Articles by JCS

Military Health Issues

                                                                                    March 3, 2011

Rep. Bob Filner

2428 Rayburn House Office Building

Washington, DC 20515

Dear Sir:

Let me thank you for helping my profession gain access within the military health services. Unfortunately, the inclusion of chiropractic care has been sabotaged by MDs and PTs in the military healthcare system (MHS).

As a legislator, you also need to be aware that chiropractors are being controlled by the MDs and PTs in the MHS to limit patient access. I have communicated this problem to Michael W. O’Bar, Deputy Chief, TRICARE Policy and Operations, Office of the Assistant Secretary of Defense Health Affairs and to Dr. S. Ward Casscells, the Assistant Secretary of Defense, concerning the discrimination against Chiropractic Care in TRICARE and military health services.

Of course, appealing to these medical men is equivalent to the sheep begging to the wolf for help. I doubt I will even get a reply, let alone a change in their policy, which is why I’m appealing to you.

In Mr. O’Bar’s letter of December 6, 2010 to me, the bottom line that the reason chiropractic care is not available to all military or TRICARE recipients is due to a few falsehoods:

“In addition, adding chiropractic care to the primary car model was estimated to increase the number of visits per episode of care. Ultimately, this increases the costs and delays a service member’s return to duty. These constraints have limited our ability to field chiropractic care beyond the 60 locations currently providing the service.”

I was most perplexed by this summation since it ignored and contradicted the positive data from the two attachments included in his response to me: Chiropractic Care Study and the Study Relating to Chiropractic Services and Benefits. It is obvious the MHS staff has distorted their own research to keep chiropractors limited.

As well, presently PTs are in charge of DCs, which is equivalent to sergeants in control of officers since PTs are therapists whereas DCs are considered physicians.

After reviewing Mr. Bar’s letter and the letter from S. Ward Casscells, MD,  I think a case can be made of the continued interference of the medical bureaucracy to obstruct the will of Congress to make chiropractic care accessible to active military and TRICARE recipients. Indeed, the facts simply do not support their conclusions.

Problem #1: Contradictory Conclusions

First of all, a September 22, 2009 letter to Congressmen from Ellen P. Embrey, then Deputy Assistant of Defense, clearly stated:

“The [Chiropractic Care Study] report reveals that our Active Duty members are very satisfied with the chiropractic care they receive, and military treatment facility personnel consider offering chiropractic care to be beneficial.”

Somehow Dr. Casscell’s conclusion failed to consider Ms. Embrey’s opinion or the enormously high patient satisfaction rates that ranged from

  • 94.3 percent in the Army;
  • the Air Force tally was also high with twelve of 19 bases scoring 100 percent;
  • the Navy also reported ratings in the 90 percent or higher;
  • even their own TRICARE outpatient satisfaction surveys (TROSS) rated chiropractors at 88.54, which was 10 percent “higher than the overall satisfaction with all providers” that scored at 78.31 percent.[1]

This Chiropractic Care Study also commented on the Unit Commanders and Military Treatment Facilities (MTF) personnel concerning chiropractic care: “The responses were overwhelmingly a five (the highest rating available); MTFs that offer chiropractic care are pleased to do so.”

This survey also contradicts one of the DOD’s claims that chiropractic care “delays a service member’s return to duty.” According to this survey, when asked “do you think chiropractic care returns Active Duty Service Members (ADSM) to duty faster?” the study concluded “Once again, it was generally positive.”[2]

Another question posed to the ADSM was the likelihood to select chiropractors over osteopaths or physical therapists (five being very likely), the response was again very positive with “responses from threes to fives.”[3]

“Overall, the surveys showed that MTFs consider chiropractic care a valuable adjunct to the care offered in the MTFs. Unit personnel generally consider chiropractors to return ADSMs to duty faster, and they would select a chiropractor as much or more than a Doctor of Osteopathy or physical therapist.”[4]

Considering the results of their own surveys, it is bewildering how their reports came to their skewed conclusions unless there was some bias or tampering. Certainly the reasons to limit chiropractic care fly in the face of their own Chiropractic Care Study. Both ADSM and Unit Personnel are very pleased with chiropractic care, “generally consider chiropractors to return ADSMs to duty faster,” and most prefer chiropractic care over osteopaths or PTs.

Dr. Casscells’ conclusion also contradicts the survey of ADSM that showed Service members preferred to select chiropractors over osteopaths or physical therapists.[5] Nonetheless, Dr. Casscells mentions in his cover letter of March 3, 2009, that “in the absence of chiropractic care, various comparative treatment options are available to active duty Service members, their families, and other beneficiaries of the Military Health System.” Dr. Casscells’ belief that chiropractic care is “comparable treatment” to osteopathic, medical, or physical therapy is hugely erroneous.

