Articles by JCS

Health Leaders Media

Physicians, Chiropractors Still Out of Alignment

Joe Cantlupe, for HealthLeaders Media , April 4, 2013

For some primary care doctors, hearing that a patient has consulted with a chiropractor can be a real pain in the neck.

MDs have been clashing with DCs (chiropractors) for years over their abilities and qualifications for certain procedures, and there's no sign of the debate letting up any time soon. In fact, as the national demand for spine care accelerates as quickly as an aging population's aches and pains, the chiropractor and physician debate over care is bound to intensify.

There's already a skirmish brewing over the Patient Protection and Affordable Care Act, which chiropractors cite as a path toward improved reimbursements. Physicians, predictably, are putting up resistance.

A Fight as Big as Texas
But there's been no longer or bigger clash between the two maladjusted professions than in Texas, where litigation between the Texas Medical Association and the Texas Board of Chiropractic Examiners is underway. At the heart of arguments by physicians is whether chiropractic work should be allowed to cross the line into the practice of medicine, in general and specific procedures.

One case centers on whether chiropractors may perform electromyography needle biopsies or manipulation under anesthesia, or whether such practices should be conducted only by licensed medical doctors. The case has been bouncing around various levels of courts in Texas, with appeals and reversals along the way.

The Texas Supreme Court, however, may soon consider part of that case, after a state appeals court ruled favorably for the Texas chiropractic board, saying that chiropractors can make limited diagnoses with these procedures. The court said that the chiropractors could diagnose conditions related to the spine and muscle system, and be within the scope of their practice.

TMA: 'A public safety issue'
In another case, the Texas Medical Association won. In December, an Austin state judge granted the association's motion to prevent chiropractors from performing vestibular testing. The vestibular system, a component of the inner ear, is linked to the central nervous system. The judge declared that chiropractors who performed vestibular tests went beyond their profession's lawful scope of practice.

"We think there's a legitimate public health issue, a public safety issue," David Bragg, an attorney for the TMA, says of the physicians' legal battles with the chiropractors.

"From a patient's point of view, many times they don't understand the difference between a doctor of chiropractic and a doctor of medicine," Bragg says. "Potentially, there could be someone exhibiting symptoms of a profound (physical) problem, and chiropractors argue that they should be allowed to diagnose that condition. But these patients maybe should immediately go to the appropriate medical provider. Is this person having a stroke? A heart attack? There should be no delay built into the process."

The chiropractors' claims for diagnostic qualification "dilutes the medical license; it weakens the medical license," Bragg says.

Although some of the debate is still being played out in court, chiropractors are winning in the legislative arena in Lone Star State. Legislation has been introduced in the Texas statehouse that would allow chiropractors to make limited diagnosis on patients. The legislation essentially expands the definition of chiropractic medicine in the state to include diagnosing the spine and muscle system.

JC Smith, MA, DC, a Georgia chiropractor who has been in practice for 33 years, supports the Texas legislation. He has been an outspoken critic of the medical establishment, which he says has unfairly labeled chiropractors as second rate, with patients being the losers. Smith is author of The Medical War Against Chiropractors, a book that traces historic obstacles faced by chiropractors in a medical doctor-dominated healthcare world.

He acknowledges that chiropractors won a big victory with the passage of the PPACA. Smith and others point to Section 2706 of the act, the so-called non-discrimination clause. It could be a potential opening for chiropractors to get equal consideration in reimbursement as physicians, he says.

Specifically, Section 2706 of the PPACA prevents health insurance plans from excluding a range of integrative health practitioners from coverage, based on licensure. That could include chiropractors and others such as massage therapists or midwives.

"It's a real blessing for us, the non-discrimination clause, that finally gives the freedom of choice" to insurers, Smith says, referring to the possible "choice" of greater reimbursement.

AMA opposes expansion of coverage
Smith noted, however, that the American Medical Association wasn't exactly pleased with the Section 2706 provision within the PPACA. "What does the AMA do?" Smith asked. "Its House of Delegates passed a resolution to repeal it."

Indeed, the AMA House of Delegates at its meeting last year reaffirmed its opposition to the non-discrimination clause, or Section 2706 of the PPACA. The House of Delegates meeting minutes showed that the AMA intended to work to repeal Section 2706, "as enacted in the PPACA through active direct and grassroots lobbying."

AMA officials declined to comment when contacted this week, but its website notes that "non-physician healthcare providers should only provide patient care in accordance with their education and in accordance with applicable state laws."

'Drugs and shots and surgery' have not worked
Generally, chiropractors are maligned, Smith says. As far as he is concerned, the AMA isn't the only problem; it's the general coverage of chiropractors by the news media. "Chiropractors remain a mystery science profession in the media," Smith says.

Still, he insists that chiropractors are making headway in healthcare, not least by the mere fact that people are recognizing the outrageous costs involved, specifically over failed back surgeries. "After a century assailing chiropractors as practicing quackery, the table has finally turned with the medical profession on the defensive," Smith insists, referring especially to changes afoot in the Affordable Care Act.

"The paradigm of drugs and shots and surgery hasn't worked," he says.

He isn't confident, however, that physicians will embrace the chiropractic profession anytime soon. "Nobody seems to be listening," he says.


Joe Cantlupe is a senior editor with HealthLeaders Media Online.

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