Chiropractor as (Potentially) Cost-Saving PCP: What Fate the Broad-Scope Practice?
Written by John Weeks
Chiropractor as (Potentially) Cost-Saving PCP: What Fate the Broad-Scope Practice?
Summary: Two months ago, a colleague in the written word, Erik Goldman, editor of Holistic Primary Care,
asked if I might write up something for his journal on the idea of
primary care services provided by chiropractors. What role does this
broad scope practice have in chiropractic, and in healthcare reform?
Goldman was particularly interested in the apparently substantial savings that
were reported from an Alternative Medicine Integration Group model in
which DC-PCPs were available to members of a Blue Cross of Illinois
subsidiary. Here is some of what I learned about the stature of the American Academy
of Chiropractic Physicians and the American Board of Chiropractic
Internists.
Note: This article was largely developed through an agreement with Erik Goldman to write an article on the topic which will run in the summer 2007 issue Holistic Primary Care. The publication reaches over 75,000 primary care practitioners with each issue.
Preface #1: Twisted Knickers and a Note on PCP DCs from David Edelberg, MD
“Here's
an idea that will probably cause some of my physician colleagues to get their
knickers in a twist: it may not be a bad idea to find a good chiropractor to
act as your primary care physician.”
Rubin: Edelberg's model of DC as primary care physician
Long-time integrative medical doctor David
Edelberg, MD, made this statement, and then explained why, in a newsletter article published for his
Chicago-based, multi-disciplinary integrative medicine practice, WholeHealth Chicago.
Edelberg, as some may recall, was the doctor behind what was the most
significant, venture capital-backed effort to develop a national network of
branded, integrative clinics, American Whole Health. Edelberg's comfort with chiropractic grew from his long-time relationship with a broad-scope chiropractor in his clinic, Paul Rubin, DC. Notably, Rubin's practice also includes the use of acupuncture, which is in the chiropractic scope of practice in Illinois.
Preface #2: Knotted Knickers and the New AMI Data
If
one’s knickers are twisted by Edelberg’s assertion, then they are likely to be tangled
into knots by the outcomes of a study of primary care chiropractic
doctors serving an HMO population in Edelberg’s backyard. The Integratoralready previewed the findings of the Chicago-based Alternative
Medicine Integration Group(AMI). These found apparent savings from their network of practitioners who are credentialed to offer natural and other non-pharmaceutical
interventions as the core of their care. AMI’s basic network, from the
beginning, was a credentialed group of chiropractors. (These may have not only acupuncture needles among their available tools, but also therapeutic nutrition, giving them core modalities from two other disciplines: acupuncture and Oriental medicine and naturopathic medicine.) More recently, AMI added some integrative MDs
and osteopaths to their network.
The
findings of the AMI study, to be published in the May 25 issue of the Journal of Manipulative and Physiological Therapeuticsas Clinical Utilization
and Cost Outcomes from an Integrative Medicine Independent Physician
Association: An Additional 3-Year Update (Richard L. Sarnat, MD, James Winterstein, DC and
Jerrilyn A. Cambron, DC, PhD). As compared to norms
in the Blue Cross population, these members had 60%
fewer hospital admissions, 59% fewer hospital days, 62% fewer outpatient
surgeries and procedures, and 85% lower pharmaceutical costs.
What is Meant by a PCP Chiropractor?
For many, these outcomes beg a significant question: What do we mean by a PCP chiropractor? The search for clarity on this question places
one smack in the middle of deep divisions and distinctions in the chiropractic
profession.
Both
the American Chiropractic Association (ACA) and the International Chiropractors
Association
assert that chiropractors are primary care providers. Yet the ICA
typically opposes practitioners
adding modalities beyond manual adjustment to their practice. The ICA opposes reference to "medicine" and "physicians" in the profession's self-definition. On the other hand, the ACA, the significantly larger and more politically involved of the two organizations, acknowledges
use of “physician” language by many chiropractors. This is in alignment with language in chiropractic
licensing statutes in over half of
the states.
The ACA characterizes the role of a chiropractic doctor in a primary
care environment as being:
a) a primary care/direct access practitioner b) health
information resource c) health and wellness advocate d) disease and injury
prevention manager; and e) spinal care specialist within the health care
system.
The professional organization, in a letter sent to the US Department of Health and Human
Services (HHS) as part of the ACA's push to have chiropractors included as
providers in the National Health Services Corp, also notes that some
chiropractors may practice much more broadly than these 5 points suggest. And in their pitch to HHS, the ACA references the findings from Alternative Medicine Integration Group's 2004 publication on the Chicago experience.
Historic Role of Chiropractors as Community Doctors, and Early Acupuncture Practitioners
Winterstein: Broad scope educator, practitioner and researcher
James
Winterstein, DC, president ofNational University of Health Sciences (NUHS) co-author of the JMPT article, was part
of AMI’s original advisory board. (See Integrator article on Winterstein's vision and NUHS's multi-disciplinary program.) Most
of the chiropractic practitioners in the AMI network were graduates of NUHS’s broad
scope chiropractic educational program.
NUHS has a long history of
educating practitioners in a variety of modalities beyond manual therapies. Therapeutic nutrition tops the list.
In fact, Winterstein proudly notes out that
starting in 1970, his school, then National College of Chiropractic, was the
first federally-recognized school in the United States to offer acupuncture
training.
