Topic 1: Acceptance of the Chiropractic profession

Acceptance of the Chiropractic profession

“What do you think needs to be done to boost acceptance of the chiropractic profession across the medical system and with the public in general?”

Results gathered from the Future Perceptions Survey identified acceptance as critical to the long-term success of the chiropractic profession. We are interested in hearing your thoughts on what you think needs to be done to accomplish this acceptance over the next five years?

We would love to hear your thoughts!

“What should be done to boost acceptance of the chiropractic profession?”
This discussion board community is intended to spark forward-looking discussions, and aid in developing the focal points for interactive events with facilitators. We invite you to share your thoughts and ideas, in a forward-looking manner. Posts that specifically reference or are intentionally divisive and/or overtly negative towards any individual or organization, or intended as a barrier-building “history lesson”, may be blocked. We thank you for your participation and your thoughtful, forward-looking thoughts and insights!

39 Comments

Standardization. Without that I don’t believe we will gain widespread acceptance within mainstream medicine. A nurse or medical doctor has no clue what to expect from a random DC when considering a referral. We practice within several deviations. As a comparison, PT’s probably practice within 2 SD. Why would they take a chance on one of us when they know exactly what they will get from a PT?

Dr. Simone – you hit the nail on the head! Without standardization we, as a whole, can’t be trusted. When I was a young student in chiro school, my father injured his lower back and thinking that all DCs were the same, chose one in our neighborhood who was a self-proclaimed “headache specialist”. All he did was manipulate my father’s neck, from which he suffered recurrent neck pain for the rest of his life. I referred him to one of my professors and his LBP was relieved with one manipulation to the SI joint. The profession needs to have the will to clamp down hard on bizarre practices or we’ll never gain the public’s trust.

Standardization may be a key but if all our attention is to standardize care to treat pain and loss of adequate function then this may be good though the chiropractic I have done and my many mentors have done is so much more than separating parts of the body and only standardizing treatment for the parts I think we are missing the point.

PT are not getting paid well either. Their reimbursements are getting worse and worse and you would want us following them? I would have to disagree.

Dentists earned their acceptance through public education and unity in what Dentist does. Chiropractors on the other hand are so varied in their procedures that a common thread will be difficult to gather around. We can’t even define a subluxation, prove one exists or show that it was fixed! Go to one DC and it’s rack’m’stack and a contract for 30 visits. Go to another and they’ll adjust your auras. some type of objectivity within the profession is needed and must be shown to the public in order for the public to think there is value in what we do.

1)I think that we should poll non-chiropractic stakeholders in healthcare services in the same fashion that Wisconsin did thru Harper Polling, rather than chewing on our collective cud and coming up with the same response breakdown. Rather than looking in the mirror and coming up with a myopic insight, maybe we should look at ourselves through the eyes of our patients, allied health care professionals, and other major stakeholders. SEE ATTACHED https://gallery.mailchimp.com/d66fd607301547a6b19cd719b/files/e9b03768-1638-4a2f-a3e4-d6914624ee52/17.06_WI_Chiropractors_Poll_Toplines.pdf

2) educate the educators in the allied healthcare fields. Participate in Physical Medicine and Rehab/ Orthopedic/Neurosurgical rounds. Invest further participation into the VA and Federally funded Medical homes.

Being a second generation chiropractic physician with over 40 years in chiropractic I feel there are many avenues to boost our acceptance. The major one would be to gain a level playing field with the medical and osteopathic physicians. The first step to achieve this would be all 50 state statutes defining us as chiropractic physicians. In my opinion this would be equivalent to the 1973 accomplishment of licensure in all 50 states.

Allow the profession to expand the scope of chiropractic so practicing D.C’s can provide more services. We have the base training and should be able to expand like every other healthcare field. We need to emphasize the quality of our base education. We need to have the ability to easily expand and lateralize our services as physicians.

Waste of time and money. We should embrace Chiropractic care as patient focus and a drug free therapy. Drug companies are the cultural authority and standard for medicine.we need to have better communication not acceptance to pubic and other professional. It not only what we say but how we say it.

In WNY, chiropractic is being pushed out. As PCPs consolidated into Medical Home group practices after the 2009 crash, chirps were not invited to join largely because our reimbursement is so low, we are too low of a price point to be considered profitable. Our medicare advantage fees run from $19.17 to $28.85 a visit. Most insurers will not pay us for physiotherapy. One company allows for $13.74 for ultrasound.

