Editor's Note: This article concludes Dr. Lehman's 2017 discussion of chiropractic scope of practice. Previous articles have been among the most read in their respective issues. Visit his online columnist page for access.
Theaetetus proposed that "Knowledge is nothing other than perception."1 Our brains reflect what we are feeling, even if that's not what really happened.2 I believe many chiropractors continue to perceive change in scope of practice as wrong because of their education, which was based upon dogma and not science.
As I complete this year's discussion on the need for chiropractors to comprehend the essential reasons to expand scope of practice and scope of reimbursement for chiropractic/medical services, some of you will immediately experience an increased adrenaline rush or hypertension. (Yes, I am even going to suggest chiropractors consider the use of pharmaceuticals.) Please don't stop reading! Try to approach this article with an open mind. You might realize changes will benefit the future of the profession and provide better access to chiropractic services.
The chiropractic profession has waged internal wars for decades regarding the scope of chiropractic practice, whether diagnosis is necessary for chiropractors, the use of drugs or the value of the term subluxation. Currently, there are more recent concerns because of third-party payments. Chiropractors are fed up with shrinking reimbursements and increasing requests for documentation. Many chiropractors and chiropractic students are leaning toward the "cash practice" as the solution to paltry third-party reimbursements that do not satisfy the revenue needs of a chiropractic practice.3
Medicare and Medicaid Restrictions
Have you wondered why the profession has accepted such a limited Medicare and Medicaid scope of practice? This severe governmental restriction, which limits chiropractors to evaluation and management of subluxations, has cheated us for decades. Limited scope of practice and scope of reimbursement is problematic at best and disastrous at worst.
Medicare considers chiropractors to be physicians providing they graduated from a CCE-accredited chiropractic institution – but only for the manual manipulation of the spine to correct a subluxation.4 Now, I pose a question to you: If our entire focus is detection and correction of a spinal subluxation, and not differential diagnosis with an appropriate treatment plan that may or may not include treatment of a subluxation, prior to treatment, are we not serving as spinal technicians?
Restrictive Practice Acts Harm Our Professional Future
At this time, many chiropractic practice acts limit and restrict, rather than support contemporary chiropractic training and expansion of scope of practice. In my opinion, chiropractors are the best trained clinicians to serve as nonpharmaceutical, manual medicine clinicians within primary care settings for the evaluation and management of acute and chronic pain. The Joint Commission calls for patient-centered treatment of pain with both pharmacological and non-pharmacological care.5
Only a small percentage of chiropractors are interested in providing services within community health centers because Medicaid reimbursement has been unacceptably inadequate or chiropractic services were not funded in certain state budgets.6 As a result of the Affordable Care Act and Section 2706, it is my opinion that chiropractors would benefit from employment within Federally Qualified Health Centers because the compensation would compare with those of medical physicians.
Reasons for Expanding Our Scope
While other providers, including physical therapists, seek and gain prescriptive authority, restrictive practice acts deny these rights to chiropractors in the U.S.7 In spite of chiropractic patients preferring chiropractors to have prescriptive authority8 and Bernese chiropractors perceiving prescription rights to be an advantage for the chiropractic profession,9 chiropractic practice acts continue to prevent this expansion of scope of practice.
All health care providers should be permitted to function according to their training and expertise based upon the evidence and practice acts, and most providers are seeking expansion of scope. Expansion of scope of reimbursement and practice will enhance compensation of chiropractic clinicians and improve access to chiropractic services. Expansion of chiropractic scope of practice will improve quality of care and reduce costs. It is time for the profession to change and seek expansion of scope of practice and reimbursement in order to protect its future.
It is time for the chiropractic profession to step forward and assume the responsibilities necessary to assist with the treatment of patients suffering with neuromusculoskeletal disease, chronic pain and opioid addictions. Chiropractors must integrate into the health care system with the knowledge that enables them to evaluate and manage patients with complicated neuromusculoskeletal conditions, which would build a higher level of cultural authority.10 Integration will improve reimbursement for our services, create career pathways and provide a process that forgives student loan debt.
Advanced Clinical Training
Chiropractic clinicians should be permitted to augment their practices with evidence-based and patient-centered contemporary care that enhances patient outcomes. Chiropractic training has demonstrated chiropractic students are competent in musculoskeletal medicine. Chiropractic specialists with advanced postgraduate clinical training are most qualified to evaluate and manage musculoskeletal conditions.11 The completion of postgraduate education with advanced clinical training including pharmacology and pharmacokinetics would prepare interested chiropractors to integrate into primary care and specialty clinics as valuable members of the medical team.
Finally, a conclusion published by five of my esteemed peers suggests the chiropractic profession must change: "The chiropractic profession has great promise in terms of its potential contribution to society and the potential for its members to realize the benefits that come from being involved in a mainstream, respected and highly utilized professional group. However, there are several changes that must be made within the profession if it is going to fulfill this promise."12
References
- Plato on Knowledge in the Theaetetus. Stanford Encyclopedia of Philosophy; first published May 7, 2005; substantive revision Dec. 13, 2013.
- "Brain Maps Perceptions, Not Reality." Science Daily, Nov. 4, 2003.
- Whitmer M. "Words of Wisdom Regarding Cash Only Practices." NCMIC, June 28, 2013.
- Medicare Benefit Policy Manual. Chapter 15 – Covered Medical and Other Health Services; Table of Contents (Rev. 228, 10-13-16)30.5 - Chiropractor's Services (Rev. 23, Issued: 10-08-04, Effective: 10-01-04, Implementation: 10-04-04) B3-2020.26.
- Baker DW. "The Joint Commission Pain Standards: Five Misconceptions." TheHealthCareBlog.com, April 18, 2016.
- Chiropractic Care, Medicaid Coverage. Department of Health and Human Services, Office of Inspector General, September 1998; OEI-06-97-00480.
- Emary PC, Stuber KJ. Chiropractors' attitudes toward drug prescription rights: a narrative review. Chiropr Man Therap, 2014;22:34.
- Lehman JJ. Suozzi PJ, Simmons GR, Jegtvig SK. Patient perceptions in New Mexico about doctors of chiropractic functioning as primary care providers with limited prescriptive authority. J Chiropr Med, 2011 Mar;10(1):12-7.
- Wrangler M, Zaugg B, Faigaux E. Medication prescription: a pilot survey of Bernese doctors of chiropractic practicing in Switzerland. JMPT, March 2010;33(3):231-7.
- Lehman JJ, Suozzi PJ. Founding integrative medicine centers of excellence: one strategy for chiropractic medicine to build higher cultural authority. J Chiropr Educ, 2008 Spring;22(1):29-33.
- Humphreys BJ, Sulkowski A, McIntyre K, et al. An examination of musculoskeletal cognitive competency in chiropractic interns. JMPT, January 2007;30(1):44-49.
- Murphy DR, Schneider MJ, Seaman DR, Perle SM, Nelson CF. How can chiropractic become a respected mainstream profession? The example of podiatry. Chiropr Osteopat, Aug. 29, 2008;16:10.
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