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Chiropractic in the United States:
Training, Practice, and Research

Chapter VII: Chiropractic in the Health Care System
Robert D. Mootz, DC; William C. Meeker, DC, MPH;
Cheryl Hawk, DC, PhD

**Comments in red by Stephen Barrett, M.D.

Chiropractic occupies a unique position in the United States health care system. It is the most widely disseminated indigenous American system of healing and the most frequently used type of alternative health care in the United States (Gaucher-Peslherbe, 1995; Eisenberg, 1993). Its steadily increasing acceptance and use by the public, third- party payers, and the Federal government indicate that chiropractic is no longer the "marginal" or "deviant" profession it was once considered to be (Wardwell, 1952). In recent years, a number of outside observers have suggested that the profession has now entered the health care mainstream (Coile, 1995a, 1995b; Stano, 1992; Wardwell, 1988). At present, chiropractic is both alternative (in that it approaches health care from a distinctly different perspective than that of the dominant health care profession, medicine) and mainstream (in that it has gained popular acceptance). This chapter discusses the characteristics of the profession that contribute to its distinct perspective and approach to patient care, and how these affect its position within the U.S. health care system.

A. Different Perspectives on the Role of Chiropractic in the Health Care System

Precisely what roles chiropractors could or should play in the health delivery system is a complex and unresolved issue. In general, three distinct (but not mutually exclusive) roles for chiropractors have been discussed in the chiropractic literature (Hawk, 1996a; Wardwell, 1992):

Patients, the chiropractic profession itself, medical physicians, third-party payers, and the managed care industry all have different perspectives on what role would be most appropriate for chiropractors. Although there is some agreement among the various constituencies, substantial differences exist, highlighting the key issues that the profession and policymakers will need to address in the future.

1. The Patient /Consumer Perspective

Chiropractors already play a significant role in health care delivery for many Americans. A recent study estimated that approximately 7 percent of adults in this country had received chiropractic treatment in the past year (Eisenberg, 1993). A substantial fraction (25-42 percent) of patients seeking care for back pain receives chiropractic care (Deyo, 1987; Shekelle, 1995; Hawk, 1995; Carey, 1995, 1996). An analysis of the 1974-82 RAND Health Insurance Experiment data found that chiropractors were the first health care providers seen for 38 percent of episodes of back pain and that chiropractors were the "primary" provider (i.e., the provider type that delivered the majority of care) for 40 percent of back pain episodes (Shekelle, 1995). Furthermore, this study determined that chiropractors were retained as primary provider for 92 percent of their patients who had a second episode of back pain, compared to 75 percent retention for general medical practitioners. Thus, many back pain patients have used chiropractors as first contact primary providers of care for at least this one common problem. Although some people may also use chiropractors as alternative/complementary care generalists like acupuncturists or homeopaths, the evidence suggests this does not frequently occur (Hurwitz, 1998; Christensen, 1993; Goertz, 1996).

Several studies have examined whether chiropractic care substitutes for medical care. Yesalis (1980), in a study in rural Iowa, found that as chiropractic care increased, medical use also increased. Chiropractic services did not appear to substitute for medical services in a group of Canadian elderly (Shapiro, 1983). In fact, chiropractic users tended to use all health services with more frequency. Other studies have also noted that patients use different providers simultaneously, even for the same problem (Eisenberg, 1993; Thomas, 1991). Thus, to date, there is no evidence that chiropractic care substitutes for medical care. Much study is still needed to determine what impacts patients' decisions to utilize one provider over another. In fact, chiropractic researchers consider this issue as a priority for their health services research agenda (Mootz, 1997).

2. The Chiropractic Profession Perspective

Because chiropractors have had to fight for their existence, they have jealously guarded their independent practice status granted them through State licensing. Organized medicine's refusal to permit physician referral to or from chiropractors ensured that direct access was the only route by which patients could receive chiropractic services.

**It is not quite correct to blame "organized medicine" for the low referral rates from medical doctors to chiropractors. In the 1960s and 1970s, various organizations had policies discouraging such referral. However, as far as I know, no physician was ever disciplined for violating such a policy. The real reason for lack of referral was lack of respect, based mainly on (1) the absurd claims chiropractors made in their advertising and (2) the absurd experiences patients would report to their doctors.

As a result, chiropractors often developed loyal patient bases and played what many chiropractors viewed as a primary care role for their self-referred patients. It is not surprising then, that most chiropractors see themselves as "primary care" practitioners (Hawk, 1996b).

**Chiropractors use a very loose definition of primary-care practitioner. The standard definition requires the ability to diagnose and treat a broad range of problems. Chiropractors are very limited in what they can do.

In recent years, a physician "gatekeeper" model of health care delivery has become prominent in managed care plans. The concept that a single physician, familiar with all of a patient's needs, could coordinate and direct care in a "primary care" role remains conceptually attractive. In practice, gatekeeping typically limits access to more expensive specialty care.