The education at NUHS supports a broad scope chiropractic practice. Winterstein
recalls a time not too long ago when, in many towns throughout the
Midwest and elsewhere, chiropractors served as general practitioners. Winterstein
estimates that one-half of the 16 chiropractic colleges in the United States
are similarly broad in their training. Yet
the organizations set up to promote and advocate for this broad,
physician-level role of chiropractic have gathered little support among the
profession’s roughly 70,000 practitioners. Organizations Promoting Chiropractors as Primary Care Physicians Gain Little Traction
Winterstein and Reiner Kremer, DC, DABCI,
co-founded the American Academy of Chiropractic Physicians (AACP) in 1999 “to
promote the concept of the chiropractic physician.” Yet the group never drew
more than 75-150 people to their meetings. The organization is presently “in a
state of hibernation,” says Winterstein.
An
entity that is similarly dedicated to advancing chiropractic practice as
general medicine is the American Board of Chiropractic Internists(ABCI). ABCI is a
specialty society of the ACA. Cindy Howard, DC, DABCI, the president of the
Board’s parent organization, the Council on Diagnosis and Internal Disorders, explains
that the ABCI offers a 300-hour training which takes place over 26 weekends
during a 3-year period. Included in the training are topics such as
pharmacognosy, biological properties of natural medicines, conventional
diagnostics, and a review of major conditions. Brian Wilson, DC, DABCI, past-president of ABCI, states: “The program focuses on what we
can do for these conditions, in a most conservative way.” The training culminates in
a three part exam, two written and one on clinical practice. Those who pass
become diplomats of ABCI, and use the “DABCI” designation after their DC.
The
ABCI courses leading to board certification have historically been offered
through NUHS, or Texas Chiropractic College, with a third broad-scope
school, Northwestern University of Health Sciences planning to offer a course,
according to Howard. Those taking the
course may do much of the program through distance learning, with the caveat
that various clinical and diagnostic components require hand-on training. Howard says 3 classes are currently running
with “30-50 students in each class.”
Board Certification as an Internist in 300 Hours Versus 3 Years of Residential Training
Asked
how she justifies a 300 hour course toward board certification as compared to
the three year, full-time, residential training requirement of a
board-certified MD-internist, Howard notes that because chiropractors “have no
access to hospital settings,” requirements are more limited. The ABCI program, for instance, does not
require education in inpatient care procedures and surgeries. And while a portion of a DABCI’s training
focuses on the kinds of pharmaceuticals patients are likely to be taking or
which might be indicated (and then sent for referral), the ABCI diplomats do
not need as extensive of training in pharmacy.
Wilson, Howard’s predecessor at
ABCI, explains the differential in hours this way: “We are training people for
a more conservative approach. So we have different purpose and different outcomes
(than internal medicine MDs). But we can certainly talk the same language.”
The philosophy and approach appear similar to that in the training of the licensed naturopathic
physicians. Howard agrees, adding: “But (the naturopaths) are only licensed in
14 states. People are wanting this kind
of care everywhere.”
Yet
like the 8-year-old and now inactive AACP, the ABCI, which dates back over two decades, has failed to gain
much ground inside the chiropractic profession. Howard estimates that there are
just 250 active DABCIs today. The ACA provides the specialty with no financial
support. A supportive continuing education program which was discussed with the
ACA has not been launched. ABCI’s website is outdated. Funding for new initiatives
is limited to revenues from classes.
The Role of Insurance Coverage in Limiting the Scope of Chiropractic Practice
Why,
with half of the accredited chiropractic educational program's broad scope, are
neither the academy nor the board attracting much interest?
Winterstein and
Kremer both pointed to the influence of insurance coverage on the
profession. Third party payments are typically limited to
musculoskeletal conditions. Kremer comments
generally on the influence of insurance on health care: “People will do
what
they get paid for.” In the past 20 years, the chiropractic practice of
many
practitioners has been correspondingly contained to treatment of the
spine.
Winterstein
worries about how this focus on what is reimbursed is limiting of chiropractic and dangerously eroding chiropractic’s
former roles as "trusted family doctors" particularly in many small towns. Kremer, who shares an office with a medical doctor, experiences the erosion as basically a fait accompli: “The consumer doesn’t think of
the chiropractor as beyond back care anymore. People will come see me and say,
I didn’t know a chiropractor could do that.”
Is a National Model Threatened with Extinction?
Few healthcare observers would have guessed that a study of a network that is
principally made of chiropractic PCPs might provide a
national model for cost-saving and health reform. Is it possible that the philosophy
and practices of chiropractic physicians can show us the way toward lower
hospitalizations, surgeries and the costs associated with them, as the AMI
study suggests?
That
HMOs and insurers are not rushing to explore the AMI model is intriguing.
Is it that they are quick to conclude
that the AMI population must have been healthier to begin with, and
less prone to needing costly interventions?
Is it
that the data were not published in a more conventional journal?
Is it that anything
which so challenges conventional care is still suppressed? (Would insurers have flocked to explore the model if the outcomes had been generated in a network of MDs?)
Or is it true that because insurers
work in a cost-plus environment that they have little incentive to reduce
costs? (The argument here is that the higher the health care tab, the higher in
gross dollars is the insurer's cut/percentage/potential profit. So where is the self-interest in holding down costs?)
While
the implications of these questions can be dismaying, Dr. Winterstein directs his
own consternation not at the insurers, but closer to home. He looks across the span of his four decades in chiropractic and shakes his head at what he sees as his profession’s
failure to promote the broad-scope chiropractic model: “Chiropractic is
shooting itself in the foot at a time when more people want a kind of care that
is safer and more natural and more cost-effective.”
Disclosure note: AMI Group is a sponsor of the Integrator.
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