We have PCPs that refer to us, but those physicians are aging out as are we in our mid 50s. We have cultivated those relationships for decades.
Today, the medical group practices often have PT offices which offer all the physio/rehab services as well as providing Graston IASTW and spinal manipulation. I had one patient go to PT and because the PT did Graston to the point of bruising her and because I never did so as heavily, I was doing it wrong. As my husband, who is also a chiro, says-we have no cultural authority.

My suggestions to improve- the profession needs a PR make over. We need to have celebrity status chiropractors blog, podcasts, be seen nationally on talk shows etc cetera talking about the benefits of hands on care, spinal myofascial research, success stories.

Our profession, with our 2 camp animosity and somewhat well known fringy styles is all that people know about. I once had a patient refuse to consent to Activator adjustment because CSI had an episode with a murderous chiro assaulting people on the temple with a killing blow activator adjustment. In the show, 2 and a Half Men, Allen is a chiro and he is a loser nebbish type character. We are the butt if way too many jokes and we are not taken seriously.
My husband scheduled a hour long meeting with the medical director of a large insurer in our area explaining our offices, the cost and scope of our tables, our therapies. He gave him articles about our efficacy and safety. He educated him about our education and CCE requirements. He did everything to help this person recognize the value of our work and the cost of doing business and why we are so viable for their members. It meant nothing. There was no change. There was little respect. When I started in practice 27 yrs ago, I charged $20 cash. Now that insurer pays $19.17 for 98940 and per Medicare, do not pay for exams or therapies.

Medicare is throwing us under the bus. This coming spring, we will have to establish websites, EMR portals that patient and insurers can access at will, provide 24/7 coverage in our offices. As the dinosaurs that we are, we are not prepared for this and do not earn enough to justify the expenses. Now, given the pandemic, although considered essential workers, our patient visits numbers are low and the changes we have made for safety have added costs to doing business. Obviously, mandating these EMR requirements could be a death knell for many practices.

Dr. Tina – I completely agree with what you’ve said. In NY, we are struggling to have our scope modernized but due to state legislator issues in the house, our bills won’t even come to the floor. Modernization of chiropractic in NY State is essentially dead in the water until we can get our changes made in the legislature. Until that happens, we’re stuck where we are. Good luck in 2021.

Thank you for your comment. I am always worried about scope expansion even though I know our scope limits us. My husband spent many years in local leadership only to be pushed out of state leadership because part of his platform was professional unity. Frankly, I am not very excited about our future as it is now.

When we are invited to participate in federal programs we need to participate. We need to continue to find opportunities to demonstrate our value to our patients and other professions. Standardize a high level of data driven care others professions can depend on.

The Federal government issues contracts to do physicals on military and civilian workers every year. These contracts are in total worth $$Billions$$ of dollars. The physicals are less comprehensive than a DOT truck driver physical which DCs can do in 47 states. However the contract language in the government’s contract is boilerplate from 1980’s and only lists MD/DO/NP/PA and we must get included to open up federal money being paid to DCs for these services. That would be an income boost 10X more than what Medicare pays us for chiropractic care without all the red tape, denials, audits, jail time, or “crap” that Medicare gives us now.

Full “PHYSICIAN” status to do whatever is in our scope of practice for any of the Federal Government programs such as physicals in above comment.

Show scientific facts that hands on spinal correction indeed has an absolute positive,enhancing effect on the sympathetic and parasympathetic nervous system which encourages symbiosis.
The public ,in general,has strongly accepted us.

I agree. We do so much more than treating the parts like they are separate entities when in fact everything is connected.

Consistency among providers in providing a patient centered, evidenced based treatment plan. While there will be a significant amount of variation from one provider to the next there has to be some consistency with the care provided that is based on evidence avoiding bias and financial reward.

Branch out from manipulation into other forms of treatment such as active rehab, soft tissue mobilization , dry needling, CNS rehab, etc.

Specialization is the key. One can’t do everything but find that one path that works for you and one you resonate with may be best. MDs specialize and maybe we should do so more.

