Industry leaders discuss advocating for chiropractic amidst coming DC and doctor shortage
CHIROPRACTIC AS A HEALTH CARE OPTION IS ARGUABLY EXPERIENCING ITS GREATEST POPULARITY AND ACCEPTANCE in 122 years, since 1897 when the Palmer College of Chiropractic was established as the first U.S. chiropractic institution.
The industry was thrust into the spotlight toward the end of 2018 when the U.S. passed the “anti-opioid bill,” the Support for Patients and Communities Act, an approach using a “stepped-care model” putting non-drug alternatives at the forefront. Currently in the U.S. House of Representatives, the Chiropractic Medicare Coverage Modernization Act of 2019 would align Medicare’s coverage of chiropractic services with that of other federal health care providers, as well as many private health plans, resulting in a dramatic increase in coverage of chiropractic care.
Conversely, the chiropractic industry finds itself at a crossroads in terms of attracting new DCs to replace an aging chiropractor demographic, with a shortage looming in the future. Chiropractic schools have historically leaned heavily on their own alumni for recommendations to new students, but a new 2019 schools survey of U.S. doctors of chiropractic conducted by Chiropractic Economics revealed that DCs do not exactly remain “true to their school.”
A coming doctor shortage across health care
Not only chiropractic, but medical doctors and other health care sectors are looking at approaching shortages of providers due to an aging population that is not being replaced quickly enough by young doctors, nor keeping up with population growth.
The report Chiropractic 2025: Divergent Futures, funded by the NCMIC Foundation and produced by the Institute for Alternative Futures, like other studies predicts a decrease in licensed chiropractors in 2025, exacerbated by a leap in the U.S. population. Under two of the report’s currently-trending scenarios, graduates will decrease to anywhere from 800 to more than 1,000, while DCs retiring or leaving practices will eclipse that mark.
Choosing chiropractic, other schools
More than 94% of students come to chiropractic either through a referral from a DC (31.4%) or from a personal experience with chiropractic (62.9%), according to a recent Cleveland Chiropractic College survey of prospective students.
With almost 75% of DCs saying they would recommend schools other than their alma mater, schools must reevaluate marketing solely to their alumni bases and move toward broader efforts to reach DCs that keep abreast of other school offerings, continuing education credits, and further educational opportunities.
The 2019 schools survey of doctors of chiropractic by Chiropractic Economics polled 629 DCs, and only schools with a significant number of respondents were included in response data. DC recommendations polled regarded prospective student references made to chiropractic schools, and opinions of the colleges they attended in various categories.
Becoming advocates for chiropractic schools
Doctors of chiropractic, say industry leaders, must step up and become advocates, and activists, for the profession to thrive and change with the times.
“Who will be the doctors and nurses that will take care of us?” says Quentin M. Brisco, DC, president of the American Black Chiropractic Association. “I graduated 12 years ago and I have personally referred two students to attend my chiropractic alma mater of Texas Chiropractic College. One has graduated and the other is still enrolled. Each of us needs to encourage potential candidates to study chiropractic.”
Changing with the times means working with other health care providers in the fast-growing fields of integrated and multidisciplinary medicine.
George Curry, DC, is past president of the International Chiropractors Association and says an advocacy effort supporting all schools to reach enrollment capacity, and establishing new schools in the coming years, is critical to the industry.
“If even only 25% of the U.S. population was under regular chiropractic care, we don’t have nearly enough chiropractors to handle that demand,” Curry says. “Therefore it’s incumbent that we make sure that not only all the schools are at full capacity but we create an environment where future programs can be started.”
Currently eight chiropractic campuses are ICA affiliated, and the ICA has had a stake in chiropractic education since its inception in 1926.
“It’s the responsibility of the doctors in the field to encourage a career in chiropractic to their patient base,” Curry says. “Chiropractors in the field must remember the Chinese proverb, ‘When you drink the water you must remember who dug the well.’ Imagine if only one out of three chiropractors referred just one student to a chiropractic school, we would double our current enrollment. In the next five years we must create a culture where our profession is consciously aware of the need to recruit young patients to pursue a career in chiropractic.”
Chiropractic schools and universities spend millions each year wooing their own alumni and alumni organizations. But the 2019 Chiropractic Economics schools survey of doctors of chiropractic unearthed a shocking statistic among DCs — a strong 80% would recommend chiropractic as a profession, but 73% responded that they would not rule out recommending a different school.
This data flies in the face of traditional school marketing almost solely to alumni bases for recommendations, and going forward schools will likely need to find marketing avenues to reach all doctors of chiropractic, regardless of their alma mater.
According to the 2019 schools survey, more than 80% of chiropractors say they recommend at least one student per year to chiropractic college. Of those, more than 26% make five or more recommendations to chiropractic colleges per year.
Of alumni surveyed, 48% would not recommend the school they attended.