**The relevant goal of managed care is to limit unnecessary specialty care.

Perhaps because of a lack of exposure to what services chiropractors provide, primary care physician gatekeepers may consider chiropractic to be similar to medical specialty care, thereby limiting access until various medical diagnostic and care strategies have been tried, or restricting access entirely.

**It isn't lack of exposure. It is lack of respect. Most doctors have a general idea of what chiropractors can do.

Thus, chiropractors have been concerned that direct access by their patients might be eliminated if medical physicians became the sole arbiters of patient flow. Some managed care organizations, however, have allowed direct access to chiropractic services (Coile, 1995b; Simpson, 1996).

Because of the overlay of political and economic issues, there is a great deal of misunderstanding about the meaning of the term "primary care," and debate about who practices it.

**Only among chiropractors. The rest of the health world has a very clear definition.

In the chiropractic community, there are two major positions on this issue. One suggests that chiropractors are not primary care physicians, but musculoskeletal specialists (Nelson, 1993). Current chiropractic patient characteristics and available clinical research support this argument. This position would place chiropractic in a practice model similar to that of dentistry or podiatry. The other position argues that, although chiropractors are not primary "medical" care providers, they may be seen as primary "health" care providers (Ebrall, 1994; Bowers, 1995).

**This argument is sheer baloney. It also clashes with the fact that large percentages of chiropractors and their organizations oppose or fail to support preventive measures such as immunization and fluoridation. Most also have little practical knowledge of nutrition.

This is in keeping with current concepts of community-oriented primary care, a definition of primary care that emphasizes the linkage between community (public) health and individual patient diagnosis and treatment (Hawk, 1996a). Further, chiropractic training typically emphasizes differential diagnosis and conservative management of many common health care problems (Bowers, 1995).

**It would be interesting to see a list of the health problems chiropractors believe they can conservatively manage.

In 1994, the American Chiropractic Association (ACA) attempted to resolve these opposing positions through a comprehensive statement that refers to characteristics of primary care as described recently by the Institute of Medicine (IOM) (Donaldson, 1994). The ACA statement describes the chiropractor in a primary health care delivery system as a first contact gatekeeper for neuromusculoskeletal conditions characterized by direct access, longitudinal, vertically integrated, conservative ambulatory care of patients' health care needs, emphasizing neuromusculoskeletal conditions, health promotion, and patient-centered diagnosis and management. (The ACA statement was presented as a statement from the American Chiropractic Association Task Force on Primary Care and Chiropractic, June 18-19, 1994.)

**In other words, they are not primary-care physicians but should have the privilege of seeing patients directly without medical referral.

3. The Medical Profession Perspective

It is only recently that medicine's opinion of chiropractic has changed from almost universal negativism (Wolinsky, 1994) to one of guarded interest among a substantial fraction of medical doctors (Cherkin, 1989; Cherkin, 1992). Until 1980, the AMA stated that it was unethical to refer a patient to a chiropractor. The loss of a landmark antitrust suit, upheld all the way to the U.S. Supreme Court, finally erased such prohibitions against medical providers working with chiropractors (Getzandaner, 1987).

**The AMA changed its official policy several years before the case was over. However, as I note above, the policy really functioned as a suggestion.

Although many reasons can be offered to explain the original mutual distrust between the medical and chiropractic professions (Curtis, 1992), it is clear that negative attitudes have been reinforced because each profession tends to see the other's treatment failures. It is also noteworthy that, traditionally, medicine has rejected the possibility of efficacy of treatments that were based on explanatory models or theories that they perceived as invalid, such as the original chiropractic theory that spinal lesions (chiropractic subluxations) cause or contribute to an individual's inability to counter disease processes.

**Subluxation theory was seen as invalid because it is invalid.

Today, the pragmatic emphasis on patient outcomes rather than on hypothetical biologic mechanisms of therapy facilitates a more objective look at the clinical utility of both allopathic and chiropractic treatments.

**The medical profession still looks at both. The consensus is does not make sense, it will not usually turn out to be useful. I suspect that authors of this chapter would like you to overlook the fact that nonsensical beliefs are rampant among chiropractors.

In at least some respects, the chiropractic procedure of spinal manipulation has met the outcomes challenge, for low back pain. Recent literature syntheses performed by researchers, both within and outside the chiropractic profession, have concluded that spinal manipulation is relatively safe (Shekelle, 1992), appears to benefit at least some subgroups of patients with low back pain (Shekelle, 1992; Anderson, 1992; Bigos, 1994; Koes, 1996), and does not appear to be simply a placebo (Hoehler, 1981; Hadler, 1987; Sanders, 1990; Brennan, 1991). These issues are discussed in more detail in Chapter XI.

**This is correct, but these assessments were based mainly on research by medical doctors and physical therapists and do not necessarily reflect what takes place in the "average" chiropractic office.

