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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

Testimony on behalf of the International Chiropractors Association
presented by Michael S. McLean, D.C.

I am Dr. Michael McLean, Chairperson of the Legislative Committee of the International Chiropractors Association (ICA). I also serve as a member of the Board of Directors of that organization. We at the ICA appreciate the opportunity to present our organization's perspective on the very important matter of chiropractic services for our nation's veterans. This is an issue that has been of major importance to us for a very long time. In fact, the first legislative initiative to provide chiropractic benefits for our nation's military veterans was introduced at the request of the ICA in 1936. We also understand that our concerns and objectives are shared by all of the other major chiropractic organizations in the United States and we are here on a collective basis to ask the Committee for action on a matter that is long overdue.

The steps that Congress must take to provide for reasonable access to chiropractic services for America's veterans are clear. What is also unfortunately clear is that unless the Congress enacts a series of very specific mandates, with a designated timetable for action, the U.S. Department of Veterans Affairs (DVA) will not make any significant effort to provide access to chiropractic services on anything other than a token basis. In fact, the obvious context of this hearing is the failure of that agency to provide for meaningful chiropractic access, despite the periodic legislative encouragement from Congress and the decades of opportunity the Department of Veterans Affairs has been given to develop a reasonable chiropractic program from within.

The status of chiropractic science and the chiropractic profession today is well understood in the greater health care community and has been embraced by and is, indeed, the product of enthusiastic consumer support and confidence. In a highly competitive marketplace, chiropractic has validated itself in the most profound and emphatic manner possible, through millions of individuals in the private sector willing to pay out of their own pocket for chiropractic care, when standard medical care was available to them at little or no cost through public or private insurance programs. I do not, however, wish to focus my time today on these details even though this information is important to the full understanding of the role chiropractic can and should play in all public health care programs. Instead, I would refer the Committee to the presentation made by the International Chiropractors Association to the U.S. Department of Veterans Affairs on February 24, 2000, Chiropractic in the Veterans Health Care System. Copies of this extensive document have been made available through the Committee staff and its full text is available on ICA's website at www.chiropractic.org. I urge every Member of Congress to review this extensively referenced and well-researched document for a full discussion of the definitions and authorities under which the chiropractic profession operates and the basic clinical elements that distinguish and define the science and practice of chiropractic as a unique approach to health and health care.

ICA does wish to frankly address the elements of public policy that need to be enacted in order to provide for reasonable access to chiropractic services through the DVA. These elements have been the subject of intensive discussions in recent weeks between representatives of the major chiropractic organizations, Members of Congress and the staff of this Committee. ICA respects and appreciates the good faith efforts of all parties to these discussions but feels that the time for specific, decisive action has come, and we are looking to the Committee for insightful and innovative leadership in this area to expand and enhance the health care choices of our nation's veterans to include chiropractic services.

ICA believes that the following elements should be enacted to insure that America's veterans have available to them the same chiropractic options and resources that are presently available in most other health benefits programs:

The establishment of statutory authority to employ doctors of chiropractic as professional care givers within the DVA. We specifically ask that Title 38, Section 7401 be amended by inserting the words "doctors of chiropractic" after "optometrists". We also ask that Section 7402 be amended by the insertion of a new sub-section after the current sub-section (2) dentists, identifying "doctors of chiropractic" in the sequence of professionals specifically authorized to be employed under that section. The employment criteria for doctors of chiropractic in such a new provision should include the requirement that any such chiropractic professional be the graduate of an institution accredited by an agency recognized by the U.S. Department of Education for such purposes, and hold a valid chiropractic license in a State. Such criteria are comparable to those provided for in this section for dentists, podiatrists, etc. Authority to hire doctors of chiropractic should be accompanied by instructions to act on that authority and a timetable to deploy an initial group of doctors of chiropractic within VHA facilities.

The establishment of a Division of Chiropractic Services, headed by a doctor of chiropractic, within the Veterans Health Administration to oversee and facilitate the effective integration of chiropractic services into the systems in place at that agency. The statutory establishment of such a division would serve to insure that appropriate means would be available on an on-going basis to address operational and procedural questions, peer review issues and to serve as a focal point for the distribution of accurate and relevant information about chiropractic services and the role of the chiropractic professional. Such a step would also signal the resolve of Congress to secure a meaningful and on-going program of chiropractic care and would serve as an important guarantee of fairness, efficiency and quality of care.

The statutory establishment of direct access to chiropractic services as a care pathway choice for eligible veterans, without the requirement of a referral from another professional as is presently required under current policy.

The statutory establishment of a chiropractic advisory committee comprised of representatives of the chiropractic profession to assist senior VHA officials in addressing program and policy questions and in developing innovative service and research initiatives to maximize the quality, timeliness and availability of chiropractic care. The establishment of such a committee would be consistent with provisions already passed by the House for chiropractic programs in the U.S. Department of Defense.

