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House Committee on Veterans' Affairs
Subcommittee on Health

Hearing on Chiropractic Services
in the Department of Veterans Affairs
October 3, 2000

Written Testimony by Dr. Rick McMichael
on Behalf of The American Chiropractic Association

Good morning Chairman Sterns and members of the subcommittee. My name is Dr. Rick McMichael, I am a practicing doctor of chiropractic with 26 years of experience. I currently practice in Canton, Ohio, and serve as the Ohio delegate to the American Chiropractic Association (ACA). I served as a member of the Department of Defense Chiropractic Health Care Demonstration Project Oversight Advisory Committee (CHCDP OAC), representing the Congress of Chiropractic State Associations. Currently, I serve as the president of the Ohio State Chiropractic Licensing Board.

This morning, I would like to share with you the eye-opening experience I had as a member of the DOD CHCDP Oversight Committee, and how this relates to providing chiropractic services to our nation's veterans. Not only did a large number of military personnel independently choose chiropractic services for care, but those who sought chiropractic care also reported significantly higher satisfaction and outcomes. There were no significant difficulties in opening chiropractic clinics, and doctors of chiropractic worked well with the other military health care providers. I believe that the CHCDP experience, the DOD's final report on the demonstration project, and the CHCDP minority report all show that chiropractic is a valuable service, needed and desired by many military personnel.

The CHCDP and accompanying reports showed that chiropractic care: reduced disability; return to duty; saved approximately 199,000 work days per year; improved patient satisfaction; decreased physical therapy and related cost savings; and produced an inpatient cost savings. I believe the benefits of chiropractic care will continue to be proven with the addition of chiropractic services in the military health care system. Our military personnel deserve the ready availability of these much-needed and much-desired services, and our nation's veterans deserve no less.

As you are aware, the Veterans Millennium Health Care Act included a provision requiring the Department of Veteran's Affairs to develop a policy with regard to chiropractic care in the DVA health care system. More specifically, Section 303 of the Act required that within 120 days after enactment of the Act, the DVA Under Secretary of Health, after consultation with chiropractors, would establish a policy for VHA regarding the role of chiropractic care for veterans.

In response to the enactment of this provision, the ACA and Association of Chiropractic Colleges (ACC) provided to the DVA a set of policy recommendations to serve as the basis of the agency's new policy on chiropractic. The recommendations included, a full scope of practice and hospital privileges for doctors of chiropractic, direct access for patients, availability of chiropractic care at all DVA treatment facilities, and other substantive pro-chiropractic recommendations. A copy of this report is respectfully submitted for the committee record.

On February 24, 2000, I had the opportunity to join representatives of the ACA, ACC and other chiropractic organizations for a meeting with officials of the Veterans Health Administration to discuss implementation of chiropractic care into the VHA. The ACA/ACC representatives' main objective was to seek direct patient access to a full scope of chiropractic services. Despite these efforts, the DVA ignored the input of the chiropractic profession and Members of Congress and ultimately developed a policy on chiropractic care that is totally inadequate. This poorly developed policy states that: "It is the VHA policy that VHA medical centers and clinics may offer chiropractic spinal manipulative therapy for musculoskeletal problems of the spine." As you are well aware, Mr. Chairman, the use of the word "may" in the policy statement means that the DVA is not mandating individual medical facilities provide chiropractic care to their patients.

Despite the exclusion of any recommendations put forth by the chiropractic profession, we are now asked by the Department of Veterans Affairs (DVA) to believe that the chiropractic policy they issued on May 5, 2000, is adequate, and will ensure that eligible veterans in need of chiropractic care will have access to it. Insofar as the ACA is aware, however, there is no DVA program or organized effort, of any type, that exists to ensure that chiropractic services are in fact made available within the DVA health care system. It is clear that the current DVA bureaucracy is quite satisfied with merely having issued a so-called chiropractic "policy"-- and now that the policy has been issued, they could care little whether the policy is appropriate or ensures adequate access to chiropractic care. Certainly, no substantive activity is currently taking place within the DVA to encourage the use of chiropractic care. The bureaucracy's contentment with their chiropractic policy most likely stems from the fact that they know, or suspect, that their policy will probably prove both inconsequential and ineffective -- and as such, will have no significant impact in the way they conduct business today. Clearly, they do not expect significant referrals to doctors of chiropractic to occur as a result of this policy. This may mean that American veterans will be denied fair access to care they want and deserve just like every other American citizen.

How do they expect the policy to work? Are they not aware of past, unlawful efforts on behalf of organized medicine to contain and destroy the chiropractic profession and the lingering effects this discrimination has had against doctors of chiropractic and their patients? Are they not aware that in some quarter's biased attitudes towards the chiropractic profession still exists? Are they not aware that medical doctors receive no education or formal training of any sort regarding chiropractic care, nor are they trained or educated as to when a referral to doctor of chiropractic is warranted? So even when bias is not present, there may likely remain little knowledge on behalf of DVA medical doctors as to when it is appropriate to refer to a doctor of chiropractic. Are they unaware of their own indifference regarding chiropractic care and of the Agency's failure -- over the past half century -- to initiate, of its' own accord, any effort to encourage the use of chiropractic care within the DVA health delivery system? Not one pro-active step in five decades...!

