Where Does Chiropractic Fit In?
As the chiropractic profession struggles to define itself and find a place in this new system, four important questions emerge that need to be answered.
Today the “buzz word” in health care is managed care. Managed care implies by its very name that someone or something is “managing,” or at least overseeing the health care of patients. Physicians of all kinds, hospitals, and health care practitioners everywhere are asking themselves what exactly is managed care, how have we survived without it, and how will we survive with it? These questions continue to remain unanswered, at least in part, and in many instances in whole as the scramble for financial position and patient access becomes almost as important as the delivery of the health care.
As the chiropractic profession struggles to define itself and find a place in this new system, four important questions emerge that need to be answered before our proper place can become established. They are:
- How do we define model of care?
- Are we primary care physicians?
- What are our standards of care?
- What is our scope of practice?
While there continues to be disagreement within the profession about the answers to these questions, it is important to answer them at least in part as we fit ourselves into the managed care world.
“How do we define model of care?” Our model of care is not based on allopathy. Allopathic medicine is a symptom-based model of care where the patient is treated in many or most instances by subspecialty practitioners who do not observe their cases as a whole. Disease is treated in part and wellness is considered secondarily or not at all.
The chiropractic model is a more patient-oriented model whereby the whole human being is considered. This model promotes prevention, and sees the patients’ lifestyles and lives as a continuum from which disease and illness can result. This model, by its very nature and its value on the continuum, promotes cooperation with other disciplines, and allows the patient the freedom to move from one model to another. Many in the chiropractic profession separate this type of discussion into philosophy, but rather, it speaks to our very existence.
The next question, “Are we primary care doctors?” is answered very simply by examining the chiropractic educational process. CCE-accredited schools teach at the core of their curricula, diagnosis and the proper administration of referrals. In addition, if we are not primary care doctors, we would be the final step or an interim step in the patient’s health care approach, rather than the beginning. In this respect, chiropractors can be separated from other “alternative practitioners” in that they are often not the alternative choice, but the primary portal of entry. State laws afford chiropractic primary portal of entry status.
The last two questions remain less clear and perhaps more controversial. There must be some differentiation and a level of understanding with respect to the differences between scope of practice and standards of care. While I will not attempt to define the exact parameters that cover standards and scope, simply defined, the standards of care are the consensus of a profession with respect with what needs to be performed by the chiropractor in the clinical setting. These standards address the practice of the doctor, not necessarily what the doctor treats. The Mercy document went to considerable lengths to define standards of care. While perhaps not a perfect document, it is clearly a good attempt to define what is usual and customary within the profession.
Scope of practice is an entirely different entity. While standards are often established with respect to scope, scope of practice is something that is constantly being refined through ongoing research, and is defined by law. In the chiropractic profession, scope varies so widely state-to-state that what is clearly within the scope of practice in one state could potentially be outlawed in another. To this end, we need far more consensus within the profession regarding scope.
While we cannot take the time to wait for emerging research as managed care is upon us, we do need to put our “best foot forward” as we venture into this new world. It continues to remain important as we sit on advisory panels for these managed care companies, that many of these questions remain unanswered within the profession. Without clear answers, one DC’s practice may be completely within the scope the standards and scope, and look as different as urology and psychiatry do for the allopaths.
One of the most difficult issues facing the chiropractic profession regarding managed care is what we do when given a place within the system that is narrower than any scope, and not in keeping with our standards, with respect to reimbursement? Do we settle for five visits for a total scope of three conditions: neck pain, thoracic pain and lumbar pain? I don’t think this is a place where we want to be.
Chiropractic is a unique and distinct science and it should be treated as such. Chiropractic has always been rooted in science, but a science that is not ours. Now we must take the same approach with our science that we have taken with our art and with our philosophy. Chiropractic science has just begun to be explored. When the sciences catch up with the philosophy and the art, and a balance has been struck, only then we will be known as a profession where we truly belong.
Managed care is forcing us to examine ourselves. It is most important not to turn our profession over to those who do not understand it, or who are not willing to look at it with us. Chiropractic is a special model of health care. It brings to the table some of the best parts of all the different models of care and yet remains distinct. It is imperative that we not allow another profession, insurance companies, or even ourselves to place us in a model where we do not belong. Chiropractors can survive managed care and can even flourish with it. If we remain true to our identity, we will survive, not only as a group of practitioners, but as a profession.s
Joan Fallon, DC, DICCP, is in private practice in New Rochelle, New York and serves in the Department of Natural Sciences and Mathematics at Yeshiva University, New York, New York. Dr. Fallon is Vice-chair of ICA’s Council on Chiropractic Pediatrics and editor of the Journal of Clinical Chiropractic Pediatrics (JCCP).