“The best way to predict the future is to study the past…” (Robert Kiyosaki)
Driven by rising health care costs, the constant barrage of new research knowledge and the increasing integration of technology, the way in which all health care providers take care of patients in this country–in this world–is changing rapidly. This evolving health care environment means that, while we remain steadfast at the core of who we are and what we do stand for as a chiropractic profession, expectations regarding some of the ways in which we practice are beginning to change.
The movement towards evidence-based clinical practice, guidelines, clinical data registries, electronic health records, participation in quality reporting programs such as the CMS quality payment program, and the ACA’s Choosing Wisely list can be both disconcerting and overwhelming. Unquestionably, change can be frightening and difficult to accept, both because change is often hard and because it is impossible to predict what an uncertain future will bring. I do not know exactly where many of these changes will take us. However, I have learned that as we look to the future it can sometimes be helpful to glance back at the past in order to mark our progress. Consequently, I have put together the following list of things that have changed within the chiropractic profession (very much for the better, I would argue) over the past 30 years.
Number 10: Codes were specifically developed to describe chiropractic manipulative treatment (CMT) for reimbursement purposes listed in the Common Procedural Terminology or CPT book. At the time, I was a vice president at the American Chiropractic Association, who spearheaded this effort, when these codes were developed and implemented. To say that this was controversial at the time is an understatement. However, these codes enabled us to effectively argue that the time, effort and medical decision-making involved in administering chiropractic manipulation was at parity with already established physician-level osteopathic manipulation codes. And this enabled us to better describe our primary service to others using a common language and led to an increase in reimbursement for CMT under the Medicare payment system and beyond.
Number 9: Those who have spent any time in Washington, D.C., realize the truth of that old saying, “If you are not at the table, you are on the menu.” Doctors of chiropractic are increasingly invited to the health care policymaking table. Currently, we have chiropractors who sit on the American Medical Association’s Relative Value Update Health Care Professional Advisory Committee, the Patient-Centered Outcomes Research Institute Board of Governors, and the Advisory Committee for the National Center for Complementary and Integrative Health at the National Institutes of Health (NIH).
Number 8: The federal government has committed federal funding to chiropractic colleges that is somewhere in the neighborhood of $80 million to evaluate chiropractic care over the past 30 years. This includes a recent NIH grant for $7.1 million, which was awarded to Palmer College of Chiropractic in order to study the appropriate “dosing” of chiropractic treatment for U.S. veterans. When I graduated from chiropractic school in 1991, this figure was much closer to zero. An additional $5.2 million has been contributed by NCMIC Foundation since 2003. Collectively, this funding has provided the resources necessary to lay the foundation for a chiropractic evidence base that now helps us deliver higher quality chiropractic care and make important inroads in the health policy arena.
Number 7: Thirty years ago, there was a small handful of studies published in the scientific literature showing that chiropractic care might be effective for low back pain. It was difficult to find enough chiropractors engaged in research activities to have even one scientific conference a year. Currently, there are somewhere in the neighborhood of 200 papers presented annually at multiple conferences held worldwide. In addition, we now have six chiropractic journals included as part of the National Library of Medicine’s PubMed search engine and high-quality scientific articles on chiropractic care have also been published in The Journal of the American Medical Association (JAMA), Annals of Internal Medicine, The Spine Journal, Spine, Medical Care, Health Affairs, Gerontologist, and the American Journal of Public Health and Military Medicine. In addition, there are numerous DCs who serve on editorial and peer review boards of multidisciplinary journals.
Number 6: It is becoming more and more common for our sports heroes to mention that value they place on chiropractic care. Doctors of chiropractic are now regularly included as treating physicians at the Olympic games, the Pan American games and the World games. Not only that, all 32 teams in the National Football League provide their players with chiropractic care.
Number 5: Chiropractic has expanded across the globe. There are now more chiropractic colleges outside the United States than within and the national chiropractic associations from 85 countries are members of the World Federation of Chiropractic (WFC). WFC represents the chiropractic profession to the World Health Organization (WHO), and we have two doctors of chiropractic working for the WHO in Geneva.
Number 4: Increasingly, doctors of chiropractic are working in multi-disciplinary offices, practicing in medical clinics and hospitals (for some examples, see www.palmer.edu/toolkit). An excellent example is the more than 100 doctors of chiropractic treating enlisted military personnel for the Department of Defense at 65 sites across the county, and the more than 100 DCs treating veterans through Veterans Health Affairs hospitals. We also have a doctor of chiropractic on the executive team at the National Center for Complementary and Integrative Health at the National Institutes of Health.
Number 3: The American Public Health Association (APHA) is the oldest, largest and most powerful public health organization in the world, representing more than 55,000 health care providers across the country. In 1969, APHA had a policy statement that said “It appears that the practice of chiropractic constitutes a hazard to the health and safety of our citizens” and in the years to follow recommended that chiropractic be cut from Medicare, Medicaid and state health programs. This policy was reversed in 1983, but it was not until 1995 that a Chiropractic Health Care section was established as part of the American Public Health Association. Since this time, we have had DCs on the governing council and in leadership positions at APHA, including the Action Board and the Executive Board.
Number 2: When I graduated from chiropractic school in 1991, half of my very small class were women. What, at that time, was a very rare event has now become commonplace.
Number 1: Just within the past year, spinal manipulation and/or chiropractic care has been recommended as the first line of defense in pain management by the American College of Physicians guideline on low back pain, the FDA’s Education Blueprint for Health Care Providers Involved in the Management or Support of Patients with Pain, and The Joint Commission’s new and revised pain assessment and management standards for its accredited hospitals.
The challenges and opportunities faced today by the chiropractic profession could not even have been imagined by our forefathers. As far as I am aware, there are no pictures of B.J. Palmer sitting in front of a computer dictating his notes using voice recognition software. However, he also never saw the American College of Physicians recommend spinal manipulation as the first line of defense in low back pain management. As we look forward towards the future of the chiropractic profession, I can say with all sincerity that I do not believe that there has ever been a better time to be a chiropractor. When I graduated, I never dreamed that the chiropractic profession would advance as quickly as it has in the past 30 years. And given the much broader platform from which we now have to launch–thanks to the events described above–one can only imagine where we will be in another 30 years.
I would like to thank Drs. Claire Johnson, Bart Green, Jay Greenstein, Louis Sportelli, Anthony Hamm and Mr. John Falardeau for providing background and data for this blog post.
Dr. Goertz is senior scientific advisor for the ACA. She also serves as vice chancellor for research and health policy at Palmer College of Chiropractic and CEO of the Spine Institute for Quality (Spine IQ).