chiropractors. But by the time studies are launched, interpreted, published and utilized it could be too late. The collective head of the chiropractic education loan program could be on the government budget-cutters butcher block. It could appear that the only government agencies to embrace chiropractic will be the United Federation of Planets and Star Fleet. It is true that the Agency for Health Care Policy and Research (AHCPR) did give a favorable response to chiropractic. But will this agency have any influence on what the Office of Management and Budget (OMB) dictates?
Issue Seven: Primary Care Providers Negative View of Chiropractic
The economics of private practice are not just affecting the new chiropractors, but changes in the insurance industry are affecting established practitioners too. Under a growing majority of insurance plans MDs and DOs are the primary care providers (PCP) or gatekeeper. What the PCP is able to do is to direct the patient where the patient "should go" to for referral-related services. Patients under the PCP program do have chiropractic benefits, but the PCP has the theoretical right to refer to where he/she feels is appropriate. Most of the time the PCP refers the patient to physical therapy. Patients do end up going where services will be covered.
In a quest to understand the "why" of MDs' thinking, I submitted a question to the local newspaper's "Health Line." My question referred to what reasons my medical doctor might have for not referring me to a chiropractor. The columnist/MDs response was this:
"Your medical doctor will make an assessment of your back pain and prescribe what he/she feels is appropriate in relation to the case. But the recommendation will be what is considered in your best interest."17But the next statement may give some insight to what the current thinking may be to justify hidden discriminations.
"On the other hand, chiropractic is defined in the Webster's Dictionary as 'a therapeutic system based on the premise that disease is caused by interference of nerve function the method being to restore normal condition by adjusting the segments of the spinal column.' I would be very much surprised if any physician would subscribe to that theory given the broad base of scientific knowledge to the contrary."17Could the philosophy of chiropractic be undermining our economics? Dr. James Winterstein, president of National College states:
"... the very philosophy which today I believe should be dismantled in favor of a true philosophy that can propel us far into the next century and convert us from a fringe profession into a widely accepted and recognized profession."18Louis Sportelli, DC supports this change that millions of people could read:
"I urged ACA to consider a project to change the definition of chiropractic in all the dictionaries and encyclopedias (a major project, but certainly one which will reap large rewards in the future.)"19Chiropractic teaching and practice must adhere to a legally sound, legally defensible scope of practice.20 But it also must include a philosophy that is clinically sound. To be clinically sound is to be legally sensible and defensible.
The current philosophy of chiropractic, as described in Webster's and Stephenson's texts, is neither clinically sound nor legally defensible. In Semlow and Murkowski's Associated Practice Liability Consultants textbook, they suggest not to discuss chiropractic philosophy in court for malpractice, workmans' compensation cases, or personal injury cases.21 If you can't use it in court what purpose does it serve?
It might be a wise idea to look over the "Nerve Chart of Spinal Misalignments" of conditions. Of the conditions listed, it needs to be decided which conditions can be defended in a court of law utilizing objective clinical research to support such claims. Or do we base our entire paradigm of the concept of "therapeutic supposition?" This philosophy may in the future have detrimental effects on our economics.
Issue Eight: Chiropractic Education
Another aspect that could possibly be creating economic problems may lie in our education system itself.
Did the inclusion of chiropractic in the various financial aid programs contribute to escalating tuitions?22 In 1983, the average cost for a chiropractic education was $12,000; today the cost is in excess of $72,000. Has the rate of inflation for the past 12 years been 600 percent?
Terry Rondberg, DC, president of the World Chiropractic Alliance, points out:
"We need to start at the college level by being honest with potential students. We must not underestimate the financial burden our education causes. We must not push loans and other monetary aid without stressing payment responsibility and warning people of possible financial risks."23But the recruitment of students creates a problem. Dr. Carl Cleveland of Cleveland-Kansas City states:
"Here is a career that offers you financial security, a sense of achievement, the personal freedom to set your own schedule. The simple truth is, there has never been a better time to become a Doctor of Chiropractic."24Issue Nine: Chiropractic Job Market
Today's chiropractic student is being led down a "primrose path" without a glimmer of the realities of obtaining gainful employment as a chiropractor.25 There is one reality that must be realized by the chiropractic profession. There is NO job market. There are only three things you can do in chiropractic. You can teach at a chiropractic college, become an associate, or set up your own practice. How many job offerings are there in the want ads that are looking to fill the position of assistant director of chiropractic services at XYZ hospital? Employment opportunities that could easily be performed by the DC are denied to us for no other reason than possession of a chiropractic education.26
Chiropractic associateships are substandard to other professions. Law, medicine, dentistry, psychology, and physical therapy are structured to absorb new licentiates in ways chiropractic is not. In other professions, positions are structured to pay a respectable salary with benefits. New licentiates can get entry-level positions that don't require cash investments.27
Let's take for example a chiropractor who gets a first position as an associate. A $2,000/month salary seems reasonable, but let's break it down with today's student loan burdens factored in. A base salary of $2,000 minus your taxes equals approximately $700, leaving a net of $1300. A student loan payment of $700 leaves the new graduate with $600 to eat and sleep with. So this is what they call financial security. This person has yet to pay rent, utilities, and other survival products.
New MDs, first as interns, then as residents, immediately earn in the $20,000-30,000/year range. New MDs can work part-time and earn up to $75,000 per year. The DC does not have access to these jobs.28 But one advantage about medical doctors and their earning power and internship is that they can defer the loan while in training. Deferment means you don't pay your loans nor does the interest accumulate. Forbearance puts more time on your side, but interest accumulates.