The enactment of a specific Congressional directive to the Veterans Health Administration to develop within a reasonable period of time a plan for making chiropractic services routinely available on an outpatient basis for those program beneficiaries outside the geographic range of VHA clinical facilities.

These five basic elements would provide the foundation for a clinically appropriate, reasonable and cost-effective chiropractic program within the Department of Veterans Affairs. Each of these elements are also firmly grounded in the clinical abilities and experience of the doctor of chiropractic, our experience in cooperative care in inter-professional settings, and the realities of contemporary health care science and administration. We are also aware, however, of concerns brought forward by members of the Committee staff regarding these proposed initiatives and I wish to specifically address a number of those points in detail.

The first of these issues is the employment of doctors of chiropractic and the integration of chiropractic professionals into the VHA system and VHA facilities. Concern has been expressed about the role doctors of chiropractic would play in the primary care system in place in that agency and the delineation of authorities and responsibilities under that system. The International Chiropractors Association believes that the employment of doctors of chiropractic in VHA hospitals and clinic facilities is an obvious and highly practical point at which to launch the integration of chiropractic services into the VHA system. Such inclusion would provide for the maximum coordination of care for program beneficiaries, facilitate professional understanding, utilize the efficiencies and economies of scale inherent in the pre-existing resources and facilities, administrative, diagnostic and professional, and provide maximum convenience and access to the greatest number of beneficiaries.

The experience of chiropractic professionals in the hospital and multi-disciplinary setting over the past several decades has established a record of cooperation and service that should serve as a positive model for the VHA. Doctors of chiropractic serve in hundreds of hospitals in the United States in a wide variety of settings and contexts. Clarity of roles and authority is well established in such settings and the team approach to health care delivery that such situations facilitate provides for the highest level of patient care. Each professional serves to address the needs of patients within their professional competence. Cooperative and concurrent care between chiropractic providers and other professionals widens the options available to patients, enhances quality and efficiency, as well as cost-effectiveness.

I would also refer the Committee to the testimony presented today on behalf of the Association of Chiropractic Colleges for an extensive report on the very positive hospital/clinical experience in the Department of Defense chiropractic project. This project demonstrates the potential for inter-professional cooperation in government programs and strongly validates the position presented by the ICA on this question.

In practical terms, there are no real barriers to the effective integration of chiropractic services and the doctor of chiropractic into the primary care system now in place at the VHA other than a reluctance to do so on the part of the policy makers directing those programs. The administrative qualification process that determines the eligibility of a veteran for care would not change. The basic intake process would remain unchanged in that the general evaluation of the patient would proceed along current lines and the primary care personnel now attending to beneficiary needs would continue their relationship with and involvement in patient care. What is different would be the existence of a clearly identified care option open to qualified beneficiaries which they would be free to seek, without the requirement of a referral from another health care professional.

The intake and general evaluation process of every patient ought to include a chiropractic evaluation, given the prevalence of spinal problems in all segments of the population of the United States. Along with the health history, baseline laboratory tests, vital signs and other standard evaluation processes, a chiropractic examination should be part of this initial evaluation process because of the unique training, skills and clinical experience the doctor of chiropractic brings to the diagnostic process. The practicality and cost effectiveness of this goal ought to be explored. At a minimum, qualified beneficiaries should have the right to choose a chiropractic program of care for chiropractic conditions rather than be limited to, indeed, forced to accept one medical pathway. This in no way removes or alters the role of other providers in the care of conditions that fall within their specific expertise. Once again, the team approach and a fully cooperative model of patient care is the goal.

In considering these issues, it is helpful to understand the exact nature of chiropractic science and practice and the separate and distinct approach to health and health care taken by the doctor of chiropractic. Chiropractic is a very specific health care science applied by doctors of chiropractic who practice under an extensive body of authorities. These authorities have evolved over more than a century of legislative and judicial development, educational growth, practical experience and professional consensus. Like other first professional degree holders, the doctor of chiropractic is a carefully regulated professional who must qualify on a number of levels to obtain the right to practice.

Chiropractic science is an approach to human health that was developed through extensive anatomical study in which the elements of the human system, particularly the spine and nervous system continue to be examined in an effort to understand the relationship between the state of those anatomical elements and optimal human health. The basic premise of chiropractic science is that abnormalities and misalignments of the spine, defined as subluxation(s) in chiropractic science, can and do distort and interrupt the normal function of the nervous system and may create serious negative health consequences. The correction and/or reduction of subluxation(s) through the adjustment of spinal structures can remove nervous system interference and restore the optimal function of the body. Essential to basic chiropractic theory is the concept of the inherent ability of the human body to effectively maintain optimal health, comprehend the environment and function in a normal manner. This concept is important since chiropractic perceives spinal subluxation(s) as barriers to normal function and obstacles to the body's innate intelligence.