Our ability to diagnose differentiates us from physical therapists, and is essential for public safety in the delivery of spinal manipulation. Re-emphasizing diagnosis, particularly if we were to require everyone to retake a board exam every ten years, can rebuild both public and institutional trust, while also improving our intraprofessional standards.

Dr. Baroody. My wife is a PT and it was interesting to work side by side with her for about 10 years and be involved in discussions with her PT friends. The ability to diagnose “legally” differentiates us in most states but reality is very different. Virtually all the referral prescriptions from the MD’s state “evaluate and treat”. The PT’s have gained cultural authority among the MD’s/DO’s and others who refer. They have proven to them that they can diagnose and the MD’s (especially PCP’s) know that–regardless of what the law says. The referrers (if that’s a word) understand exactly what they will get when they refer to any PT. And they know they will get a well written report on a regular basis. Luckily I’ve been fortunate to serve on a hospital board in Greeley, CO and have spoken candidly with many MD’s. They have DC’s they will refer to–DC’s who have proven themselves. But they will not refer to any DC–to them it is still too potentially dangerous. The way we get “acceptance” is to understand we have to change–not them.

Dr. Simone,

Thank you for your thoughtful reply. With your experience, what do you suggest we change?

Steve Baroody, DC

Podiatry gained its cultural authority with a name change from chiropody and expanded its education and scope. DOs did do as well . Limited prescriptive righrs and expanded scope as well as updating chiropractic terminology to remove antiquated terms and join the lexicon of standard medical terminology.

WI tried to initiate that conversation and it created a nuclear war. Think ACA vs ICA. Progress vs Dogma. Our philosophical in-fighting has the profession, as a whole, backed into a tight corner. We are doing the most damage to ourselves. Long-term…we need a broader scope to appeal to the masses. Those who want to participate in expanding their scope can, those who don’t shouldn’t be forced to. But…everyone should respect the other’s view even if it’s 180 degrees different from theirs philosophically. The profession has been giving talks, two day report of findings, TIC-talk for over a century and look where we are. Until we get expanded scope….we’re screwed. (Think definition of insanity…doing the same thing over and over, expecting a different result. That’s chiropractic.) Physical therapy is expanding their scope (ordering xray, performing manipulation, dry needling, etc). Nursing is expanding their scope (BSN, NP, DNP)…shoot, everyone is a “doctor” now. We just think we hold a special nugget that, at some point, will explode our popularity and demand in the healthcare setting. And we’re still waiting….

We need to get our medicare modernization act through during the political horsetrading that is going on now with stimulus. Once its done, we will gain business, more cultural authority, better fees since medicare will pay better than most insurers using rbrvs and insurers will need to compete with that.
Perhaps this is why insurers are pushing so hard to get more people to switch to medicare advantage plans which almost universally suck. Higher fees make us more employable in larger system. Like it or not, you are worth what you can produce. Hospitals will want to hire us as well. The real question is not about cost effectiveness but the incentives to bill higher fees. not sure how you fix a problem that has insurers ultimately behind the problem with our current culture of healthcare.

The US health care system is built on the economic model of competitive therapeutics. Providers, hospitals, and other stakeholders compete for a limited pool of health care dollars by trying to convince the public that their approach to the same clinical entity is superior to their competitors’. For example: orthopedists, neurologists, and most chiropractors all try to convince the public that their approach to back pain is the best. As long as economics are at the core of the competition, the battle will one of marketing superiority. It has little to nothing to do with standard of care, standardization, or scope of practice.

Expanding acceptance within the medical system will lead to expanded acceptance by the public. To expand our acceptance within the medical system, we must maximize our presence within the health care delivery models that optimize for value, not fess. The models that currently offer the most opportunity include Veterans Affairs (VA) and Federally Qualified Health Centers (FQHCs). Most hospitals and health systems do not consistently build high-functioning health care delivery teams, which is why those settings have not provided consistent experiences for doctors of chiropractic or our patients and thus, have not created wide medical acceptance. To expand acceptance from private practice settings, we must capitalize on the new information blocking rules by casting a wider net of communication in our communities with other health care providers and physicians.

Research, publication, and clinical outcome documentation direct clinical care. The compressive and chemical inflammatory changes within the central nervous system are the keystones of manual medicine of which chiropractic is a leader. Knowledge of the autonomic nervous system reaction to spine manipulation is a strong foundation of our contribution to medicine.
To accomplish this research, funding is mandatory, yet no such fund exists within our profession. There is no question that manual medicine will continue to grow, the only unknown is who will direct it.
As we document our clinical results, acceptance and increased scope of practice will follow.