Recommendations play a huge part in building the industry. James Walters, a current chiropractic student and national chair of the Student ACA (American Chiropractic Association), which represents chiropractic students from accredited chiropractic colleges across the country, says visiting with a chiropractor and receiving guidance helped cement his future direction.
“Prior to chiropractic I was a professional dancer for 11 years,” Walters said. “I had developed an overuse injury in my left hip and my director referred me to his chiropractor. After that first visit, I knew that chiropractic is where I wanted to end up.”
Working with others
“Recent graduates want to work with other provider groups and integrate into multi-professional clinical settings,” says Robert C. Jones, DC, APC, president of the American Chiropractors Association and board of trustees, and past chair for the University of Western States. “They want a varied clinical practice that enables them to utilize more treatment options and a larger portion of their education. Over time, I believe fewer chiropractic physicians will choose to be individual practitioners and smaller entrepreneurial clinics will become less common. This is already occurring in chiropractic, albeit slowly. We see increased integration into managed care groups, patient-centered medical home models and government programs like the Veterans Administration system.”
The ABCA’s Brisco adds that Medicare will provide an avenue for DCs over the next 5-10 years to become health care leaders in pain management and combating opioid overuse.
“I’ve read an article that says 10,000 citizens are enrolling in Medicare every day, and that trend is expected to continue until 2035,” he says. “Because of this trend it will only be a matter of time until laws are put into place allowing chiropractors to treat and bill Medicare for all services allowed under state law.”
Economic barriers to growth
“Speaking as a student currently in the field, I will say that tuition costs and loan repayment are two huge barriers of entry that I most frequently hear about,” says the student Walters, a statistic backed by the 2019 Chiropractic Economics schools survey. “I think the way we treat education in this country is less than desirable. In many ways, we punish students who go to school to enter professions such as health care by burying them in debt. ACA and SACA for some time now have been advocating for doctors of chiropractic to be included in civil programs that would allow DCs to treat in underserved areas in exchange for deductions from their loans. We need more advocates calling for this kind of change so that we, as a profession, have ways of mitigating this hurdle.”
Subsequently a report by Kaiser Health News this year noted that graduates of U.S. medical schools are becoming less likely to choose to specialize as primary care physicians, and that the percentage of primary-care positions filled by fourth-year medical students was the lowest on record.
“I think part of it has to do with income,” said Mona Signer, CEO of The Match. “Primary care specialties are not the highest paying.”
The Association of American Medical Colleges predicts a shortage of roughly 21,000-55,000 primary care physicians by 2032.
Not enough students
The chiropractic industry is currently not producing enough DCs to replace the halcyon days of the 1980s-90s when an estimated 16,000 students were in chiropractic schools across the country. After 30+ years in the industry, those DCs are retiring or slowing to part-time work, and these practices cannot be filled by the estimated only 10,000 students now in DC schools.
To ensure the future of chiropractic, industry leaders agree that DCs need to refer more potential students to chiropractic schools while remaining active in local, state and national organizations.
“I believe that we have some very real challenges,” says Walters, the chiropractic student and SACA leader. “The big one is getting the profession mobilized and engaged in a way that takes an opportunity and makes it a reality. As SACA’s national chair I am privileged to work alongside the most engaged and hardworking students in our profession, but there is always room for more people to get involved. Not just with ACA/SACA, either — state associations across the country are making their voices heard on issues like Medicare, and these are great places to get involved at the local level. We have some amazing opportunities in front of us as chiropractors; we need to be ready and willing to rise to the challenge so that these opportunities are realized.”
Current Medicare act is key
The ACA President Jones says he was in the midst of his chiropractic schooling during the Wilk v. American Medical Association trial, and believes the current Chiropractic Medicare Coverage Modernization Act of 2019 legislation under consideration could similarly rally the industry with the support of doctors of chiropractic.
“This bill is key to our profession, being able to practice as our individual state laws allow and vital to chiropractic being included in emerging health care models that replicate Medicare,” Jones says. “Physician assistants, nurse practitioners, doctors of pharmacy and physical therapists are strongly supporting their associations — it’s apparent from their increasing scope of practice and integration into the health care system.”
The industry has never had a better time in this modern day of chiropractic, Jones and other industry leaders say, to increase chiropractic outreach, put aside differences, and band together to raise up the chiropractic profession.
“We have a finite window of opportunity to raise our profession’s status to help alleviate the physician shortage,” Jones says. “Every chiropractor should join their state association and the ACA and support laws that facilitate the participation of our profession in the health care system.”
RICK VACH is editor-in-chief of Chiropractic Economics magazine. We welcome your opinion and letters to the editor; send to firstname.lastname@example.org.
This article appears in issue #15 of Chiropractic Economics magazine, Sept. 20, 2019. To receive your free subscription click here.
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