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Independent Practitioners under Medicare (1968)

APPENDIX B (CONTINUED):
Statement by the
American Chiropractic Association
submitted to the Public Health Service
October, 1968.

I. THE DISCIPLINE

A. Definition

Chiropractic is a study of problems of health and disease from a structural point of view, with special consideration given to spinal mechanics and neurological relationships.

All states (other than Louisiana and Mississippi) have statutes recognizing and regulating the practice of chiropractic as an independent health service. In 1929 the Congress of the United States passed a law for licensing of chiropractors in the District of Columbia.

The practice of chiropractic is officially recognized in six of the provinces of Canada, in Switzerland and in West Germany, and is acknowledged and accepted in the Scandinavian countries, France, Italy, the British Isles, Australia, New Zealand, South Africa, Rhodesia, and Japan.

B. Scientific Theories and Principles of Chiropractic

Chiropractic is built upon three related scientific theories and principles:

1. Disease may be caused by disturbance of the nervous system.

While many factors impair man's health, disturbances of the nervous system are among the most important factors of disease etiology. The nervous system coordinates cellular activities for adaptation to external or internal environmental change. Environmental agencies and conditions which irritate the nervous system, and to which the body cannot successfully adapt, produce fluctuations in the frequency of nerve impulses deviating from the norm. Thus originate many diseases.

2. Disturbance of the nervous system may be caused by
derangements of the musculo-skeletal structure.

Off-centerings (subluxations) of vertebral and pelvic segments represent a common mechanical pathology in man, the biped. Extended abnormal involvement of the nervous system may result from disturbances, strains and stresses arising within the musculo-skeletal system due to man's attempt to maintain this erect posture. The mechanical lesion, or "subluxation," is a common result of gravitational strains, asymmetrical activities and efforts, and developmental defects. Once produced, the lesion becomes a focus of sustained pathological irritation which may trigger a ful1fledged syndrome of severe nerve root irritation or compression.

3. Disturbances of the nervous system may cause or
aggravate disease in various parts or functions of the body.

Vertebral and pelvic subluxations may he involved in common functional disorders of an organic visceral and vasomotor nature, and at times may provoke phenomena that relate to the special organs. Under predisposing circumstances almost any component of the nervous system may directly or indirectly cause reactions within any other component, by means of reflex mediation.

The conjunction of independent causes of bodily disfunction may jointly have more serious debilitating effect than either cause might have had separately. Subluxation may contribute to the "triggering" or exacerbating of migrainous types of headaches, asthmatic syndromes. and certain types of neurovascular and neurovisceral instabilities. Often correction of the spinal lesions is an imperative toward effective total management of the case.

C. The Practice of Chiropractic

1. The Role of Diagnosis

In general diagnosis plays the same role in chiropractic as in all the healing arts, the basis for determination of the treatment.

(a) Interview. The initial interview and consultation with the patient is of utmost importance. Every measure of observation that will more substantially profile the patient is employed and recorded.

(b) Physical Examination. The Doctor of Chiropractic conducts a systematic and thorough physical examination using the methods, techniques, and instruments that are standard with all health professions. In addition, he includes a postural and spinal analysis, an innovation in the field of physical diagnosis and examination.

(c) Diagnostic Aids. The Doctor of Chiropractic uses the standard procedures and instruments of physical and clinical diagnosis and is well acquainted with the need for differential diagnosis. Diagnostic radiology, especially as it relates to the skeletal system, is a primary clinical diagnostic aid in chiropractic.

(d) Laboratory Tests. Doctors of Chiropractic are knowledgeable in the standard and the special clinical laboratory procedures and tests usual to modern diagnostic science. Each ACA-accredited college has a laboratory licensed to carry on clinical laboratory examinations. including such fields as cytology, chemistry, hematology, serology, bacteriology, parasitology, and EKGs.

2. Treatment Methods.

Chiropractic treatment methods are determined by the scope of practice authorized by State Law. Chiropractic methods do not include the use of drugs or surgery.

(a) The Chiropractic Adjustment. The most characteristic aspect of chiropractic practice is the correction (reduction) of the subluxated vertebral or pelvic segment or segments, by means of making a specific chiropractic adjustment. The purpose of this adjustment is to normalize the relations of segments within their articular beds and relieve the attendant neurological and vascular disturbances.

(b) Dietary and Nutritional Supplementation. Vitamin and mineral food Supplementation can, if professionally supervised, serve to prevent the onset or assuage the existence of some types of dysfunction of the nervous system.

