April 2004

What's next in the VA?

by Leona Fischer, D.C., member of the Veterans Administration Chiropractic Advisory Committee

It's been a long, hard battle to make sure our Armed Forces veterans can receive chiropractic care. In recent months, the turmoil over the direct access issue has dominated the discussion. Yet, because of a steady stream of misinformation, many doctors are confused over what really happened in the Committee and what it will mean for chiropractic.

In brief, here's what happened:

1) Secretary of Veterans Affairs Anthony J. Principi charged the committee with making recommendations on four issues. One of those issues was direct access. The two alternatives were: a) to allow veterans to make their own decision to see a doctor of chiropractic; or b) to allow veterans to see a doctor of chiropractic only after getting approval (a "consultation") from a medical doctor or other "primary care provider."

2) Just hours prior to the Committee voting on the recommendation, all the D.C. members on the Committee met privately and discussed the matter. ALL of them verbally pledged to vote for direct access. None of the Committee members has ever denied taking part in this discussion or making that pledge.

3) When the vote was taken, I voted for direct access along with Michael McLean. Dr. McLean is the ICA Legislative Chair for the International Chiropractors Association and I serve as a member of the Board of International Governors for the World Chiropractic Alliance. ALL of the others voted for the recommendation that required veterans to see their primary health care provider first and receive permission to see a D.C.

Dr. McLean and I submitted Recommendation # 9, the "Dissenting Recommendation," and gave forceful arguments for why the approximately seven million veterans currently in the VA health care system should have direct access to chiropractors. That dissenting recommendation -- along with the vote showing that all other Committee members voted for the "gatekeeper" recommendation -- is part of the official record and cannot be denied. As Dr. McLean so eloquently stated, "You can spin it eternally, but it all comes down to this simple truth: If you can't see a D.C. without permission, it ain't direct access."

What happens now?

Secretary Principi has been given the final Committee recommendations.

One possibility is that he will choose to honor and implement VHA notice 99-02, dated June 15, 1999, which defines "shared decision making" as:

"The case for letting patients decide which choice is best. A process by which patients are educated about likely treatment outcome, with supporting evidence, and engaging with them in deciding which choice is best for them, taking into account their preferences, values and lifestyles."

As a CAC committee member who is familiar with recommendations, I have some concerns and what I see as solutions to those concerns.

First is the issue of access.

By law, the only professional to be educated in and licensed to detect and correct nerve interference -- the subluxation -- is a doctor of chiropractic. Is the VA going to overlook the law, and disregard professional scope of practice?

If a referral via a consultation is necessary from a primary care physician to determine if patient is a candidate for care by a doctor of chiropractic, this is costly, unnecessary, and a waste of resources.

Is the PCP going to "engage the patient" in deciding if chiropractic care is an option? That would the like a D.C. "engaging" the patient to decide the best course of action for a root canal. It's not within my scope. I am not qualified, nor do I pretend to be. So why and how can a PCP be expected to make these decisions when it comes to chiropractic -- something that is not within their scope and they are not qualified to do?

I am also very concerned about the censorship of chiropractic information, and its availability to patients. We must as a profession be allowed to communicate to patients what we do. We detect and correct nerve interference. Our intent is to improve overall health and function of the patient. We offer a separate, distinct option to patients. No other profession offers what we do. I am so very proud and blessed to be a doctor of chiropractic. We as a profession should have the right to communicate this to all patients. Anything less is censorship.

Here's my solution to all of these quandaries.

Patients come to a VA health facility for care. There, they see posters and pamphlets about chiropractic care and are asked if they would like to have a chiropractic screening. There would also be a written option for the patients to be screened.

Then, when patients choose to be evaluated by a doctor of chiropractic, they are evaluated with measures such as x-ray, SEMG, thermography, hand dynamometer, bilateral scales, visual scoliosis check, palpation, derifield check, etc. These are non-invasive, inexpensive tests to determine if nerve interference exists. The evaluations take approximately three minutes. Just as blood pressure check ups are done to detect hidden health issues, the chiropractic tests could detect unnoticed areas of nerve disturbance.

NOW, you have objective data to determine if a patient is a candidate for chiropractic care. The issue of PCP/direct access/need for care has been solved. We would be "letting the patients decide which choice is best" as noted in VHA 99-02. This could be a very simple solution to a contentious issue.

The question remains: How will Sec. Principi choose to implement chiropractic care for our veterans?

We may find out at our next VA meeting, March 30-31. Stay tuned!