There may be a great deal of overlap among the types of patients seen by chiropractors, family physicians, and orthopedists particularly relating to back pain, neck pain, and headache. Because medical science has not been wholly successful in understanding these common syndromes, nor in developing highly effective management strategies, there has been increasing curiosity about what chiropractors may have to offer. As a result, chiropractors have begun to develop close collaborations with members of the medical specialties that most commonly treat such complaints (Curtis, 1992; Triano, 1994).

Recent survey data suggest that a significant proportion of medical physicians perceive value in chiropractic. Berman (1995) reported that 49 percent of East Coast family practice respondents found chiropractic to be "legitimate medical practice," and that 56 percent had made referrals to a chiropractor.

**This was a very bizarre report. Although the survey was said to have been conducted at three conferences for family physicians. However, The 27.2% of those who respended responders said they practiced chiropractic. I thonk this means that 27.2% of the people who took the survey were chiropractors. Although I raised this question in a letter to the editor of the journal, the author failed to respond.

Cherkin (1989) found similar results in a survey of family physicians in Washington State. Patel-Christopher (1990), quoted in Manga (1993), noted that in Canada, 62 percent of medical physicians refer patients with musculoskeletal pain to chiropractors and that 9.5 percent of medical practitioners are chiropractic patients themselves.

**It appears from the citation that the study was not published, so that it would probably be difficult to find out how the study was done.

Even though many medical doctors believe chiropractic may be of value, few feel well informed about it and many would like to learn more (Cherkin, 1989). For example, while 70 percent of general practitioners in Nova Scotia felt chiropractic to be useful, and 58 percent made referrals to chiropractors, only 10 percent admitted knowledge of chiropractic (Goldszmidt, 1995). This lack of knowledge about alternative therapies may partially explain why only 30 percent of patients who use these therapies discuss their use with their medical provider (Eisenberg, 1993).

**Another rationalization. The authors imply that if medical doctors knew more about "alternative" therapies, they would endorse or make greater use of them. I doubt that. Also, the Eisenberg paper's definition of "unconventional" treatment was overbroad, and its survey included methods that were not outside of mainstream medical care (such as exercise, reported by 26%) and some (such as prayer, reported by 25%) for which there was no reason to discuss with a physician. The paper stated that 10% of patients had used chiropractic within the previous month but only 70% of these had seen a chiropractor. The authors didn't explain how patients could use chiropractic without seeing a chiropractor. Nor did they inidcate what percentage of those who did so failed to tell their doctor.

Patients who are aware of organized medicine's past hostility toward chiropractors (Getzendaner, 1987) may be especially reluctant to discuss their use of chiropractic with their medical providers.

**Organized medicine's campaign to inform doctors about chiropractic deficiencies stopped about 20 years ago because chiropractors filed a series of antitrust lawsuits that made it legally dangerous to continue to do so. The authors are correct that some patients are reluctant to tell their doctors that they are seeing a chiropractor. But this has nothing to do with what the AMA and other groups did in the 1960s and 1970s.

The medical profession's perspective on the role of chiropractic is also complicated by the caregiver vs. gatekeeper issue. Although there is now enough scientific evidence to convince many medical physicians that spinal manipulation has a place in managing certain patients, it appears that most medical providers believe that access to chiropractors should be managed by medical gatekeepers, viewing chiropractic as a supplement to, rather than a substitute for, medical care. This perspective is reinforced by concern on the part of many medical physicians about the ability of chiropractors to reliably identify and refer patients with potentially serious medical conditions (Curtis, 1992). However, professional liability experience with chiropractic does not suggest that this is a major problem (see Chapter VIII).

**Chapter VIII reports that malpractice insurance is cheaper for chiropractors than for medical doctors. Malpractice data say little or nothing about the ability of chiropractors to make appropriate referrals. Most patients who need medical care don't go to chiropractors or need a chiropractor to refer them. As far as I know, no study has attempted to determine whether chiropractors appropriately manage patients who need medical care but have not seen a physician (patients, for example, who have back pain due to a tumor rather than muscle strain).

In fact, some chiropractors are functioning in supplemental roles even in multidisciplinary settings, without being "gate kept" (Triano, 1994).

**Although no survey has been published, I believe that the chiropractors in reputable medical facilities tend to be more clear-thinking and medically oriented than average.

Finally, it is worth mentioning that the third potential role of chiropractors, as members of interdisciplinary primary health care teams, has so far largely been ignored by the medical profession. However, such an approach is receiving increasing attention from the government and from academia, as evidenced by education and training efforts funded by the Health Resources and Services Administration (HRSA), which awarded chiropractic colleges contracts pertaining to rural and geriatric practice.

**I am not aware of the extent to which this is being done or the politics invlved in the awarding of the grants. It would be interesting to know the numbers involved. This report seems to prefer general statements such as "increasing attention," which may sound more impressive than small numbers.