(c) Physiotherapeutic Measures. Physiotherapy is used as an adjunctive therapy to enhance the effects of the chiropractic adjustment.

D. Contributions of Chiropractic to Health Field

1. New Knowledge

Chiropractic has developed new areas of knowledge, and refined other areas, in the clinical aspects of human biology, physiology and anatomy. as they relate to the mechanics of the spine and pelvic areas and to their interrelation with the nervous system.

2. New Techniques

Diagnostic: spinal palpation, soft tissue palpation, postural evaluations, inspection for asymmetries, variation testing, and spinography.

Therapeutic: The chiropractic adjustment, corrective manipulation, aspects of spinal traction, heel and sole lifts, and sleeping aid facilities.

3. New Approaches to Health

Chiropractic regards disease processes as a result of the multiplicity of factors among which structural abnormalities and their effect upon the neurological component play important roles in relation to abnormal functional performance. Disturbances of the neurological components at one area may extend to other areas. Because of the body's structural and functional interrelationship, a structural disturbance may induce or aggravate disturbances in other organs, systems and body areas. Chiropractic's approach is to the total person.

II. THE PROFESSION

A. Doctors of Chiropractic

1. There are some 23,400 Doctors of Chiropractic in the U. S.

2. The greatest number of Doctors of Chiropractic are in independent private practice. ACA membership surveys indicate that 85.4% are in general practice, and 14.6% in the specialties (roentgenology, orthopedics, nutrition, physiotherapy).

3. A survey of annual income showed an annual income for Doctors of Chiropractic of $14,000 in 1962.

4. All Federal agencies accept sick leave certificates signed by Doctors of Chiropractic, and fees paid to Doctors of Chiropractic are allowable deductions as expenses for "medical care" for Federal income tax purposes.

5. Chiropractic has relationship with third party payers such as commercial insurance companies, workmen's Compensation agencies and Medicaid under Title XIX of the Social Security Act.

B. Chiropractic Patients

1. In 1963-64, 4 1/4 million persons consulted a Doctor of Chiropractic or 2.3% of the civilian noninstitutional population.

2. Most chiropractic patients are afflicted with involvements of the musculo-skeletal system.

C. The American Chiropractic Association

1. ACA is a national non-profit professional organization with ties and affiliations to state chiropractic associations; ACA has a staff of some 45 members. Its income comes from dues, its JOURNAL and convention exhibits.

2. ACA conducts the Customary professional and other activities of a national health professional association.

3. As of June 1, 1968, ACA has 7,327 members.

4. ACA's Councils include: Education, Roentgenology, Technic, Mental Health, Orthopedics and Physiotherapy.

5. ACA has a Code of Ethics and established disciplinary procedures (State associations also have such codes and procedures.)

III. CHIROPRACTIC EDUCATION

A. Chiropractic Schools

Eight chiropractic schools are either fully, conditionally or provisionally accredited by the ACA, and one other is affiliated, but unaccredited.

The eight schools had 2,110 graduates between September 1960 and June 1967. Their total enrollment in 1967-68 was 1,192 students.

Chiropractic colleges require a minimum of four academic years of professional resident study (not less than 4200 clock hours), including clinical experience under strict supervision. For a major part of two years the chiropractic student is educated in anatomy, biochemistry, microbiology, pathology, physiology, public health, diagnosis and X-ray, clinical disciplines, related health sciences, and chiropractic principles and practice. The remaining two years are devoted to practical or clinical studies dealing with the diagnosis and treatment of disease with approximately half of the time spent in the clinic.

The validity of a Doctor of Chiropractic (D.C.) degree is attested by the United States Office of Education in its publication entitled "Academic Degrees" (p. 169).

B. Accreditation Procedure

1. ACA has established a five-member Committee on Accreditation.

2. The accreditation process involves:

(a) Self-Evaluation by school of every facility, program and procedure, and all personnel (including students).

(b) Committee's study of self-evaluation report.

(c) On-campus study by an evaluation team composed of two members of the Committee (who are not alumni of the visited institution), two experienced science professors from recognized universities, and ACA's Director of Education (who formerly was president of two non-chiropractic colleges).

(d) Committee's study of report of evaluation team, and decision in Committee meeting.

C. Accreditation Requirements

1. There is a "Standard Basic Curriculum." (See Exhibit IV, A, 3, p. 32 of full document).

2. Prescriptions are set for faculty qualifications, faculty-student ratios, and physical plant.

3. Entrance requirement: at least two years of college work.

IV. MEDICARE

A. Basic Principles

1. Freedom of Choice

Congress mandated two overriding principles in the very first two sections of the medicare law:

"PROHIBITION AGAINST ANY FEDERAL INTERFERENCE," (Section 1801)

"FREE CHOICE BY PATIENT GUARANTEED," (Section 1802).

