11/21/03 Dear ACA Members ACA's goal in sponsoring the VA legislation was for veterans to have the opportunity to seek chiropractic care without unreasonable barriers. Our chiropractic representatives understood this goal, but at the same time, they were faced with the problem of being part of an advisory committee appointed by the Secretary of the Veterans Administration whose members weren't all sympathetic to the profession. We want to commend our team for working with the majority on the committee and getting them to agree to recommendations that clearly benefit not only the veterans but also this profession. The Secretary isn't mandated to accept these recommendations. He stated clearly at NCLC that he would do the best he could to support our position without altering the way the Veterans Administration operates. We believe the consensus developed and the program recommended by the Chiropractic Advisory Committee will make it more likely that the Secretary will embrace the proposals. Last week, I sent you a report from Dr. Rick McMichael, one of our representatives on the Chiropractic Advisory Committee, providing an insider's view of what occurred in developing these recommendations. We also asked Dr. Cynthia Vaughn, another member of the committee, to comment. Her commentary is below and expands on the story provided by Dr. McMichael. It continues to be an interesting story about how a few chiropractic representatives were able to work with the majority of committee members in developing a consensus that was in everyone's best interest. To me nothing better illustrates what was accomplished than the following statement that is contained in the recommendations of the committee: "Patients presenting with neuromusculoskeletal complaints who prefer chiropractic care as their treatment option should be referred to a doctor of chiropractic for evaluation and care." Dr Don Krippendorf ACA President ANOTHER VIEW FROM A REPRESENTATIVE OF THE CHIROPRACTIC ADVISORY COMMITTEE Dr. Rick McMichael, a fellow member of the Veterans Affairs (VA) Chiropractic Advisory Committee, recently released a statement that responded to questions that arose regarding the VA Committee's recommendations. I concur fully with the comments he made and wish to add a few points. Although some have criticized the recommendations of the VA Committee since they do not recommend "pure" direct access in all cases, they have missed the bigger issue. This is not about "direct access" for our profession; this is about VETERANS BEING ABLE TO ACCESS chiropractic care. In other words, it's not about us...it's about veterans. And as long as veterans are able to reasonably access chiropractic care without having to jump over artificial barriers, that's all that is needed. In my opinion - if the Secretary agrees to our recommendations - veterans will most certainly be able to reasonably access chiropractic care. The most interesting part about the criticism is that it seems to be coming from those in the profession who have traditionally argued that a differential diagnosis is not necessary and that chiropractic care should be limited to the detection and correction of subluxations. With all due respect, it doesn't work both ways. Although some may be able to practice that way in the private sector, the VA is very different. In other words, if a doctor of chiropractic wants to be a direct access, first contact provider for veterans, there is an inherent, inseparable responsibility attached to that privilege. To a great extent, the "subluxation only" philosophy espoused by some chiropractic websites and in correspondence received by the VA made the medical members uncomfortable, and doomed any real chance we had to convince the medical members of the Committee that doctors of chiropractic were qualified to serve in the important first contact, direct access ("gatekeeper") role. I also believe it's important to point out a key factor about the VA. The VA is different from the private sector where HMO medical gatekeepers have a financial disincentive to refer a patient for chiropractic care. The VA employs staff physicians who are salaried, and as such, their income is not reduced when they refer a patient for chiropractic care. Therefore, the barriers patients have experienced with medical gatekeepers in the private sector is not necessarily one those veterans will face in the VA system. Once doctors of chiropractic are in the system and are officed down the hall, earning the same salary whether they see one patient per day or one hundred patients per day, I believe they will be utilized. In fact, I believe that the doctors who are eventually hired into the VHA system will be incredibly busy. There are those who have criticized the Committee since chiropractic care has been available by referral through the "fee basis" system (a true "gatekeeper" model) for quite some time, yet history has shown it to be woefully underutilized. Therefore (they assert), by not ensuring "pure" direct access, it represents nothing more than what we have now. This is completely inaccurate, or - as the expression goes - "comparing apples to oranges." The reality is that the VA fee basis system has rarely been used because it added additional administrative hurdles to the referral process, the VA providers didn't know the doctors of chiropractic in the community, and it required money to be distributed to practitioners outside the system. All that changes if and when the Secretary accepts our recommendations since PCPs should refer veterans to a doctor of chiropractic when chiropractic care is indicated and when the veteran requests it. Specifically, recommendation #9 as submitted reads, "Patients presenting with neuromusculoskeletal complaints who prefer chiropractic care as their treatment option should be referred to a doctor of chiropractic for evaluation and care." [Emphasis added] Should the PCP not refer in these instances, the VA already has provisions in place whereby the veteran may change his/her PCP. In conclusion, our recommendations do not represent merely "getting our foot in the door" like Medicare was. Our recommendations are for full scope of practice; even more importantly, they provide four protocols under which a veteran will be able to access chiropractic care: 1. Of course, by referral from the PCP, particularly when it is a neuromusculoskeletal complaint and the patient "prefers" chiropractic, or 2. By changing the PCP to one who will refer, or 3. By merely consulting with the PCP, which may not even require the patient be seen, and 4. "Pure" direct accesses for newly discharged veterans without a referral from a PCP. I am extremely proud of the Committee's recommendations to Secretary Principi and am optimistic that he will accept them. If that occurs, our nation's veterans will finally be able to access the chiropractic care they need and deserve, and in the process...a new full-scope federal model will have been created. Cynthia S. Vaughn, D.C., Member Veterans Affairs (VA) Chiropractic Advisory Committee Email: DrVaughn@ChiroAustin.com