Although some have criticized the recommendations of the VA Chiropractic Advisory Committee, since they do not recommend "pure" direct access in all cases, they have missed the bigger issue.
Our recommendations do not represent merely "getting our foot in the door," like Medicare was. Our recommendations are for full scope of practice; even more importantly, they provide four protocols under which a veteran will be able to access chiropractic care:
- "pure" direct accesses for newly discharged veterans without a referral from a PCP (primary care provider);
- by merely consulting with the PCP, which may not even require the patient be seen;
- by referral from the PCP, particularly when it is a neuromusculoskeletal complaint and the patient "prefers" chiropractic; and
- by changing the PCP to one who will refer to a doctor of chiropractic.
The most interesting part about the criticism is that it seems to be coming from those in the profession who have traditionally argued that a differential diagnosis is not necessary, and that chiropractic care should be limited to the detection and correction of subluxations. With all due respect, it doesn't work both ways.
Although some may be able to practice that way in the private sector, the VA is very different. In other words, if a doctor of chiropractic wants to be a direct-access, first-contact provider for veterans, there is an inherent, inseparable responsibility attached to that privilege. To a great extent, the "subluxation only" philosophy espoused by some chiropractic Web sites and in correspondence received by the VA made the medical members uncomfortable, and doomed any real chance we had to convince the medical members of the committee that doctors of chiropractic were qualified to serve in the important first-contact, direct-access ("gatekeeper") role.
It is important to point out a key factor about the VA. The VA is different from the private sector, where HMO medical gatekeepers have a financial disincentive to refer patients for chiropractic care. The VA employs staff physicians who are salaried, and as such, their incomes are not reduced when they refer patients for chiropractic care, rather than keep them under medical care. Therefore, the barriers patients have experienced with medical gatekeepers in the private sector are not necessarily ones those veterans will face in the VA system. Once doctors of chiropractic are in the system, with offices down the hall, earning the same salary, whether they see one patient per day or 100 patients per day, they will be utilized. I believe the doctors of chiropractic who are eventually hired into the VHA will be incredibly busy.
Those who have the most experience with the system share that opinion. One military DC sent me the following unsolicited comment:
"Having worked with military health care for 8 years at Scott AFB and now with the Navy, I can tell you we will be appreciated in the VA system, once rational DCs are allowed the opportunity to practice and interact with the medical staff. Resistance from PCMs falls away with results and communication."
For a "second opinion," here is another unsolicited comment from a military DC:
"I currently work as a chiropractor at Ireland Army Hospital in Fort Knox, KY and I have been met with nothing but respect and had no problems with getting referrals for patients. As a matter of fact, I started here in July of this year and by Sept 1 was seeing a full load of patients. Now, my new patients are booked 2 to 3 weeks out!"
Some have expressed concerns that the recommendations are similar to the current program, where chiropractic care has been available by referral through the "fee basis" system (a true "gatekeeper" model) for quite some time, yet history has shown it to be woefully underutilized. Therefore (they assert), by not ensuring "pure" direct access, it represents nothing more than what we have now. This is completely inaccurate, or - as the expression goes - "comparing apples to oranges." The reality is that the VA fee basis system has rarely been used because it added additional administrative hurdles to the referral process; the VA providers didn't know the doctors of chiropractic in the community; and it required money to be distributed to practitioners outside the system.
Under our recommendations, a PCP should refer a veteran to a doctor of chiropractic when chiropractic care is indicated and when the veteran requests it. Specifically, recommendation #9 as submitted reads, "Patients presenting with neuromusculoskeletal complaints who prefer chiropractic care as their treatment option should be referred to a doctor of chiropractic for evaluation and care." [Emphasis added] Should the PCP not refer in these instances, the VA already has provisions in place whereby the veteran may change his/her PCP.
You can be extremely proud of the committee's recommendations to Secretary Principi, and optimistic that he will accept them. If that occurs, our nation's veterans will finally be able to access the chiropractic care they need and deserve, and in the process, a new full-scope federal model will have been created.
Cynthia S. Vaughn, DC, Member,
Veterans Affairs Chiropractic Advisory Committee
Editor's note: For background information, please read "VA Chiropractic Advisory Committee Finalizes Recommendations," DC, Nov. 17, 2003. www.chiroweb.com/archives/21/24/17.html.
Dr. Cynthia Vaughn, a graduate of Los Angeles College of Chiropractic, practices in Austin, Texas. A former president of the Texas Board of Chiropractic Examiners, she is the East Texas delegate to the ACA, chairs the Clinical Documentation Committee, and is a member of several other ACA committees. Contact Dr. Vaughn at
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