February 2004

Profession could be locked out of VA

ACA ignores its promise to fight for direct access

Time and again, officials of the American Chiropractic Association (ACA) stated publicly that they were in favor of direct access to chiropractors working in the Veterans Affairs Health Care system. In an article for the American Medical Association's AMNews (Nov. 11, 2002), ACA spokesman Jerome F. McAndrews, D.C., even went so far as to say, "If this committee does not come out with direct access, we simply will go back to Congress."

Yet, when the VA Chiropractic Advisory Committee voted on the issue, all of the ACA‑aligned members sided with medical opponents and recommended a gatekeeper system that could, in essence, exclude chiropractors from all but a few low‑back pain cases.

The only two Committee members who voted for direct access were Leona Fischer, D.C., a member of the World Chiropractic Alliance (WCA) International Board of Governors, and Michael McLean, D.C., Legislative Chair of the International Chiropractors Association (ICA).

The true impact of the vote against direct access may be far worse than previously realized. According to VA representatives, there is a possibility that D.C.s could be hired based on demand for their services. The VA could choose to contract D.C.s "as needed" to work in VA facilities on a limited basis rather than placing them on staff.

If medical doctors and other primary health care providers don't refer patients to chiropractors, there will be no perceived need for their services. The end result could be that D.C.s would be, in essence, locked out of the VA system.

To add injury to insult, the gatekeeper provision allows nurse practitioners and rehabilitation therapists ‑- as well as orthopedic surgeons and primary care physicians ‑‑ to decide which patients are permitted to see a chiropractor.

D.C.s around the country have strongly criticized the ACA and the Committee members who voted for a "D.C. by referral only" system for what they see as a betrayal of their trust. In response to this criticism, the ACA posted a report by VA Committee member Rick McMichael, D.C. on its website. Dr. McMichael is the ACA's Ohio Delegate and was nominated to the Committee by the ACA.

McMichael says he and the other D.C.s who voted against direct access did so because they felt it was the only way to secure chiropractic presence in the VA system. He noted that they were persuaded to vote for the gatekeeper system by one of the other Committee members ‑‑ Michael O'Rourke, a physician's assistant who serves as the assistant director of Veterans Health Policy with the Veterans of Foreign Wars.

"As a staunch supporter of our veterans' rights to access chiropractic care, Michael O'Rourke strongly encouraged us to agree to work within the VA system in coordination with VA primary care physicians," McMichael explained. "He assured us that this was the best way to give this new service a real opportunity to work effectively for the veterans we were avowed to serve. He asked us to consider this a new day, leave the past behind and move toward the future. This is what the majority of the CAC chose to do."

The notion that giving up direct access was the only way to have chiropractors in the VA health care system was dismissed by most chiropractic legislative experts, who said the law passed by Congress ‑‑ Public Law 107‑135 ‑‑ mandated that a chiropractic benefit be offered in all VA medical centers. The Committee's task was to recommend the policies and procedures that would govern those chiropractors. The other chiropractic members who voted with McMichael against direct access were Charles Duvall, Jr., D.C., president of the National Association of Chiropractic Medicine and long‑time chiropractic opponent; Cynthia Vaughn, D.C., president and executive director of the Texas Board of Chiropractic Examiners and partner in the Chiropractic & Spine Center of Austin with James D. Edwards, D.C., former president of the ACA; and Reed C. Phillips, president of Los Angeles College of Chiropractic who served as a member of the Mercy Center Consensus Conference Commission.

A report from Dr. Vaughn was also posted on the ACA website, which stated that "Although some have criticized the recommendations of the VA Committee since they do not recommend 'pure' direct access in all cases, they have missed the bigger issue. This is not about 'direct access' for our profession; this is about VETERANS BEING ABLE TO ACCESS chiropractic care. In other words, it's not about us...it's about veterans."

Dr. Fischer, the Committee member from the WCA, agrees that the best interests of the veterans should come first, particularly since she is a veteran herself. She served as a medic in U.S. Navy Special Operations from 1988 to 1992. Assigned to the Explosive Ordnance Disposal unit, she was awarded two Navy Achievement Medals for rendering primary care and triage to five Special Ops members who suffered severe trauma during a parachute accident. Her military service took her to assignments throughout the U.S., as well as Africa, Portugal, Spain, Italy and Bermuda.

"I was usually the only medical support in the rural places we traveled," Fischer told The Chiropractic Journal shortly after her appointment to the Committee. "While working with these guys, I was not satisfied with the quality of care we were limited to. They often had musculo‑skeletal injuries and we kept giving them 'vitamin M' ‑‑ Motrin ‑‑ to fix it. That's when I began my quest for true health."

Fischer voted in favor of direct access because she knows that could very well be the only way many veterans get to see a D.C. "If they can't easily get in to see a D.C. when they need one, what difference do the other recommendations make?" she asked. "If veterans cannot access us, we cannot help them."

She wasn't alone in predicting that, without direct access, many veterans would be unable to see chiropractors.

In 2001, Jerome McAndrews, D.C., ACA's national spokesman, stated, in another AMNews article: "Because of the illegal boycott by physicians, it has been proven that for chiropractors to be welcomed or accepted there needs to be legislation requiring it because the resistance is all through the system. We need direct access."

James D. Edwards, D.C., chairman of the ACA said very much the same thing in an AMNews article last summer, before the Committee voted. "The [primary care] model hasn't worked well in everyday practice because often the primary care physician doesn't refer to a chiropractor when chiropractic care is indicated," he argued. "We want to make sure those artificial barriers do not preclude veterans from getting the care that they need."

Yet, now, ACA leaders appear to be minimizing the importance of direct access, and have not alluded to earlier statements. "We want to commend our team for working with the majority on the Committee and getting them to agree to recommendations that clearly benefit not only the veterans but also this profession," stated current ACA President Donald J. Krippendorf, D.C.

Despite the ACA's efforts to put a positive spin on the situation, statements by the medical doctors on the Committee show clearly that they intend to put D.C.s into a small box labeled "back pain."

Committee member Warren Jones, D.C., president of the American Academy of Family Physicians, grudgingly admitted, "I have referred patients with low back pain to chiropractors," but added, "but only after I ruled out other more serious conditions... Physicians will refer to chiropractors for low back pain if warranted" (AMNews, March 4, 2002).

Richard Roberts, M.D., chair of the American Academy of Family Physicians voiced his disapproval for direct access in that same publication (Nov. 26, 2001): "Like many family practice physicians across the country, I work with several chiropractors in my community for patients with low‑back pain..." he said. "Chiropractors define themselves as treating neuromuscular and biomechanical problems. People have a lot more problems than that when they seek primary care. I am really concerned that this perpetuates a fraud on veterans."

Terry A. Rondberg, D.C., WCA president, said that the real problem stems from chiropractors who continually represent chiropractic as a treatment for neuromusculoskeletal problems.

"This is precisely why the World Chiropractic Alliance fights so hard to make sure that every piece of legislation about chiropractic contains a reference to subluxation correction," he explained. "This is the only way patients are going to have a clear path to chiropractors. So long as we include mention only of NMS problems, we're going to have to deal with medical opposition."

The Committee recommendations were given to VA Secretary Anthony J. Principi, who has final authority to formulate the rules governing how, when and where chiropractic services will be implemented, including the direct access question.

Dr. Rondberg stated that the WCA would continue to work with the VA administration to help educate all health care providers about the true role of chiropractors, and to offer advice and assistance to D.C.s wishing to apply for and work in the VA system.