To the contrary, no one but chiropractors offer chiropractic care. What Dr. Casscells calls “comparative treatment options” are, in fact, not comparable. Various research studies confirm standard physical therapy is not equivalent to chiropractic spinal care, and to suggest it is completely misleading. As well, RAND has reported that 94 percent of all manipulative care was delivered by chiropractors, with osteopathic physicians delivering 4 percent, and general practitioners, physical therapists, and orthopedic surgeons accounting for the remainder.[6]

Nor is it reasonable to state that non-chiropractors can render chiropractic care according to a federal appellate court. In its Dec. 13, 2005 decision, the three-judge Appeals Panel overturned the District Court’s ruling, noting that the District Court lacked the jurisdiction to decide whether medical doctors and osteopaths may manipulate the spine to correct subluxations. The appeals panel also raised an important point on the issue of which health care providers are qualified to provide chiropractic services, not just which providers are licensed to provide such services:

“The regulation states that ‘[I]f more than one type of practitioner is qualified to furnish a particular service, the HMO may select the type of practitioner to be used’ (emphasis added). The HMO’s invocation of this provision would squarely present the question whether medical doctors and osteopaths, as well as chiropractors, are ‘qualified to furnish’ the service of manual manipulation of the spine to correct a subluxation.”[7]

Then-ACA President Richard Brassard, DC, remarked about this decision;

The ACA is extremely pleased that the District Court’s ruling allowing MDs and DOs to provide a uniquely chiropractic service was nullified. We are happy that the issue is now whether or not a practitioner is ‘qualified,’ not whether or not a practitioner is simply licensed. The ACA’s position has been and remains that only chiropractors are qualified by education and training to correct subluxations. Because of the Appeals Court’s decision, chiropractors can continue to fight to safeguard their right to be the sole providers of this service, and to ensure Medicare patients’ rights to access doctors of chiropractic.[8]

As well, the Evaluation of the TRICARE Program, Fiscal Year 2010 Report to Congress, also mentioned this erroneous comparison:

TRICARE does not cover chiropractic care, but family members may be referred to nonchiropractic health care services—physical therapy, family practice or orthopedics—for treatment as appropriate. http://www.tricare.mil/ChiropracticCare

The research is clear that MDs, DOs, and PTs are not comparable spine specialists as Dr. Casscells suggests. Considering chiropractors have carried the banner of manipulative therapy since 1895 while, for the most part, the osteopaths relinquished this art in the early 1960s in order to be assimilated into the medical ranks and Medicare, physical therapists have ignored this treatment to avoid the quackery stigma, and medical physicians have chosen to vilify this form of care, it is obvious that chiropractors are the professionals who lay claim by far to the most experience in manipulation, and rightfully so.[9]

For the DOD to suggest that “nonchiropractic health care services—physical therapy, family practice or orthopedics—for treatment as appropriate” flies in the face of the research and the law.

Problem #2: Physical Therapists Control Chiropractors in MHS

Another sad fact is the DOD has chosen to put technician-level PT providers in control of physician-level DCs. In effect, this is equivalent to sergeants ranking higher than officers.

A chiropractic colleague of mine who works within the MHS has complained to me of abuses within the system that are detrimental to patients attaining chiropractic care, and it begins with PTs in charge of chiropractic care. It appears the medical profession is up to its old tricks to see chiropractic “wither on the vine” as the AMA’s Committee on Quackery stated during its witch hunt in the 1960s that led to the famous Wilk et al. v. AMA et al. federal antitrust trial in Chicago.

One of the points that is pivotal for the chiropractic profession’s success in the military is to get out from under the authority of military physical therapists. To do this we need to have at least two things take place:

1)      Place a chiropractic service chief in charge of the chiropractors in each branch of the military service.

2)     Convert the chiropractors employed in the DOD from being Title 5 employees to Title 38 employees. 

Title 5 is what civilian PTs and DCs are hired under in the DOD.  The pay ranges from $55k-$95K.    The military PTs are really "going to the wall" to insure that DCs stay Title 5 employees.  Title 5 is a non-independent clinician, a technician-level health-care worker.  Title 5 maximum government pay scale tier is GS12.
Title 38 employees include DPM, OD, psychologists and other [non medical doctor] physicians.