The potential for chiropractors to be involved in interdisciplinary primary care in rural settings (Hawk, 1996b) and in primary, secondary, and tertiary capacities within multidisciplinary spine centers have been the subject of discussion in the chiropractic literature (Triano, 1994, 1995).

4. The Third-Party Payer and Managed Care Perspective

In recent years, the insurance industry has made a variety of chiropractic benefits available (see Chapter VI). This development has been influenced by market demand from subscribers, legislation regarding insurance equality, and pressure from chiropractic trade organizations. All providers whose services are covered by insurance, including chiropractors, have had to deal with the realities of managed care delivery systems that have imposed greater competition, oversight, and accountability (Hansen, 1995). These changes and their impact on chiropractors are discussed in Section C below. Because much of the evolution in managed care stemmed from staff and group model HMOs, chiropractic inclusion has not been a central part of most plans, perhaps due to the limited experience with chiropractors in such settings.

**More likely due to chiriopractic's generally poor reputation among insurance executives.

The model of primary care gatekeepers traditionally used in HMOs has aimed to exclude delivery of services from providers outside of the plans. Medical physician responsibility for case-management decisions, the limited data on cost-effectiveness of chiropractic care, and the low visibility of chiropractors in medical settings were additional factors that have precluded consideration of an increased role for chiropractic. Thus, the changes taking place in health delivery structures have placed chiropractors at risk of being shut out of reimbursement systems, if not by design, then through benign neglect.

Some experts see a challenging opportunity for chiropractic in this environment. Commentators point to a growing understanding of the popularity of "alternative/complementary" medicine (e.g., Eisenberg, 1993), the money already being spent on chiropractic care (Stano, 1992, 1996), the growing legitimacy of spinal manipulation (Bigos, 1994), the high prevalence of musculoskeletal disorders in the United States (Deyo, 1991), and a new emphasis on pragmatic patient outcomes as reasons why chiropractic may be expected to thrive in the coming years (Coile, 1995a, 1995b). In fact, many managed care organizations are beginning to use chiropractors through in-house positions or via subcontracts with chiropractic networks (Simpson, 1996).

**Any arrangement that limits the total number of covered visits will dent the incomes of chiropractors who try to keep their patients coming back indefinitely for "maintenance care."

Chiropractors are used alone or in combination with physical therapists, for the evaluation and management of musculoskeletal problems (Coile, 1995a).

B. Interprofessional Relations

In contrast to professions that train and practice within the same context and often within the same institutions, chiropractic's historical development as a separate and distinct profession has required that chiropractors approach interprofessional relations from outside the context of the health care mainstream (Mootz, 1995a). Chiropractic's integration into the health care system has likely been impeded by its isolation from other professions in clinical settings, academic institutions, research, professional organizations, government, and the insurance industry.

1. Professional Isolation from the Health Care Mainstream

A central premise of chiropractic, which emphasizes the therapeutic importance of the body's inherent healing abilities, is in conflict with many traditional biomedical views, which have focused on counteracting external causes of disease (Coulehan, 1985; Coulter, 1983; Cobb, 1977; Inglis, 1964).

**This is a simplistic, weasel-worded description. Chiropractic's central premise is delusional, Medical science has focused both on internal and external causes.

However, what began in 1895 as a difference in theory eventually resulted in the evolution of two distinct approaches to patient care (Coulter, 1983). The differences between the allopathic and chiropractic approaches were intensified by the antipathy of organized medicine toward chiropractic, which for many years excluded chiropractic from every aspect of the American health care system, including professional educational institutions, government policy, and funding opportunities (Willis, 1984). This isolation fostered professional independence and justified an anti-intellectual attitude among some chiropractors (Keating, 1989).

**Are the authors suggesting that the medical profession is responsible for the perpetuation of chiropractic delusions?

Chiropractic developed an office-based practice model due in large part to its isolation from the medical establishment and exclusion from hospital-based care (Keating, 1989). This isolation has also affected chiropractic education in that students are not afforded exposure to a broad spectrum of clinical conditions (Keating, 1989; Baer, 1984).

**It would be interesting to know why the authors think chiropractic students should be exposed to a broad spectrum of clinical conditions. They certainly can't treat them.

Additionally, a lack of access to a university-style research tradition and to government funding has impeded scientific development within the profession.

**Of course, the biggest impediment to chiropractic research has been lack of interest in doing research.

Chiropractic is best known for its primary treatment mode, manual manipulation of the spine (Shekelle, 1992; Coulehan, 1985; Cobb, 1977). Although a variety of natural and conservative interventions are used by chiropractors, the exclusion of drugs and surgery is a significant factor in separating the chiropractic profession from mainstream health professions. In fact, chiropractors are the only doctors licensed in all 50 States diagnosing and treating physical illnesses who do not use drugs or surgery.

Chiropractic practice, developing outside the medical mainstream, is more "client-dependent" than "colleague-dependent" (Wardwell, 1988; Keating, 1989). Because chiropractors have traditionally received new patients through personal contacts and non-medical referral sources, they often perceive that they have a stronger sense of alliance with patients than with other health professionals.

