November 2003

ACA reps vote against direct access in VA

Only WCA, ICA members oppose medical gatekeeper

When the Department of Veterans Affairs (VA) Chiropractic Advisory Committee voted on its final recommendation, only two members ‑‑ Leona Fischer, D.C., and Michael McLean, D.C., opposed the controversial medical gatekeeper provision. Dr. Fischer is a member of the a member of the World Chiropractic Alliance (WCA) International Board of Governors; Dr. McLean is a Board member of the International Chiropractors Association (ICA) and ICA Legislative chairman.

All other committee members ‑‑ including Cynthia Vaughn, D.C., Rick McMichael, D.C., and Reed C. Phillips ‑‑ cast their votes against direct access, a move that has been called "disastrous" for chiropractic in the VA system.

Dr. Vaughn is a member of the National Board of Chiropractic Examiners and the Federation of Chiropractic Licensing Boards and partner in the Chiropractic & Spine Center of Austin with James D. Edwards, D.C., former president of the American Chiropractic Association (ACA),

Dr. McMichael is a member of the DoD Advisory Committee and was recommended by both the ACA and the Association of Chiropractic Colleges for the appointment.

Reed C. Phillips, president of Los Angeles College of Chiropractic served as a member of the Mercy Center Consensus Conference Commission.

Ironically, Drs. Vaughn, McMichael and Phillips all cast their votes along with Charles DuVall, D.C., president of the National Association of Chiropractic Medicine. The ACA had originally maintained that they wanted to handpick the nominees for the VA Committee‑ rather than allow other organizations to have representation on it ‑‑ in order to keep DuVall off the panel. In the end, on this critical issue, the ACA‑endorsed members voted with DuVall and the non‑D.C.s on the Committee.

The WCA alerted the profession to the possibility of a gatekeeper provision in September 2003, when it provided written comments to the Committee about its draft recommendations. Although numerous letters and public comments were submitted by organizations and individuals, the response wasn't enough to sway Committee members.

The final recommendations stated that: "Access to chiropractic care should be by consultation with the patient's primary care provider or another VA provider who is treating the patient for the condition(s) for which chiropractic care is indicated."

Fisher and McClean were the only two to submit a dissenting recommendation calling for VA health facilities to "offer information on, and availability of, chiropractic services and offer all patients with neuromusculoskeletal complaints the option of direct access to chiropractic care"

In the Committee report, they outlined the rationale for their recommendation, stating that the "VHA (Veterans Health Administration) has had the ability to refer to doctors of chiropractic for years, but has seldom made such referrals in the past. It is doubtful such an ingrained institutional culture will be altered from within by directives. Indeed this is the reason Congress mandated that this Committee give advice on protocols for direct access. It is much more likely to happen if the changes are driven by the ultimate beneficiaries, the patients; this is most certain to occur only if patients have true choice: direct access."

Fisher later told WCA officials that "we were opposed because, as American citizens, we can choose to see a D.C. without a referral. We felt a 'required referral' was a step back from free choice."

In its public comments on the report, the World Chiropractic Alliance also argued against the need for referrals to chiropractors.

"We vehemently oppose the use of medical gatekeepers to control access to chiropractic services," Terry A. Rondberg, D.C., WCA president noted. "The American public has the freedom to choose chiropractors without referral by M.D.s. Our veterans deserve that same right. As the committee correctly points out, anti‑chiropractic bias still exists among some M.D.s, and a patient's right to have access to D.C.s would ultimately be determined by the personal prejudices of his or her medical provider."

Dr. Rondberg went on to say, "Requiring a medical referral to a D.C. would also be inappropriate since M.D.s receive no training in the detection or correction of vertebral subluxation, which is specifically mentioned under the chiropractic Scope of Practice. It would be impracticable to give M.D.s the responsibility of determining the appropriateness of chiropractic care when they have no training or experience in analyzing the subluxation complex."

The Committee did soften the blow a bit by adding a provision that would allow some veterans, including newly discharged veterans who have been receiving chiropractic care while on active duty, to have direct access for continued chiropractic care at a VHA facility.

Although applauding this provision, Fisher, who served as a medic in U.S. Navy Special Operations from 1988 to 1992, noted that this exclusion "does not help the seven million vets currently in the health care system, with 25 million enrolled."

In a press release issued by the ACA boasting that the organization "played a leadership role in the successful effort to enact legislation mandating the establishment of a permanent chiropractic benefit within the Department of Veterans Affairs (DVA)," there was no mention of the gatekeeper requirement.

The WCA pledged to continue working with the VA Committee and agency officials to education them about the unique role of chiropractic in the health care system and to convince them that referral by an M.D. or D.O. is neither necessary nor cost effective.

The recommendations report was the culmination of a series of meetings by the 11‑member Committee, which was formed in order to advise the Secretary of Veterans Affairs on how to incorporate chiropractic into the VA health care system.