The VA has already changed chiropractors to Title 38 employees.  Title 38 allows chiropractors to be hired as limited practice physicians like podiatrists, optometrists, and psychologists. The VA uses title 38.  Medical Doctors, DOs and Dentists are considered physicians. This increases the pay to up to $136k + benefits and raises the maximum government service level to GS 15.  This would allow chiropractors to assume leadership positions in the VA and DOD perhaps even as the head of a spine center, a medical center, a hospital, a region of care. This would in effect place us strategically over physical therapists as it should be. A GS 15 may be a VA policy maker and conceivably the head of a hospital or medical center.  

PTs are limited to GS 12 and are treated as technicians in both the DOD and the VA.  Title 5 treats chiropractors as technicians, like PTs.  It limits DCs’ maximum pay to GS 12 with a pay range from $55k to $95K. The PTs in the military are fighting to hold DCs to the same scale as PTs in the GS system (GS 12). They refuse to acknowledge there is a difference between a physician-level DC and a technician-level PT.

With that in mind, it is incomprehensible that the PTs have wrangled their way to the head of all of the Chiropractors in the DOD:   An Air force PT over the Air Force chiropractors, an Army PT over the Army chiropractors, and a Navy PT over the Naval chiropractic benefit.  They work together to limit the chiropractic benefit and keep the Title 12 employment policy intact.    The irony in this situation has technician-level therapists overseeing physician-level practitioners. It appears the medical profession will do anything to put a yoke on chiropractors.

Problem #3: Inadequate Training for MDs and PTs in Musculoskeletal Disorders

Subsequent studies have also shown medical primary care physicians and physical therapists are poorly educated and clinically inferior to the services of chiropractors for musculoskeletal disorders. New studies have confirmed that most primary care physicians are inept in their training on musculoskeletal disorders,[10] more likely to ignore recent guidelines[11], and more likely to suggest spine surgery than surgeons themselves.[12] As well, biased physicians suffer from “professional amnesia”[13] when they inexcusably forget to inform patients that chiropractic care is a recommended option to the often ineffective medical methods.

In 1998, Kevin B. Freedman, MD, and Joseph Bernstein, MD, published a landmark study in Journal of Bone and Joint Surgery wherein they administered a validated musculoskeletal competency examination to recent medical graduates who had begun their hospital residency; 82 percent of these medical doctors failed to demonstrate basic competency on the examination, leading the authors to conclude, “We therefore believe that medical school preparation in musculoskeletal medicine is inadequate.” [14]

In their 2004 review published in Physician and Sports Medicine, Elizabeth A. Joy, MD, and Sonja Van Hala, MD, MPH, described the formal training of a sample of medical graduates. “The average time spent in rotations for courses devoted to orthopedics during medical school was only 2.1 weeks. One third of these examinees graduated without any formal training in orthopedics. As would be expected, these data suggest that limited educational experience contributes to poor performance.” [15]

Many physical therapists hold themselves out to be spine therapists, but a study by JD Childs et al.[16] on the physical therapists’ knowledge in managing musculoskeletal disorder (MSD) conditions found that only 21 percent of students working on their Master’s degree in physical therapy and 25 percent of students working on their doctorate degree in physical therapy achieved a passing mark on the Basic Competency Exam.

Even those physicians with a special interest in low back pain were more likely to believe in outdated concepts such as narcotics, complete bed rest, and avoidance of work are appropriate for acute low back pain—concepts now regarded as inappropriate. Oddly, there were no important differences in back pain beliefs between those with and without a special interest in musculoskeletal medicine.[17] It appears that any MD with an interest in back pain can hang out a “pain clinic” shingle even when poorly trained in this area.

According to one DOD chiropractor, the majority of his patients had prior physical therapy that proved to be unsuccessful:

“In reviewing my own charts I found that 70% of my patients failed PT before trying chiropractic, so I am curious how they can say that we are less effective than the PTs, or usual and customary care.”

Problem #4: PTs Taint DoD Studies

It is my belief that the PTs performed the "study" that shows that DCs are not as effective as the PTs.   But this study raised spurious questions:

“The study quoted by military medicine was released two years ago.  It was unsolicited by Congress and its results were, in my opinion, predetermined.  That study was an almost secretive study that was an internal audit.  They hired an outside company to perform the study and it has not been published or subjected to peer review.”

Not only have the military PTs taken charge over chiropractic physicians, they also have restrained their incomes unfairly. According to a military DC:

“Two years ago the Navy was offering a chiropractic position in Okinawa Japan with a pay range up to $185K,  The Army PT in charge of the chiropractic benefit found out about this and called the Navy PT in charge of the chiropractic benefit and convinced her to lower the pay range to $55-95K.”