Therefore, a medicare beneficiary should be free to choose the services of a licensed health professional and the States should have freedom to license health services.

State laws provide as follows:

(a) Chiropractic is a recognized health profession licensed in 48 states, the District of Columbia, and in Puerto Rico. In 1966 a study by the U.S. Public Health Service classified chiropractors among "medical specialists and practitioners," including pediatricians, obstetricians and ophthalmologists, among others. Public Health Service's HEALTH MANPOWER SOURCE BOOK includes Doctors of Chiropractic along with physicians, surgeons and dentists.

(b) Within the scope of practice authorized by the States, a Doctor of Chiropractic provides a health service which is alternate to that provided by a Doctor of Medicine or a Doctor of Osteopathy for benefits already authorized under medicare. Therefore, within State-autho6zed scope of chiropractic practice, a patient may freely and legally choose the health service of a D.C. as an alternate to the health services of an M.D. or a D.O.

Consequently, where medicare authorizes a patient to choose professionals already specified in the law for health services for an ailment or condition, that patient should also be authorized full freedom of choice to obtain health services from any Doctor of Chiropractic licensed by State law to provide health services for that same ailment or condition.

2. Continuity of Health Services

Medicare should enable its beneficiaries to continue receiving legally permissible health services which they obtained prior to medicare eligibility. Title XIX of the Social Security Act (Medicaid) already authorizes Federal matching of State expenditures for chiropractic services. As a result, at least 17 States now provide chiropractic services under medicaid. Thus, the medically indigent can obtain chiropractic health services under medicaid (Title XIX), but the medically self-sufficient cannot obtain chiropractic health services under medicare (Title XVW), although they voluntarily pay for medicare benefits.

However, the continuity under medicare of prior chiropractic services in medicaid is threatened by a provision that takes effect in 1970, that a State must "buy into" medicare for all of its medicaid beneficiaries eligible for medicare. Thus as soon as a medicaid patient becomes eligible for medicare, he will be automatically cut off from all chiropractic services.

This same discontinuity of chiropractic services strikes medicare beneficiaries who, prior to medicare eligibility, obtained chiropractic services financed out of non-Federal funds, such as personal funds, health and accident policies, the workmen's compensation program of 48 States, and job-provided health plans.

B. The Crisis in Health Manpower

The crisis in health manpower emphasizes the public interest in assuring medicare coverage for chiropractic health services.

Chiropractic can play a major role in alleviating this crisis.

1. There were 23,409 active D.C.s in 1965, compared with 305,115 M.D.s and D.O.s according to the Public Health Service.

2. Farm and rural families are especially in need of chiropractic services:

(a) A major Public Health Service study indicated statistically a greater orientation of D.C.s to rural and non-urban America than is true of other health professions.

(b) The President's National Advisory Commission on Rural Poverty reported that only 12% of M.D.s are located in rural areas.

(c) ACA's estimate is that in 1968 60% of D.C.s were located in communities with a population of 50,000 or less.

The omission of chiropractic from medicare will adversely affect the national interest in at least three ways:

1. It will spread the health crisis to the millions of Americans receiving chiropractic health care.

2. It will exacerbate the crisis for patients of other health professionals to whom chiropractic patients will have to turn, thus further overloading such other health services.

3. It will most seriously damage those parts of the United States already most endangered by the health crisis, e.g., the rural and non-urban areas of America.

V. CONCLUSIONS AND RECOMMENDATIONS

CONCLUSIONS:

1. Medicare's statutory principles of "Freedom of Choice" and "Prohibition Against Any Federal Interference" require that medicare patients should be free to choose chiropractic health services to the extent that such services are authorized by State law.

2. The interest of medicare patients in the continuity of legally authorized health services obtained prior to medicare eligibility requires that they be enabled to obtain chiropractic services under medicare.

3. The public interest in coping with the crisis in health manpower requires that medicare patients be authorized to obtain the health services of Doctors of Chiropractic to the extent authorized by State Law.

4. Equity and public policy require that the medically self-sufficient should have the same right to chiropractic services under medicare that the medically indigent already have under medicaid.

RECOMMENDATIONS:

The ACA respectfully recommends that, as the U. S. Senate voted overwhelmingly in 1967, the medicare law be amended to include the services of a Chiropractor with respect to functions which lie is legally authorized to perform as such by the State in which he performs them.

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