Tribal clinics offer a unique career path and benefits for DCs

Working at Tribal clinics is a new and growing opportunity for DCs, as well as for the Tribes, with financial and professional incentives.

Tribal clinics, or federally qualified health centers (FQHCs), are a unique practice setting and expanding option for doctors of chiropractic. As part of the provider team at a Tribal FQHC, I have had the opportunity to experience the professional satisfaction and challenges in this setting. It might be a good fit for other DCs, too, especially those who would like to make a significant impact on the health and wellness of an historically underserved population while working in an integrative setting.

As chair of the American Chiropractic Association’s new Tribal Health Interest Group, I am raising awareness of this unique career path. To that end, I would like to share some information and tips here on navigating employment opportunities in a Tribal clinic setting (much of which will also apply to FQHCs).

Indian Health Service or self-determination control

Traditionally, Tribal clinics are operated and staffed by the Indian Health Service (IHS) to fulfill federal treaty obligations to the Tribes. In 1975, the US Congress enacted the Indian Self-Determination and Education Assistance Act, Public Law 93-638. The Act allowed for Indian Tribes to have greater autonomy and to have the opportunity to assume the responsibility for programs and services administered to them on behalf of the Secretary of the Interior through contractual agreements. Self-determining Tribes or “638” (pronounced “6-38”) Tribes have used this law to take control of their clinics to offer services they feel best fit the needs of their members and communities, rather than just the basic care IHS provides. These are Tribes that have hired chiropractic physicians, as the IHS does not employ DCs or pay for chiropractic services. Of 574 federally recognized Tribes, approximately 564 are either Title 1 or Title 5 “638” self-determining. They must negotiate with IHS to determine what services they offer and then receive a lump sum annually that they manage.

Insurance: IHS vs. private vs. government

“638” Tribal clinics often only treat members of their Tribe or other Tribes, as a choice. These clinics operate within their IHS budget and any additional money the Tribe elects to put into the clinic to care for its citizens. They may also get Medicare and Medicaid payments.

Some, especially the FQHCs, have opened patient enrollment to non-Tribal patients. Often this is done to serve the larger rural population. The advantage of this is that it brings in private insurance and cash monies, in addition to the IHS-funded direct care, Medicare and Medicaid. These clinics often have more services commensurate with the increased revenue. This is a choice the Tribe must make and contract for appropriately.

Credentialing

As a federally regulated medical facility, the clinic will need to credential the chiropractic physician. This process can take weeks to months to complete. During this period, the DC may use the time to create procedures and policies for the new department, educate peer providers and staff, conduct community education and events or other non-clinical tasks. It may be possible for the DC to see patients but likely “incident to” and billed under the medical director’s license and “supervision,” as would a new and uncredentialed medical provider.

Salary

Typically, the new DC will be an employee of the clinic, with a salary and benefits including health insurance and often a 401(k). There are examples of some Tribes contracting a local DC to work at the clinic part-time, but this should be a test phase, not a permanent solution, as the DC should be too busy for part-time work. If the DC has an existing practice nearby, an option to propose to Tribal clinic leadership is to open the clinic to non-Tribal patients. The DC would bring their entire practice to the clinic with the option that they may choose a Tribal clinic primary care provider as their new PCP. Many Tribes reside on reservations in rural areas, so, like Tribal members, many area residents lack medical resources. This creates an opportunity.

Student loan repayment program

Although the IHS does not pay for chiropractic services nor hire chiropractic physicians as employee providers at their clinics, they do allow them to participate in the loan repayment program (LRP) if they work for a Tribe. Currently, this pays up to $22,600 annually to be applied directly to student loans as long as you fulfill a contract period. The LRP has a limited budget and only accepts a certain number of providers. It has a scoring system based on perceived need in each clinic’s area and what services are available, and the applications are considered on a first-come basis. There is no real understanding of chiropractic, so it is often grouped with physical therapy. Therefore, if a clinic already has a physical therapist, the LRP does not consider a new DC necessary and likely will deny their application. I overcame this in two ways: 1. the CEO of our clinic wrote a letter to the IHS program stating the Tribe felt that chiropractic was distinct from physical therapy and the current physical therapy was not meeting the Tribe’s needs and 2. as the system scores each applicant on the time and date of application, I was at the computer at 5am PST (system opened at 8am EST) and submitted my application as fast as I could complete it. It must be done in one sitting. Once accepted, you get first rights of refusal for renewing your contract thereafter and no longer must compete. It starts with a two-year contract and is renewed annually. There are currently six DCs in the LRP.

Direct or referral

Another consideration is whether the patients have direct access to the chiropractic services or need a referral from the PCP. This is something that will have to be negotiated with clinic leadership when you start the position. I encourage you to have this written into the founding of the department to avoid internal politics if a different medical director takes over who is not chiropractic-friendly. I have seen several clinics, including a large one, that should have been a great success but failed due to access issues. Typically, the chiropractic department is a subdepartment of the medical department and under the medical director.

Billing

Often the existing billing or revenue staff for the Tribal clinic will have no experience in billing for chiropractic services and will require training. That should be accounted for in the proposed budget and planned as soon as possible to avoid billing mistakes and missed money. The chiropractic position should more than pay for itself while providing a much-needed service to patients and support for the primary care team by handling many of the musculoskeletal (MSK) cases. The addition of chiropractic will be more about the service, patient satisfaction and reduced opioid prescriptions and use, than revenue.

Independent contractor vs. employee

When a Tribal clinic is operated similarly to a well-run hospital or private practice, the DC should be very busy. As most Tribal clinics are on rural reservations, there are limited opportunities for quality healthcare without significant travel and expense other than the Tribal clinic. When I started, we had a 100-patient waiting list and it never slowed down, with eight to 12 new patients every week for seven years until the patients and I convinced them to hire another DC. PCP provider buy-in and support was crucial. Instead of the Tribe paying money to an outside provider that the patients would have to travel to see, they kept it in-house with constant communication with the patients’ providers as “their” DC in a profitable department (in a Tribal FQHC). The “purchase and referred” money saved could then be spent on other needs for the patients.

Instead of taking the leap to hire and create their own chiropractic department, some Tribes will for various reasons sometimes contract with a local DC to provide care for their members, usually at a discount for exclusive volume. Normally, they require a referral from the Tribal PCP, who may or may not be willing to provide it.

This can be a starting point to build relationships with Tribal leadership and the Tribal providers and patients, but it has limitations and will cost the Tribe more money in the long term than doing it in-house.

Final thoughts

It is very rewarding to serve this unique and underserved population, which has a great need for better MSK treatment provided by DCs. The National Congress of American Indians (NCAI), the largest lobby organization for the Native American Tribes, has had a resolution in front of IHS since 2015 asking them to cover and provide chiropractic and other nonpharmacological treatments. Some Tribes have taken it upon themselves to do so, and more are interested. But there are numerous challenges to accomplishing this. I hope this article assists you in having discussions with Tribal leadership about starting a chiropractic department at their clinic.

Ryan Kain, DC, CFMP, is a graduate of Palmer College of Chiropractic with a certification in functional medicine from the Functional Medicine University. After 15 years in private practice, he transitioned to integrative multispecialty care at a Tribal FQHC for the past 9+ years. He currently serves as the chair of the ACA’s Tribal Health Interest Group with the goal of expanding Tribal populations’ access to chiropractic by increasing the number of Tribes hiring DCs and recruiting native students to become DCs. To learn more about the Tribal Health Interest Group, visit acatoday.org and search “Tribal health” or email rkain@marimnhealth.org.