 Conclusion

If our military personnel are to receive the best of spinal care, it is imperative the DOD stop with its “wither on the vine” policy toward chiropractors. Actually, the DOD’s policy flies in the face of the military’s greatest problem—back injuries.

The DOD admitted that 20% of their disabled vets came from low back pain, and recent research indicates that 30% of hospitalizations were for low back pain. According to research done in 2000 by Johns Hopkins, Unintentional and Musculoskeletal Injuries Greatest Threat to Military Personnel, “...in all three branches of the service, injuries and musculoskeletal conditions among all groups of disorders, resulted in more soldiers missing time from work than any other health condition.”[18]

Imagine the thousands of soldiers who have sustained and suffered with back injuries who were denied chiropractic care, leading to permanent disability from failed physical therapy and back surgeries. I urge you to mandate chiropractic care for every active military personnel that will not only improve their health, but decrease costs and improve job performance.

Considering the comparative studies showing the superiority of chiropractic care to medical care, it appears the DOD and Dr. Casscells goal is to deprive patients of the benefit from spinal manipulation as practiced by doctors of chiropractic, and to deprive doctors of chiropractic of the opportunity to treat those patients based on insufficient evidence. Indeed, medical bias is the underlying problem with this issue.

The present policy of DOD to limit chiropractic care smacks of the same boycott strategy that led to the Wilk v. AMA antitrust suit. DOD has ignored favorable research studies supporting chiropractic care is faster, safer, more effective and less costly than anything the medical world has to offer. The fact that TRICARE is willing to promote acupuncture as a medical service despite the proof that chiropractic care is more effective illustrates the bias among the TRICARE medical bureaucrats.

I believe the TRICARE decision making process demands reevaluation and transparency due to the lack of chiropractic advocates in this obvious illogical conclusion to contain the expansion of chiropractic care.

I hope to hear from you on this matter.

 

Regards,

 

JC Smith, MA, DC

Warner Robins, GA

 




[1] Chiropractic Care Study, Senate Report 110-335 accompanying the National Defense Authorization Act for FY 2009; letter sent to Congressmen by Ellen P. Embrey, Deputy Assistant Secretary of Defense (September 22, 2009):2.

[2] Ibid. p. 3.

[3] Ibid.

[4] Ibid.

[5] Ibid.

[6] PG Shekelle, AH Adams, MR Chassin, E Hurwitz, RE Park, RB Phillips, RH Brook, “The Appropriateness of Spinal Manipulation for Low-Back Pain: Project Overview and Literature Review,” RAND (1991):3. Santa Monica, Calif.

[7] Michael Devitt, “Landmark Decision in ACA Lawsuit Against HHS,” Dynamic Chiropractic 24/02 (January 15, 2006)

[8] ibid.

[9]  Ibid.

[10] EA Joy, S Van Hala, Musculoskeletal Curricula in Medical Education-- Filling In the Missing Pieces, The Physician And Sports Medicine,” 32/11 (November 2004).

[11] PB Bishop et al., The C.H.I.R.O. (Chiropractic Hospital-Based Interventions Research Outcomes) part I: A Randomized Controlled Trial On The Effectiveness Of Clinical Practice Guidelines In The Medical And Chiropractic Management Of Patients With Acute Mechanical Low Back Pain,” presented at the annual meeting of the International Society for the Study of the Lumbar Spine Hong Kong, 2007; presented at the annual meeting of the North American Spine Society, Austin, Texas, 2007; Spine, in press.

[12] SS Bederman, NN Mahomed, HJ Kreder, et al. In the Eye of the Beholder: Preferences Of Patients, Family Physicians, And Surgeons For Lumbar Spinal Surgery,” Spine 135/1 (2010):108-115.

[13] A Rosner, “Evidence or Eminence-Based Medicine? Leveling the Playing Field Instead of the Patient,” Dynamic Chiropractic, 20/25 (November 30, 2002)

[14] KB Freedman, J Bernstein, “The Adequacy Of Medical School Education In Musculoskeletal Medicine,” J Bone Joint Surg Am. 80/10 (1998):1421-7

[15] Joy ibid.

[16] JD Childs, JM Whitman, PS Sizer, ML Pugia, TW Flynn, A Delitto, “A Description Of Physical Therapists’ Knowledge In Managing Musculoskeletal Conditions, BMC Musculoskelet Disord 6 (2005):32.

[17] R Buchbinder,  M Staples, D Jolley, Doctors With a Special Interest in Back Pain Have Poorer Knowledge About How to Treat Back Pain,” Spine, 34/11 (May 2009)  

[18] Inteli-Health (Johns Hopkins); March 15, 2000.

 

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