When examining the DVA track record regarding chiropractic care in its' totality, one is forced to conclude that the DVA bureaucracy today, either remains biased against the chiropractic, is woefully ignorant about the benefits of chiropractic care -- or both. If either of these is true, it reflects poorly on stewardship of the DVA health care program. At a bare minimum, it must be said that the Agency has engaged in a pattern of long-term neglect with respect to the provisioning of chiropractic care.

Because of the well-documented record of prejudice and neglect towards chiropractic, the ACA recommends that the House Committee on Veterans Affairs move forward, at the first opportunity, to advance legislation that would require the DVA at a minimum to make available chiropractic care on a "direct access" basis and allow doctors of chiropractic practicing within or furnishing services to the DVA health care system to provide the full-scope of their services as enacted under applicable state law. As you may know, a similar chiropractic provision applicable to the Department of Defense health care system was recently included in the House-passed version of the FY2001 Defense Authorization Act (H.R. 4205), which was voted on and approved by the full U.S. House of Representatives.

With respect to direct access, I would like to clarify that an eligible veteran could self-select to be examined and treated by a doctor of chiropractic, without first having to receive a referral from a medical doctor or other health care provider. Ensuring direct access to doctors of chiropractic is extremely important to the proper utilization of chiropractic care. Patients often experience difficulty accessing chiropractic care when a referral from a medical doctor or nurse is required. AHCPR recognized this problem in a report entitled "Chiropractic in the United States: Training, Practice and Research". In this report, AHCPR stated: "Given that medical practitioners have little exposure to chiropractic training or practice, a case can be made for not requiring medical referral." A direct access system within the DVA would expand an eligible veteran's "choice" of care and "choice" of provider within the DVA health care system, and it would go far towards ensuring that artificial barriers would not be erected in an effort to discourage access to chiropractic care.

It should be noted that doctors of chiropractic are licensed and regulated in all fifty states as independently practicing health care professionals. All of these jurisdictions recognize chiropractors' rights and responsibilities to serve as first-contact, portal-of-entry providers. As such, doctors of chiropractic possess the diagnostic skills necessary to differentiate health conditions that are amenable to their management from those conditions that require referral or co-management with another professional. Doctors of chiropractic recognize the value of working in cooperation with other health care practitioners and acknowledge their responsibility to do so in the best interest of their patients.

An additional benefit of direct access should also be noted. Such a system within the DVA would encourage the use of chiropractic care -- a low cost, non-surgical and non-pharmaceutical form of care. This may help avoid unnecessary surgeries and pharmacological interventions within the DVA health care system -- and would help emphasize the benefits of the chiropractic profession's natural, "wellness" approach to health care that includes advice on diet/nutrition and exercise/rehabilitation. As added benefit is, that to the extent that some surgical and pharmacological interventions could be eliminated, the risk of life-threatening medical mistakes and/or adverse drug reactions could be lessened within the DVA health care system -- a laudable goal in and of itself.

The other component of any viable chiropractic benefit within the DVA is a doctor of chiropractic's ability to provide the full scope of their services (as determined by state law) to veterans seeking chiropractic care. The practice and procedures that may be employed by doctors of chiropractic are based on the academic and clinical training received in and through accredited chiropractic colleges. These include, but are not limited to, the use of diagnostics and therapeutics. Such procedures include the adjustment and manipulation of the articulations and adjacent tissues of the human body, particularly of the spinal column. Included is the treatment of intersegmental disorders for alleviation of related functional disorders. Patient care is conducted with due regard for environmental, nutritional, psychotherapeutic factors as well as first aid, hygiene, sanitation, rehabilitation, and physiological therapeutic procedures designed to assist in the restoration, and maintenance of neurological integrity and homeostatic balance.

We request that the Committee ensure that the "direct access" and "full scope" provisions comprise the core provisions of any legislative initiative aimed at ensuring access to chiropractic care for our nation's eligible veterans. The ACA stands ready and willing to work with the Committee to ensure the adoption of an appropriate legislative provision and is anxious to assist in the development of specific legislative language to address our concerns. The American Chiropractic Association also stands willing and able to work with the DVA to devise and implement an acceptable plan to provide for chiropractic care, as envisioned by the statutory provisions we propose. We are confident that a detailed, workable plan can be developed and implemented, provided the DVA is mandated to do so by Congress and acts in good faith to accomplish the legislative requirements.

Mr. Chairman, we have before us an historic opportunity to take decisive steps to ensure that our nation's veterans are afforded access to the benefits of chiropractic care by advancing legislation that would establish a framework within the DVA that would ensure the delivery of chiropractic services in an appropriate and effective manner. Undoubtedly this will require the DVA to make some modifications to the way they currently conduct business today. Change, of course, can often be unsettling to any government agency ­ however, in this case I am hopeful that DVA will not further resist a better way of serving our nation's veterans. I believe we have much to offer to the DVA, and if its representatives will work with the chiropractic profession in good faith to enhance health care for our nation's veterans, there is much we can achieve together.

We wish to be clear, however, that in our judgment it will be necessary for Congress to firmly establish in statute, desired policy goals and objectives to ensure that a full scope of chiropractic services are made available to our eligible veterans on a direct-access basis, without the imposition of unnecessary barriers to that care. Once Congress establishes those firm statutory directives, the chiropractic profession looks forward to working though our current differences with the DVA and in good faith develop an effective chiropractic policy that will benefit the health of our nation's veterans.

This concludes my brief remarks, and I will be happy answer any questions the Committee may have regarding this testimony.

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This page was posted on October 18, 2000.