A strong consensus exists within the chiropractic profession on such self-defining issues. This consensus is best depicted by the unanimous adoption of a paradigm statement by the Association of Chiropractic Colleges, International Chiropractors Association, American Chiropractic Association, Federation of Chiropractic Licensing Boards, Council on Chiropractic Education, the National Board of Chiropractic Examiners and the Congress of Chiropractic State Associations. This paradigm statement reads as follows:

"Chiropractic is a health care discipline which emphasizes the inherent recuperative power of the body to heal itself without the use of drugs or surgery.

The practice of chiropractic focuses on the relationship between the structure (primarily the spine) and function (as coordinated by the nervous system) and how that relationship affects the preservation and restoration of health. In addition, Doctors of Chiropractic recognize the value and responsibility of working in cooperation with other health care practitioners when in the best interest of the patient.

THE CHIROPRACTIC PARADIGM

Purpose

The purpose of chiropractic is to optimize health.

Principle

The body's innate recuperative power is affected by and integrated through the nervous system.

Practice

The practice of chiropractic includes:

Foundation

The foundation of chiropractic includes philosophy, science, art, knowledge, and clinical experience.

Impacts

The chiropractic paradigm directly influences the following:

The Subluxation

Chiropractic is concerned with the preservation and restoration of health, and focuses particular attention on the subluxation. A subluxation is a complex of functional and/or pathological articular changes that compromise the neural integrity and may influence organ system function and general health. A subluxation is evaluated, diagnosed, and managed through the use of chiropractic procedures based on the best available rational and empirical evidence.

A subluxation is a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health. A subluxation is evaluated, diagnosed, and managed through the use of chiropractic procedures based on the best available rational and empirical evidence."

This professional consensus is well reflected in the statutes establishing and authorizing chiropractic practice and in the chiropractic professional education process. The doctor of chiropractic is a primary care, direct access, first professional degree level provider who serves as a portal-of-entry into the health care system. ICA understands the term primary care provider to be defined as: Any health care provider capable of providing first level contact and intake into the health delivery system, any health care provider licensed to receive patient contact in the absence of physician referral. All laws and regulations in the United States allow any citizen to seek the services of the doctor of chiropractic without referral from any other provider. Individuals are free to seek basic essential care on the same individual initiative basis that applies to other direct access providers.

Only the doctor of chiropractic is professionally competent to evaluate the chiropractic needs of a patient and to determine the level of service appropriate to meet those needs.

In order to assist the Committee in understanding the nature and flow of chiropractic patient evaluation and care, the following chiropractic patient evaluation and care pathway model is offered. This model for the patient presenting in a chiropractic clinical setting is based on the doctor of chiropractic's competence to evaluate the general health status and needs of each patient and determine the appropriateness of chiropractic care and/or the need for referral to other provider(s) for urgent care, additional diagnostic evaluation in the context of another branch of the healing arts, concurrent care, or no care at all, etc. It also recognizes that the majority of patients making the decision to seek the services of any health care professional do so on the basis of some self-perceived symptom, problem or health concern, or at the behest of a parent or guardian.

  1. Routine Checkup and Prevention/Wellness Care
  2. Initial Presentation--Is Emergency Care Needed?
    Upon presentation of each new patient, the doctor of chiropractic determines whether there is any condition, element or crisis that requires the immediate referral for emergency life-saving care or urgent care.
    The attending doctor of chiropractic is competent to determine, on the basis of immediate findings whether the patient is in immediate need of emergency intervention.
  3. Initial Presentation--Is the Care of Another Provider Needed?
    In the course of this evaluation, the attending doctor determines whether there are findings that indicate the need for referral to another provider.
    If indications for immediate referral are not present, the patient proceeds along the care pathway to the next level. If such a referral is necessary it does not preclude concurrent chiropractic care.
  4. Determining Appropriate Chiropractic Care -- Are There Potential Restrictions On Chiropractic Care?
    The elimination of imperatives to refer having been undertaken, the next step on the chiropractic care pathway centers on the development of an appropriate course of adjustive care, if needed. In that process, the patient's needs and circumstances are evaluated to determine whether there is a need, and if so whether there are any restrictions on the delivery of adjustive care. This evaluation process will direct the attending doctor to employ specific chiropractic techniques that are appropriate to the status of the patient.
  5. Care Delivery
    Having carefully worked through the evaluation process eliminating potential red flags to standard care and techniques, the doctor of chiropractic next outlines and delivers a program of adjustive care and other wellness advice, etc., according to the individual needs of the patient, based on the presenting factors.
  6. Re-Evaluation for New Condition(s) and/or Re-Injury
    On each encounter, the doctor of chiropractic determines whether new conditions and/or injuries might require alterations in the care plan. If there are no such indications, the program of care previously devised will continue.
  7. Progress Evaluation
    After a reasonable period of care, the patient's progress is evaluated by the chiropractic clinician to determine the effectiveness of the chosen course of care and to determine whether alterations in that program are indicated, as determined by the clinician.

