March 2004

Direct access in the VA for chiropractic care

by Dr. Michael S. McLean, FICA, Member, VA Chiropractic Advisory Committee

Many of my colleagues have asked me what really happened at the Veterans Affairs Chiropractic Advisory Committee meeting during which we voted on the question of direct access to D.C.s for the VA patients. Many opinions have been expressed on this matter. I was there. Let me tell you what occurred.

The three D.C.s who are ACA members and the one D.C. who is a "Chiropractic Medicine" member voted along with the M.D.s, one D.O., one P.T. and one Veteran's Organization member to make chiropractic available to the Veteran only by referral from a member of the medical team.

Firstly, let me assert I have not accused the ACA of "voting for medical referral." I know too many good and principled ACA members to believe the association would support that. But that is just my point. All three VA CAC members who are ACA members (and ACA leaders, at that) voted to make chiropractic care available only by referral.

It is just stunning to me that such high‑profile ACA leaders would all vote this way. I believe the ACA Board must disavow the actions of these three. Otherwise, the ACA consents by its silence to this disastrous precedent and can no longer plausibly deny responsibility for this stance.

The ACA in its news release of January attempts to differentiate between "referral" and "consultation," stating that their members didn't vote to have chiropractic access in the VA "by referral only" but instead "by consultation."

It is a distinction without a difference. The act of making a referral is called a "consultation;" the consultation is the paper the referral is written on, or the phone call which grants permission for the patient to see a D.C. The key idea here is that permission must be given before a VA patient may see a D.C.

In explaining the actions of its members, the ACA release stated they voted for "referral only" because the VA would likely not implement a recommendation in favor of direct access made by a minority vote of 5‑6.

I disagree. Our recommendations are not binding on the Secretary of the VA and he would surely recognize the "turf war" quality of the vote.

Even more importantly, if the VA still did not provide meaningful access to D.C.s once the Secretary's directives were made, we could always go back to Congress and ask them to help out, since the VA did not meaningfully try to make chiropractic available.

Now that the D.C. members of the CAC have voted 4‑2 for "referral only," we have no standing to go back to Congress for help. Their reply will be: you made your bed; don't complain to us.

In its release, the ACA goes on to defend its members' actions as voting for what they believed would best serve Veterans' needs. It is disingenuous to deny responsibility for the actions of ACA leaders because they were not official ACA representatives but then put out an official ACA defense of their actions.

In any case, it is difficult to reconcile putting more barriers in the way of Veterans accessing D.C.s with serving their needs. When the CAC held its first meeting, I stated that I had been seeing a few VA patients by referral for over 15 years, and if we did not end up with direct access, we were wasting our time, since chiropractic has been available to the VA patient for decades by referral. And here we are, recommending to the Secretary to continue this failed policy. This is not "serving the Veteran's needs."

I must point out that the CAC did recommend direct access for any Veteran who had previously had chiropractic care while in the military.

I am proud that the CAC had the insight to make this recommendation. Unfortunately, the DoD military health care also limits chiropractic to "by referral only" which makes it much more difficult to be a member of this category.

I do find it more than a little bit curious that the DoD project was initiated and overseen by ACA members exclusively, two of which are also on this VA committee. But at least, they are consistent.

It is highly ironic that after all the clamor the ACA leadership made about the inclusion of a representative of "chiropractic medicine," the ACA members on the CAC unanimously voted with him (and against the ICA and WCA members) supporting chiropractic BY REFERRAL ONLY.

The magnitude of this disaster is hard to estimate at this time, but it will not only make it harder for VA enrollees to access care, it will make it harder to pass future legislation without having chiropractic "by referral only."

Our ability to see patients directly is being slowly eroded. It will make it terrifically difficult to "correct" the flawed legislation that put chiropractic in the DoD "by referral only."

And it will make it harder to pass legislation exempting D.C.s from medical gatekeeper oversight in HMOs or other managed schemes.

And because 50% of the M.D.s receive their training in a VA setting, future M.D.s will believe D.C.s should be by referral only in the private hospitals in which they will eventually practice.

It was the wrong decision both for the short run and the long, and those responsible should be taken to task for their decision.