December 2003

Will chiropractic lose direct access in the VA?

by Dr. Leona Fischer, member of the Veterans Affairs Chiropractic Advisory Committee

In early 2003, a law went into effect that provides for chiropractic benefits in the Veterans Affairs health system. The law called for the establishment of a Chiropractic Advisory Committee to make recommendations regarding the implementation of the new law's provisions. I was honored to be chosen to serve on this committee.

I'm a Navy Veteran and my husband is a Gulf War Veteran. I'm also a doctor of chiropractic who firmly believes in the value of subluxation correction. Before making any recommendation, I wanted to be sure it would be in the best interest of the seven million veterans served by the VA Health Care system.

That's why the recommendation concerning direct access was so important to me. It definitely wasn't the only issue we discussed. We needed to work out details about the scope of practice, references to vertebral subluxation, instrumentation, educational requirements and an array of other concerns that would impact the role of chiropractors in the VA system.

But, to me, if veterans weren't given the right to have direct access to a chiropractor ‑‑ without going through a gatekeeper ‑‑ the rest just didn't matter. If they can't easily get in to see a D.C. when they need one, what difference do the other recommendations make? If veterans cannot access us, we cannot help them.

I was concerned we'd have some opposition from the non‑chiropractic members of the committee. But I was shocked when Dr. Michael McLean and I were the only two people on the entire committee to vote FOR direct access. All the others ‑‑ Drs. Reed C. Phillips, Cynthia Vaughn, Rick McMichael, and Charles Duvall ‑‑ voted against the recommendation for direct access.

In the report, Dr. McLean and I wrote our rationale for direct access, and it's hard to believe any D.C. could not agree with it. This wasn't, in my mind, a philosophical debating point. It was a matter of equality and rights for veterans.

In defense of the direct access recommendation, we argued that: "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."

All American citizens have the right to see a D.C. without a referral. Why couldn't our veterans?

What was most shocking was that less than two hours prior to taking the vote on this critical recommendation, all the D.C. members of the committee met to discuss the issue, along with representatives from Association of Chiropractic Colleges. At this meeting we decided direct access was the only acceptable recommendation. Throughout the entire meeting, we were in total agreement to support direct access. There were six of us and, if we stood together on this issue, we would have the majority vote.

Before this meeting ended, I personally ‑‑ and publicly ‑‑ asked all the D.C.s there how they would vote. ALL OF THEM stated they would vote FOR direct access.

Two hours later, the vote was taken and Dr. McLean and I stood alone while ALL the others voted against direct access. I was stunned. I felt betrayed, lied to. The level of deception was beyond my comprehension. I could not believe that, in just a few hours, we went from having a majority recommendation that could have given our nation's veterans direct access to chiropractors, to a provision whereby they had to get a referral from a primary care physician.

Dr. McLean and I stood firm, but we were now in the minority. Draft #7 ‑‑ with the recommendation for a 'gatekeeper' ‑‑ was submitted by Dr. Reed Phillips as the final recommendations to VA Secretary Anthony J. Principi. Unfortunately, the recommendations were submitted without the committee being given a chance to visit a VA health care facility. Committee members had repeatedly requested a site visit in order to better understand the system and its needs.

The issue of direct access isn't merely a matter of pride for the chiropractic profession. It's a matter of health and rights for veterans and of efficiency for the VA Health Care System.

Right now, the VA system is overburdened. Some vets have to wait months for an appointment to see a primary care provider (PCP) ‑‑ the "gatekeeper" who can permit them to see a chiropractor. It's a waste of resources to take up appointment times and the PCP's time to ask permission to see a D.C.

The nurse practitioners, physicians assistants, or M.D.s who first see the patients get to decide if they can see a chiropractor. They may have no concept of what a subluxation is or may have deep prejudices against chiropractors, yet they must give their blessing before the patient can be evaluated by a D.C. That is, in my opinion, not in the best interest of veterans.

There are other questions are well:

***  Will other courses of care (medication... physical therapy... surgery...) be required prior to having access to a chiropractor?

***  Will chiropractors be able to educate veterans about correction of a subluxation?

***  Will chiropractors be used only as a last resort for NMS patients?

***  Are we going to be able to practice chiropractic so that we can do the greatest good for the veterans? Or, are we there to merely comply with what Congress mandated?

All of those questions will be left up to Sec. Principi. He will ultimately choose to what extent, how, when and where chiropractic services will be implemented.

There is, of course, some real reason to worry about the ultimate outcome, some of it stemming from the fears of other chiropractors themselves. Incredible as it may sound, I've been asked by some of the chiropractic members of the committee not to even talk about "correcting a subluxation." The M.D.s discredit the notion of subluxation entirely (just as do some D.C.s!).

This is censorship at its worst. It's clear that we need to educate those who don't know what a subluxation is or how and why chiropractors work to correct them. Yet, I have experienced an absolute resistance to educating or discussing what we do as a profession.

After much work and effort by the World Chiropractic Alliance and the International Chiropractors Association, the VA law specifically allowed for the correction of subluxation. But, until all chiropractors have the guts to stand up and tell the world that what we offer is unique, that we are separate and distinct, and that we correct nerve interference, we will forever be second class citizens in the health care world. We must do just that if we want to best serve our veterans.

I realize that the VA system has structure and protocol and I know, if we want to be accepted there, we must be team players. I also know that if we are given a fair, unencumbered opportunity to educate the veterans and the other health care providers about what we really do, we will be accepted. We will be valued members of the multidisciplinary health care team.

Despite my worries, I also have reason to be hopeful that chiropractors will play a meaningful role in the VA health care system. I know that VA administrators have said they are serious about implementing D.C.s into the system and that the VA Committee Advisor Sara McVicker, who works directly for the VA, has been a Godsend! Her professionalism, attention to detail and knowledge of the system have been extremely valuable to us and greatly appreciated.

It's also encouraging to recall that, except for the gatekeeper rule and the failure to include surface electromyography and thermography to the list of chiropractic privileges, the recommendations were positive for chiropractic. I concurred with all of them.

So, in my dreams, Sec. Principi incorporates Doctors of Chiropractic into a triage/PCP team, so that veterans may self‑select a D.C. and have direct access to chiropractic care. He chooses to do so very soon, in multiple locations.

Patients are screened with SEMG/Therm to rule out a subluxation (just as they have a blood pressure check to rule out hypertension). Those who are subluxated are told how those areas of nerve interference can compromise the function of different parts of the body. Then, they can make a truly informed decision whether they would like to incorporate chiropractic as part of their health care. They will be given information on how correcting subluxation will improve the quality of their life.

This is my vision of chiropractic care serving my fellow veterans.

I am an optimist.

(Leona Fischer, B.S., D.C., a 1998 graduate of Life University, 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. She is a member of the World Chiropractic Alliance International Board of Governors and is in private practice.)