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Chiropractor as (Potentially) Cost-Saving PCP: What Fate the Broad-Scope Practice? PDF Print E-mail
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.
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Article initiator Holistic Primary Care
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

AMI: Knicker knotting data from a knicker twisting model
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 Integrator already 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 Therapeutics as
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 of National 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.

Image 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.

Image 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?

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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