But Terry Rondberg points out one item that needs to be clarified to chiropractors and potential chiropractors.
"If people want to make an MD's wage by doing an MD's job, then let them become MDs. If you want to make an MD's wage by doing a DC's job then let's create a bigger more lucrative market for the DCs."28Issue Ten: After the Tassel Is Moved
But the profession must look at itself for an answer to the student loan default problem. With the HEAL loan there is less than a year to have a grace period. A grace period is the time you get from graduation before you start paying back the loan. Some students won't be able to sit for their boards, due to the trimester program for a period of six months. Licensing examinations for chiropractors are often out-of-phase with graduation dates.10
The World Congress of Chiropractic Students (WCCS) in 1991 had the concern prior to the HHS Federal Register display.
"Some of us will be required to wait up to six months from our graduation dates before we can sit for board exams, thus facing loan repayment burdens before we might be licensed to practice chiropractic. This is particularly urgent in light of recent government attempts to remove or exclude chiropractic from various loan programs citing the professions high default rate in the HEAL program."29Issue Eleven: Turnover Rate
The suicide rate in chiropractic is another dimension of denial that exists in this supposedly barrier-free profession. The turnover rate for chiropractors who are leaving the field due to economic reasons is a statistic that is not kept. But the new DCs struggle on, determined either to make it or die trying. For many, "making it" will come to late or not at all. For some dying will be literal.23
Nature heals: chiropractic proves it.2 This is the only tenant of chiropractic that is true. Once you die (which is a part of nature) your student loan is forgiven and forgotten.
Issue Twelve: Employability
But the question of employability of chiropractors is debated within our own ranks. Terry Rondberg responds:
"It doesn't take much to convince the public to try chiropractic. Telling them the simple truth about how well it works can do it. Think of it, if everyone in your area believed in chiropractic as much as you do, do you think you'd have to worry about employability?" 25But this point can be argued in two ways. If the truth of chiropractic were so simple wouldn't there be more than 10 percent of the general public utilizing services? After one hundred years of chiropractic, would not the demand for chiropractic exceed supply? Also, if the public can be convinced as easily as alluded too would the default rates for the profession be at 37.2 percent of the total, and also cause a federal deficit of $78.9 million? The simple truth is that it is very difficult for the public to try to go to a chiropractor, taking into consideration all the years of bias, discrimination, a dysfunctional philosophy, and now insurance companies tactics to eliminate provider status. These new tactics just might fall under a new legal interpretation of anti-trust.
Then Terry Rondberg points out:
"We must not gloss over the difficulties and
discrimination DCs face every day of their
careers or the challenges of a health care
system gone mad."23
References
2. Parker J. Parker College of Chiropractic, Letter, June 10, 1994.
10. McAndrews, J. HEAL update: ACA says correction of inequities will allow DCs to pay up. Special Report, American Chiropractic Association, ACA/FYI, Sept/Oct 1993, p 11.
11. Gregg J. Chiropractic: A timeless science, Today's Chiropractic, (24):1, Jan/Feb 1995 p 68-72.
12. Schools facing dismissal from loan programs, Associated Press, August 24, 1993.
13. CNN: "Inside Edition," interview with Bob Dole, Jan 9, 1995.
14. Koppel T. Balanced budget amendment, "Nightline" Jan 26, 1995.
15. Gingrich pledges support for chiropractic. Chiropractic Journal, (8):9, June 1994.
16. McCormick J. Texas guaranteed student loan corporation: Letter, Jan 21, 1991.
17. Godwin P. Health line: you ask the doctor, Lawrence Journal-World, Nov. 9. 1993.
18. Winterstein J. Is traditional "chiropractic Philosophy" valid today?, Philosophical Constructs for the Chiropractic Profession, (1):1, July 1991, p 37.
19. Sportelli L. Oklahoma attorney general's opinion on Oklahoma law, Letter, Jan 10, 1994.
20. Rutherford W. A look back, a look ahead, Today's Chiropractic, (20):1, Jan/Feb 1995. p 102.
21. Semlow DG, Murkowski, KSG. Doctor's Guidebook: A Malpractice Prevention Vol. 1, p 171.
22. Wruck B. Wants national dialogue, Letter, Chiropractic Journal, (6):7, April, 1992.
23. Rondberg T. There's absolutely nothing painless about suicide: Chiropractic Journal, (6):5, Feb, 1992.
24. Cleveland C. The president's message, Educating Leaders in Chiropractic Health Care: Cleveland Chiropractic College Catalog, 1994-1995, p 5.
25. Lynn M. Widen the scope, Letter, Chiropractic Journal, (6):7, April 1992.
Rondberg T. Publishers Response to "Widen the scope," Chiropractic Journal, (6):7, April 1992.
26. O'Berence T. Limited options await new DCs, Letter, Chiropractic Journal, (6):9, June 1992.
27. Elyad L. Article on Ethics, Dynamic Chiropractic, Oct 23, 1992.
28. Blumberg L. Limited scope-limited income, Letter, Chiropractic Journal, (6):5, Feb. 1992.
Rondberg T. Publisher's Response to "Limited scope, limited income." Chiropractic Journal, (6):5, Feb, 1992.
29. Brady D. Appeal to all state board of chiropractic examiners by world congress of chiropractic students: Dynamic Chiropractic, (9):24, Nov. 22, 1991.
Timothy Mirtz, BA, DC
935 Iowa Street, Suite 2
Lawrence, KS 66049