2. Interprofessional Relations in Clinical Settings

As the profession has become increasingly integrated into the health care system, interprofessional contact in clinical settings has also increased, frequently by patient request. This usually involves simple referrals, but occasionally includes multi- or interdisciplinary arrangements (Triano, 1994). Although awareness of chiropractic remains limited among other health professions, patient requests, in addition to the increasing evidence for efficacy and patient satisfaction, may prompt medical and other practitioners to view chiropractic more favorably (Cherkin, 1992). However, while nearly all chiropractors (99-100 percent) report they routinely refer patients to medical practitioners (Mootz, 1994), only about 50-60 percent of medical providers refer patients to chiropractic physicians (Cherkin; 1989, Mootz, 1994).

**I doubt that 50-60% of medical providers refer to chiropractors. The Mootz report was based on a questionnaire distributed at a meeting of the American Back Society, whose attendees were presumably much more interested than the average physician in manipulative treatment. Of 41 medical doctors who responded, 48% of said they never referred to chiropractors. I have not read Cherkin's paper, but the abstract states that 57% of family physicians in the State of Washington who responded to a questionnaire said they had "encouraged patients to see a chiropractor." I am uncertain whether that is the same thing as a referral.

3. Interprofessional Relations in Academic and Research Settings

The historical antecedents of chiropractic relationships to other health professions and the scientific community must be acknowledged in any discussion of current interprofessional relations. Until 1980, the American Medical Association's (AMA) code of ethics expressly forbade any professional association with chiropractors (Wolinsky, 1994). In 1969, the American Public Health Association adopted a policy that urged that, ". . . state legislatures and health agencies not include chiropractors . . . under state health programs" (APHA Policy 6903). It was not until 1983 that the APHA instituted a new policy, which recognized spinal manipulation as safe, and effective for certain neuromusculoskeletal disorders (APHA Policy 8331). The effect of these initially negative pronouncements and policies from such august bodies of health professionals had the effect of further isolating chiropractors from mainstream clinical, professional, and scientific settings.

Almost all chiropractic training takes place in privately supported, freestanding institutions designed expressly for that purpose. Very few chiropractors can be found in nonchiropractic academic settings, although this is gradually changing.

**The phrase "gradually changing" is a meaningless without knowing the numbers involved.

Although most individuals end their formal education with a chiropractic degree, a small group pursues additional education, in public health, medicine, or other disciplines. These chiropractors have had important beneficial effects on the relationship between chiropractors and other professions. Many chiropractors are authors or co-authors with other health providers on a variety of topics and are beginning to publish in mainstream scientific journals as well as in the peer-reviewed chiropractic literature.

**How many is "many"? Have there been more than ten? I think that most of the articles have been generated by the handful of chiropractors associated with RAND.

Greater collaboration with researchers in other fields is also occurring (Mootz, 1995a).

Established scientific journal and textbook publishers have discovered that chiropractic is a significant professional market. There are now at least eight peer-reviewed journals competing for chiropractic-related readership. All have editorial boards that include other health professionals. The Journal of Manipulative and Physiological Therapeutics (JMPT), established in 1976, is the profession's leading research vehicle and draws submissions and readership from scientific and clinical fields beyond chiropractic.

**Fewer than 10% of chiropractors subscribe to JMPT, which strongly suggests that chiropractic journals have very little influence on chiropractic practices.

It is indexed in a number of databases, including Index Medicus and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). Four of the profession's other scholarly journals (Topics in Clinical Chiropractic, Chiropractic Technique, Chiropractic History, and the Journal of Chiropractic Humanities) are also indexed in CINAHL.

Many major textbook publishers have commissioned chiropractic-related books, frequently with chapters contributed by other health professionals. Some of these have wide distribution beyond the chiropractic market and are available in medical bookstores.

**Again, how many are "many" and "some."

There are a small number of organizations that fund or otherwise contribute to chiropractic research in the United States (see Chapter IX). Each of these maintains a proposal review board consisting of scientists and providers from a variety of backgrounds.

From initial research funding by the Veterans' Administration to researchers at National College of Chiropractic through recent chiropractic project grants from the National Institutes of Health, the chiropractic research enterprise has seen steady growth. Multidisciplinary panels have been convened and funded by both private (the RAND corporation) and public sources (Agency for Health Care Policy and Research) to arrive at clinical consensus on the appropriateness of spinal manipulation for low back pain (Shekelle, 1991; Bigos, 1994), manipulation of the cervical spine (Coulter, 1995), and headache (AHCPR, in progress). The credibility of the RAND studies has facilitated improved communication between chiropractors and other health professionals. Interdisciplinary research efforts have begun at several major universities, often in collaboration with chiropractic institutions. One of the most visible efforts in recent years involves a research program administered by the U.S. Health Resources and Services Administration, Bureau of Health Professions. The grants and contracts recently awarded to four chiropractic colleges required medical collaboration (Bureau of Health Professions, 1995)