It is also important for the Committees to understand the Doctor of chiropractic recognizes of professional boundaries and willing to fully cooperate with and seek the consultation and/or concurrent involvement of other health professionals when the needs of the patient so indicate.

Referral is a professional obligation that is present throughout all phases and aspects of the chiropractic practice. The primary obligation of doctors of chiropractic is to provide the highest quality of care to each patient within the confines of their education and their legal authority. It is the position of the International Chiropractors Association that this primary obligation includes recognizing when the limits of skill and authority are reached. At that point, it is the ICA's position that doctors in all fields of practice are ethically and morally bound to make patient referrals to practitioners in their own and/or other fields of healing when such referrals are necessary to provide the highest quality of patient care.

Doctors of chiropractic are also obligated to receive referrals from other health care providers, applying to those patients the same considerations for quality and appropriateness of care as with any other patient. It is the position of the ICA that the professional obligation to the patient includes honest, full and straightforward communication with the referring provider for optimal patient care.

Summary

The International Chiropractors Association urges the Committee to develop a comprehensive access program that begins with the employment of doctors of chiropractic as professional care-givers in DVA facilities. The DVA should be instructed by Congress to promptly take such steps as are required to provide for reasonable and timely access to chiropractic services at DVA treatment facilities, including hospitals and clinics.

ICA recognizes that facility-based care is impractical in many instances because of demographic and other reasons. In such instances, the DVA should be instructed to establish a plan for out-patient care according to agreed protocols, especially in remote and underserved areas of the nation, and be given a timetable for its implementation.

In accessing chiropractic care, the determination of the need to seek chiropractic care should be at the discretion of the patient. All other federal programs such as Medicare and FEHBP programs provide for such direct access. The unique nature of chiropractic science and practice make it difficult for non-chiropractic doctors to easily recognize the need for and appropriateness of chiropractic care. Thus, direct access provides for an effective means of access that will not delay, confuse or otherwise prevent a beneficiary's access to the care of first choice, while waiting for a referral that may never come. This does not compromise or minimize the procedures and primary care structure presently in place in the VHA, but obligates that agency to expand the decision options available to eligible beneficiaries. This is entirely consistent with procedures in place in a wide range of other clinical and administrative settings. ICA rejects as obstructionist and unreasonable the arguments that direct access is incompatible with the primary care system now in place at the VHA and believes that the initial phase of any direct access program will rapidly demonstrate the ease and practicality of this status.

DVA should undertake to fully orient existing personnel and regularly review procedures to insure that the system understands the potential of chiropractic care and works to facilitate, not obstruct a smooth implementation of a chiropractic benefits program. To this end, the establishment of a permanent chiropractic department, on par with other divisions, through which policies and procedures can be fully and effectively developed and implemented, is indicated.

ICA urges the Congress to require the DVA to maintain an open and objective dialogue with chiropractic professional organizations and educational and research institutions. Such a dialogue should be broad based and inclusive, yet focused on the established organizations and institutions that have a demonstrated record of service to the chiropractic profession and the public. The International Chiropractors Association would seek to participate in such an on-going dialogue and believes that the program, beneficiaries and the profession would benefit by such an effort.

In conclusion, I want to emphasize that the fundamental issue in this discussion is and should be recognized by all parties, as one of fairness to our nation's military veterans. Chiropractic has a powerful, non-invasive, drugless contribution to make to the health of our veterans and the time has come to offer this very special segment of our population the respect, dignity and participation that comes from giving them the choice to seek chiropractic care if they wish. Furthermore, the research and outcomes record clearly shows that chiropractic services represent a significant cost-savings potential, rather than added costs, because of the non-surgical, natural approach to health and healing that chiropractic represents. ICA urges the Committee to objectively examine both clinical outcomes and cost data to understand this impressive record.

I want to thank the Committee and the staff for the serious attention that this body of issues is receiving and to urge the Committee to move forward to do the right thing and enact a meaningful program of chiropractic services for America's veterans. I will certainly be happy to answer any questions any member of the Committee or Staff may have on these topics and the ICA stands ready to provide any additional documentation, clinical perspective or other materials the Committee may wish as all parties work to resolve this important question. Thank you once again for your attention and consideration.

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This page was posted on October 18, 2000.