It is my opinion that the chiropractic profession has an ethical responsibility to improve accessibility to chiropractic services for patients in pain. The chronic pain epidemic costs the United States up to $635 billion annually, and the burden of chronic pain is greater than that of diabetes, heart disease and cancer combined.1
My intentions are to stimulate actions by the profession to create legislative changes and regulatory modifications that will "modernize" Medicare and Medicaid regarding our scope of practice and scope of reimbursement. To be successful, we must create a national chiropractic practice act. Limited Medicare and Medicaid scopes of reimbursement and individual state scope-of-practice restrictions reduce access to chiropractic services for patients in pain.
Don't misinterpret my intentions. I am not declaring mastery over the definition of chiropractic medicine. I do, however, hope to stimulate thoughts, discussion and action by the profession to properly address the question that continues to be posed by the public, health care providers and elected officials: "What is chiropractic?" This is the 21st century; it is high time for professional collaboration that enables those in need of chiropractic care to gain access to it.
Individual State Scopes: Not Enough
A few years ago, I wrote about the difference in scope of chiropractic practice and definitions of chiropractic as defined in the Connecticut, New Jersey and New York practice acts. At that time, I also boldly offered a brief definition of chiropractic practice:
The evidence-based practice of differential diagnosis, patient-centered treatment, and prevention of pain and human disease as taught by CCE-approved chiropractic colleges/institutions/schools.2
Although I continue to suggest this definition is better than many of the current practice acts in North America, I do realize the profession must create a national practice act. Hopefully, the American Chiropractic Association (ACA), Congress of Chiropractic State Associations and National Board of Chiropractic Examiners will support the creation of a contemporary and comprehensive practice act that will be adopted by all of the state boards of chiropractic examiners.
Chiropractic needs a contemporary practice act that meets the needs of the general public and promulgates continuing improvement in chiropractic education, post-doctoral training, federal and state regulations, and chiropractic care offered to those in need.
Key Characteristics of a National Act
The effort to create a "National Practice Act" presents a daunting challenge for the profession, but it is not an impossible endeavor. First of all, the specific characteristics necessary to define a contemporary and comprehensive practice act that would meet the ethical and safety needs of the general public and the chiropractic profession must be determined. Let me suggest that the six key elements offered by the ACA House of Delegates be considered as essential characteristics in a modern chiropractic practice act:
- "Chiropractic Physician" and "Chiropractic Medicine" as the regulatory terms of licensure.
- Scope of practice determined by Doctoral and Post-Doctoral education, training and experience obtained through appropriately accredited institutions.
- Full management, referral and prescription authority commensurate with contemporary chiropractic education for patient examination, differential diagnosis, working diagnosis, and health assessment.
- Full evaluation and management, referral and prescription authority commensurate with contemporary chiropractic education for the care and treatment of neuromusculoskeletal and other health conditions or issues.
- Full authority for the delivery of information, advice, recommendations and counseling regarding general health matters, wellness and health optimization.
- Full authority and adaptable requirements for the management and training of health care teams and the participation in collaborative or integrative health care groups.
Modernization of Scope of Practice
It is no longer reasonable for the scope of chiropractic practice to be based upon the personal opinions of members of state chiropractic boards of examiners. As a former member of the board of examiners in New Mexico, I am quite familiar with the appointment process. Gaining political support from the governor does not ensure competence regarding the defining of scope of chiropractic practice.
I suggest a collaborative effort similar to the Mercy Conference may be a reasonable starting point. Our profession should be able to offer a unified definition of chiropractic and scope of chiropractic practice that does not vary from state to state. Chiropractic clinicians should be permitted to practice as trained and credentialed, and reimbursed accordingly.
Modernization of Medicare and Medicaid Coverage
Although section 2706 of the Affordable Care Act3 demonstrates the importance of our scopes of practice, it has done little to reduce discrimination against chiropractors in private practice. American DCs should be asking why section 2706 has not protected private-practice chiropractic clinicians from discrimination by third-party reimbursement organizations.
It has been my position since 1997 that the creation of the chiropractic manipulative treatment (CMT) codes would be used to control the growth of the chiropractic profession thorough the economic credentialing process. In medicine, the term economic credentialing is well-understood by chief medical officers and insurance company chief executive officers. While the International Chiropractic Association (ICA) accepts the restriction of the chiropractic scope of reimbursement because of ideological reasons, the American Medical Association (AMA) appreciates the economic restrictions because of the damages experienced by the entire chiropractic profession in the U.S.:
Economic credentialing is a term of disapproval used by the American Medical Association (AMA). The association defines the term as "the use of economic criteria unrelated to quality of care or professional competence in determining a physician's qualifications for initial or continuing hospital medical staff membership or privileges."4
It is obvious that third-party insurance companies and the AMA support the ICA position regarding restrictive Medicare and Medicaid reimbursement for chiropractic services. Unfortunately, scopes of chiropractic practice that restrict DCs based upon individual, ideological constraints rather than scopes of practice based upon education, training and credentialing prevent access to chiropractic services for millions of patients in pain. Consequently, these patients have been offered opioid medications, addiction and death instead.
Are We Truly Prepared?
Is the chiropractic profession prepared to meet the needs of chronic pain patients and reduce opioid addictions? If yes, then when will we work together to make our salubrious services available to all Americans in pain? It is my opinion that the chiropractic profession needs to modernize the state practice acts and properly define the chiropractic scope of practice in order to improve quality of care, enhance ethical behavior, and mitigate the effects caused by antiquated restrictions imposed by previous members of state boards of chiropractic examiners.
References
- Data on specific disease burdens is available from the Centers for Disease Control and Prevention's FastStats website. Data on the burden of pain is available here.
- Lehman JJ. "Scope of Chiropractic Practice: Time for Change?" Dynamic Chiropractic, January 2017.
- FAQs: Affordable Care Act Implementation.
- Economic Credentialing. Wikipedia.
Click here for previous articles by James Lehman, DC, MBA, DIANM.