In 1989, the Agency for Health Care Policy and Research (AHCPR) funded the Back Pain Outcome Assessment Team (BOAT), which included chiropractors on the advisory committee (Deyo, 1990). Chiropractors have also participated in a related project by BOAT investigators comparing chiropractic care with a physical therapy program emphasizing self care for low back pain. AHCPR has also awarded a large grant to UCLA to conduct a comparative study of chiropractic care in an HMO setting, with chiropractors closely involved with the design and conduct of the project. The Armed Forces of the United States recently agreed to conduct a pilot study of the utility of chiropractic care as part of health care provided to active military personnel and their families. Chiropractors have been central to the design and execution of this study.

A small number of chiropractors serve as peer-reviewers and advisers for the National Institutes of Health, the Agency for Health Care Policy and Research, the Health Resources and Services Administration, and the U.S. Department of Defense, where they interact with other health providers and scientists in appropriate scholarly tasks.

4. Health Professional / Scientific Organizations

There has been a Chiropractic Special Primary Interest Group (SPIG) in the American Public Health Association since 1983 with membership ranging between 200 and 700. In 1995, the APHA Board of Governors voted to admit the SPIG into full section status with voting privileges and agency funding. This provided official recognition for chiropractic and cleared the way for full cooperation and collaboration on an equal basis with other health professions represented at APHA. Many chiropractors also work within the Radiological Health, Gerontological Health, and Occupational Health & Safety Sections of the APHA. Eight chiropractic colleges and both national associations are APHA agency members. Since 1985, the Chiropractic SPIG has consistently sponsored multiple scientific paper sessions at the annual meeting. The sessions attract co-sponsorships with other Sections, nonchiropractic paper presentations, and a multidisciplinary audience.

**I attended an SPIG session in 1994. Nearly everyone in the audience was a chiropractor.

Chiropractic members of APHA have served on the Governing Council and on advisory committees and have been active in public health policymaking efforts.

Chiropractors are also members and officers in a wide variety of health profession organizations and groups. For example, about 25 percent of the membership of the American Back Society are chiropractors. Chiropractors have also been active in the North American Spine Society, the American Society of Biomechanics, the International Society for the Study of the Lumbar Spine, the American Academy of Pain Management, the North American Primary Care Research Group, National Association of Medical Minority Educators, the American College of Sports Medicine, Society for Medical Decision Making, the American Public Health Association, and the Silicon Valley Ergonomics Institute.

C. Accountable Delivery Settings and Chiropractic

1. Impact of Practice Accountability on Chiropractors

Changes in Delivery and Reimbursement

The health care delivery system has undergone dramatic changes during the 1980's and 90's (Coile, 1993). Many of the key changes in health care delivery and reimbursement impacting chiropractic practice are outlined in Table 16. Most chiropractic practices have traditionally been set in individual offices operating under a fee-for-service system based on customary prevailing and reasonable reimbursement practices. Political and public sector concern over access to services and the plight of the un- and underinsured has drawn attention to general health care financing and delivery reforms. Although massive federally mandated reforms are not likely in the near future, several revisions have taken place in the reimbursement and delivery of health services that directly affect how all providers function.

Table 16. Changes in Health Care Delivery and Reimbursement

Traditional Practices

New Trends
  • Fees set by individual physicians
  • Reimbursement levels determined by actuarial review of customary, prevailing, and reasonable billing patterns
  • Physicians paid on fee-for-service basis
  • Health insurer accepts all financial risk
  • Appropriate and necessary care determined by individual physician on case-by-case basis
  • Individual practice
  • Fees set by health purchasers
  • Reimbursement levels determined by resource-based relative value analysis of individual procedures
  • Physicians paid on capitated or contractual basis
  • Physicians share in financial risk
  • Clinical decisionmaking increasingly driven by practice guidelines and algorithms developed through expert and evidence-based processes
  • Group practice and provider networks

Determination of physician reimbursement levels has traditionally been based on actuarial review of customary billing practices. In 1992, the Health Care Financing Administration implemented a resource-based relative value scale system that quantitatively assessed physician work, practice overhead, and malpractice risk for every procedure that physicians perform (Hsiao, 1992a). Prior to 1994, however, no work on valuation of chiropractic services for the purpose of reimbursement had been done along the lines required by the Health Care Financing Administration for other clinical procedures (Kirschner, 1997; Hsiao, 1992b). A few proprietary studies and recommendations for "best-fit" billing practices have existed that were based on informal estimation of which existing billing code might best fit chiropractic procedures (ACA, 1993; Olsen, 1993). Recently, several qualitative and quantitative reports have begun to appear in the chiropractic literature in this area (Mootz, 1995b, 1995c, 1996; Dobson, 1995; Hess, 1997).