In my opinion, nothing moves forward until Medicare / CMS recognizes our abilities (diagnostically and therapeutically) and establishes reimbursement commensurate with what we provide.
Most insurance carriers follow CMS’ lead, and their archaic stance is to pay the DC for only one procedure – 9894X.
How exactly are we to arrive at any diagnosis whatsoever without an examination, which we are not paid to administer?
We have patients present with multiple co-morbidities or red/yellow flags that may require imaging, and we cannot order them for the sake of an accurate diagnosis and to know whether or not our approach would even be safe in that clinical scenario?
What if they may fare better with traction, rehab, ultrasound adjunctively, etc. and it is within our scope to administer – but we will not be reimbursed for it despite the training, equipment and time invested in those 3 non-CMT examples of therapeusis?
Medicare parity has to be the foundation on which all else is built at this point.

I find the comments by all of my colleagues to be of interest and add value to the discussion. Quite frankly, I think that I could write a paper about each of the comments. Yet, I will offer brief comments and hope to add value to the discussion.
Standardization would be helpful. Starbucks is not successful because of the quality of the product but the consistency of their services. When you go to Starbucks, you know what you are going to get. Even if it is burned coffee beans, you find the service and products to be acceptable or you go elsewhere. Millions of customers continue to buy Starbucks because they are comfortable with the product, envioronment and service.
I do not agree that we should limit our discussion from outside of the profession. I suggest that we must gather valuable information from all stakeholders both inside and outside of the chiropractic profession.
It has been 52 years since starting my chiropractic education and I have enjoyed the opportunities to integrate chiropractic services, education, and clinical training into a Health Maintenance Organizations, a medical center, a medical school, and five Federally Qualified Health Center organizations. In my opinion, this is the best time during my career to position to chiropractic medicine as a valuable member of the medical team. Chiropractic services are listed by the Joint Commission as one of the non-pharmacological treatments for the treatment of patients in pain that are requirements to maintain hospital credentialing. When I was in Logan, the Joint Commission advised all hospitals that if chiropractic was included in their services, the hospital would lose their credentialing.
With that stated, I offer the following 10 comments/suggestions:
1. The practice acts must enhance our clinical and financial opportunities. Chiropractic practice acts must enable growth and expansion of our scopes of practice based upon education, training and credentialing.
2. The dichotomy caused by ideology must end.
3. The chiropractic profession must offer an evidence-based, patient-centered form of healthcare that promulgates an image of a profession that is safe and effective with salubrious outcomes.
4. We must accept medical physicians and primary care providers as valuable partners in healthcare. No longer should the profession be on the outside of the healthcare system looking in.
5. The Medicare guidelines with the narrow scopes of practice and reimbursement must be changed to include E/M codes and equal reimbursement as described in the Affordable Care Act, Section 2706.
6. Chiropractic education must be offered in both private and state funded universities.
7. Chiropractic post-doctoral, clinical training must be offered nationwide within residencies that lead to board certification as a chiropractic specialist.
8. Chiropractic physicians must purchase or create Rural Health Centers that will enhance reimbursements for chiropractic services from both Medicare and Medicaid.
9. All 50 States must cover chiropractic services for Medicaid.
10. Chiropractic services must be available in every Federally Qualified Health Center in the United States.
I look forward to feedback from the participating audience members.

You need to be side by side with medical professionals during rotations. That way we can network and share our knowledge. We can show other professionals how much education we go through chiro-school. In time build up mutual respect respect each other.

Medical doctors are required to retake boards every certain number of years. A board exam that existing doctors are required to retake say, every ten years, could do a good deal to raise our standards. It would also keep existing licensees focused on the science.

Educate the medical world and world in general. Have classes for the hospital staff on chiropractic 101 etc. at their offices. We could also do this in our own offices for the public.

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MORE INFORMATION​

For more information about the Future of Chiropractic strategic visioning and planning project, please contact:

Elizabeth Klein, Executive Director
Congress of Chiropractic State Associations
Phone: (503) 922-2933
lizz@chirocongress.org
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