Stimulated by concerns about large variations in how health care services are utilized, the Federal government took the lead in attempting to more formally assess what science says about clinical tests and procedures by developing evidence-based guidelines for patients and providers (Hansen, 1994a). In 1989 the U.S. Congress established and charged a new Federal agency, the Agency for Health Care Policy and Research (AHCPR), with the review and synthesis of scientific evidence on specific clinical procedures, which has resulted in the publication of evidence- and consensus-based practice guidelines.

Private sector insurers, faced with increased competition from managed care organizations, have also taken greater interest in the delivery end of health care. Due in part to rapid increases in premium costs, innovative delivery and financial risk-sharing insurance products dramatically increased managed care organization's market share with employer-sponsored health benefits programs (Hirschman, 1994; Coile, 1995a). Changes in reimbursement practices, development of practice guidelines, and the rise of managed care delivery systems have had significant impact on practicing physicians' incomes and practice patterns. The result has placed greater accountability on providers, including chiropractors, and the chiropractic profession has responded to these changes with the development of their own managed care organizations, practice guidelines, and health services research initiatives (Mootz, 1995a).

Practice Inventories, Parameters, Guidelines, and Technology Assessments

Perhaps as a byproduct of chiropractic's long-standing "outsider" status, there has been a great deal of uncertainty and misunderstanding among policymakers, health purchasers, and various providers regarding what chiropractors actually do.

**One reason for this is that most things chiropractors do have not been standardized. Most chiropractors have little idea what is going on in the offices of most of their colleagues.

In addition, practice variation (as much of a problem in chiropractic as it is in other specialties) may have contributed to inaccurate assumptions regarding its value.

**"As much of a problem in chiropractic as it is in other specialties." What crap! The problem is vastly greater among chiropractors than it is among any other type of health practioner. As chiropractic sages have noted, "For every chiropractor there is an equal and opposite chiropractor."

These circumstances, in addition to system-wide trends toward increased practitioner accountability, have stimulated the chiropractic profession to begin to inventory practice methods, define practice parameters, and develop some general practice guidelines (Bergmann, 1990; Haldeman, 1993; Hansen, 1994a). In addition, numerous condition-specific critical care pathways have begun to be published in the chiropractic literature (Hansen, 1994a; Hansen, 1994b). Chapter VIII, Section E, "Practice, Guidelines, Clinical Pathways, and Technology Assessments in Chiropractic," provides a more detailed review of key initiatives to date. As in other health care fields, published chiropractic practice guidelines have been met with mixed responses ranging from endorsement and adoption to controversy and rejection.

**Chiropractic guidelines are not similar to medical guidelines, and the responses to them are very different. Although they represent a step in the right direction, they actually give very little guidance. One set has been published by the more modern-thinking chiropractors and another has been published by "straight" (subluxation-based) chiropractors.

In response to the increasing interest on the part of health care purchasers and policymakers to better understand and rationalize clinical decisionmaking, chiropractors have developed expert and community-based physician practice guidelines (Hansen, 1994a; Henderson, 1994).

**Hansen's book chapter describes how medical audit processes can be applied to chiropractors. It is unclear whether they can actually influence what chiropractors do.

Further, chiropractors are increasingly involved in multidisciplinary practices and in managed care organizations. In fact, chiropractors have established their own managed care organizations, mostly in the form of independent practice associations (IPAs) and preferred provider organizations (PPOs) and are gaining market share (Coile, 1995b). Table 17 summarizes several key managed care options that currently exist for chiropractors.

Table 17. Options for Chiropractors in Managed Care

Sub-contract reduced fee for service provider: IPA receives capitated contract from purchaser and manages chiropractic care with subcontracts with individual providers. This is the most common type of chiropractic MCO arrangement.
Capitated contract provider: Individual DC receives monthly or annual payment adjusted for number of covered lives in contract providing all needed chiropractic services to plan members who present for care.
Salaried position in HMO/clinic: DC is hired as salaried employee of clinic providing all care needed. Very few currently in place but popularity with MCOs seems likely to increase as potential cost containment incentive.

McElheran and Sollecito (1994) have offered guidance for providers to identify and revise clinical staffing procedures, and documentation to meet the increased requirements for accountability and efficiency in chiropractic practice (Table 18). One of the aims of managed care is to facilitate appropriate care, which by nature may involve collaborative and multidisciplinary patient management. Strategies and examples of truly integrated interdisciplinary care using explicitly developed evidence and consensus-based protocols are beginning to appear (Triano, 1994).

2. Quality Management Initiatives

Although a focus on quality and customer service has been a central component of business and industry since World War II, quality management initiatives are a relatively recent phenomenon within health care in general and within chiropractic in particular (Hansen, 1995). Attributes of quality in health care include "technical" considerations such as provider credentialling, nature of facilities, ratios of providers to patient populations, and utilization experience. Less technical attributes of health service quality such as patient satisfaction, ease of access to care, and patient involvement in care planning are also viewed as important (Hansen, 1995).

In recent years, discussions of quality in chiropractic care have begun to appear in the chiropractic literature (Hansen, 1995; Vear, 1992; Ianelli, 1995; McElheran, 1994; Nelson, 1994). With increasing inclusion of chiropractic services in managed care settings, chiropractic networks (practice associations and preferred provider organizations) are being required to meet accreditation standards of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the National Commission on Quality Assurance (NCQA) in order to receive capitated contract dollars. These organizations require adherence to various quality standards even down to the individual clinic and doctors' office settings (JCAHO, 1994; O'Kane, 1993). As a result, individual chiropractors are beginning to be held accountable to multiple, quantifiable measures of quality in order to become or remain affiliated with preferred provider networks.

**Since quantitivate measures of chiropractic quality are rare (if they exist at all), chiropractic leaders are very worried about this trend. In some states, chiropractors are using lawsuits and legislative efforts to try to force managed-care companies to admit them.

Table 18. Recommendations for Chiropractic Practice Efficiencies Under Managed Care

Facility: Maintain professional appearance, clean and accessible furnishings, impaired patient access, record storage and retrieval that permits access and confidentiality, documented emergency protocol, equipment certification (e.g., x-ray), etc.

Staff: Training in managed care protocols, interdisciplinary protocols, patient relations, billing procedures, reporting requirements.

Care appropriateness: Emphasis on clinical effectiveness, careful use of treatment resources, timely referral of nonresponders, consideration of available clinical guidelines.

Entrance forms: Legible, understandable paperwork that provides adequate insight into patient's past history, condition chronicity, baseline status, nature of complaints, informed consent, etc.

Outcomes assessment instruments: Regular use of self-report instrument that can document patient progress in a meaningful fashion.

Record keeping: Standardized and legible record keeping formats, which clearly document patient progress, care, and diagnostics provided.

Clinical algorithms: Incorporation of algorithmically driven and evidence-based critical care pathways as a reference point to assess individual patient responses.

Outcomes management: Regular assessment of patient progress compared to baseline with both clinical and self-reporting instruments.

Source: Adapted from McElheran L, Sollecito P. Delivering quality chiropractic care in a managed care setting.
Top Clin Chiropr 1994;1(4):30-39.

D. Chiropractic Experience in Health Policy and Health Administration Positions

1. Public Sector Positions

There are numerous reports in the chiropractic literature that exemplify efforts of the chiropractic profession to contribute to public health policy (Mootz, 1995d; 1995a; Haas, 1996).

**Chiropractors might gain greater acceptance if they embraced and promoted immunization and fluoridation.

However, opportunities for employment in State and Federal agencies within the public health sector have been limited. This in part has been due to past practices by medical and public health trade organizations (e.g., AMA, APHA), which maintained prohibitions against interactions with chiropractors and encouraged that "state legislatures and health agencies not include chiropractors under state health programs" (Haas, 1996; Wardwell, 1992). The past two decades have seen significant changes in chiropractic's status, including a successful anti-trust suit against the AMA (Getzendaner, 1987), along with a revision of the AMA's code of ethics related to working with chiropractors and the reversal of the APHA's stand on chiropractic (Baird, 1996). The World Health Organization also has established official relations with the chiropractic profession through the admission of the World Federation of Chiropractic as an affiliated nongovernmental organization.

Most jurisdictions appoint chiropractors to serve on examining, licensing, quality assurance, and/or disciplinary boards to ensure competency and to regulate practice (Haas, 1996). Positions for chiropractors also exist on industrial insurance boards, health care commissions, and staffs of medical directors, among others (Mootz, 1995a). Additionally, chiropractors have served as reviewers and consultants for the National Institutes of Health, the Agency for Health Care Policy and Research, the Health Services Resource Administration, the Department of Defense, and the Health Care Financing Administration (Mootz, 1995a; Haas, 1996).

Given the large number of physician visits for musculoskeletal conditions, particularly low back pain (Cunningham, 1984; Deyo, 1987), along with chiropractors' interest and expertise in this area, and the growing evidence for the effectiveness of their treatment, it is reasonable to anticipate greater involvement of chiropractors in the policymaking and public health positions in the future. Chiropractors have pursued postgraduate training in public health (Mootz, 1995a) and proposals have been made to increase training opportunities within chiropractic schools for career options in health services research and public health (Mootz, 1995d). Several such individuals have received appointments at major universities and "think tanks" around the world.

2. Private Sector Positions

Positions for chiropractors as claims consultants, medical directors, and in health administration positions have existed in the private sector for many years, although no formal inventory of such positions has ever been undertaken (Haas, 1996; Mootz, 1995a). Many of the chiropractic practice parameters, guidelines, and technology assessment efforts discussed previously have been stimulated by public policy initiatives, private sector insurers, and managed care organizations' needs (Hansen, 1995; 1994a). As a result, involvement of chiropractors in this area may continue to

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