11-14-03 Setting the Record Straight on Chiropractic in the Veterans Health Care System > The ACA's involvement in the integration of chiropractic into the Veterans Health Administration is too important to chiropractic for distortion of fact. It is important that the chiropractic profession know what took place leading up to the draft recommendations by the Chiropractic Advisory Committee (CAC) and why. Some recent articles circulating via e-mail and on the Internet have misrepresented the facts regarding ACA's role in this process and may have caused you to have a distorted view of what really happened. > > In order to clarify the Chiropractic Advisory Committee recommendations, and how they were derived, we asked one of the chiropractic representatives, Dr. Rick McMichael, to describe the activity and explain the outcomes of the consensus process developed by the interdisciplinary CAC. Dr. McMichael has been a member of the VA Chiropractic Advisory Committee for more than a year. Prior to his appointment, he also served on the federal government's Chiropractic Oversight Advisory Committee that developed recommendations for integrating chiropractic into the Department of Defense health care program. You should realize that this is not the establishment of a new health care service but rather the incorporation of chiropractic care into an established, structured, federal health care program. This incorporation will expand the market share for our profession as well as provide a number of opportunities for advanced training and research that we have only been able to dream about in years past. We ask that you carefully read Dr. McMichael's report. > Donald J. Krippendorf, DC > ACA President > __________________ > > Department of Veterans Affairs Chiropractic Advisory Committee Recommendations > > This report offers information specific to VA Chiropractic Advisory Committee (CAC) recommendations. Incomplete, inaccurate and inappropriately negative information is being circulated about these CAC recommendations, without regard to the complexities of integrating a new service into the existing VA health care system. It would serve our profession well to seek more information, to become fully informed, prior to condemning either the recommendations or the CAC members who created them. Hopefully, this report will help to clarify the access recommendation and explain how it gained support from the majority of CAC members. The report also notes a few other important issues addressed in the recommendations. > > The Department of Veterans Affairs (DVA) Health Care System operates on a primary care model. Veterans using the system are assigned a primary care provider who coordinates that patient> '> s healthcare services. Considerable discussion was held within the Chiropractic Advisory Committee (CAC) regarding past barriers to chiropractic care for veterans, and the anti-chiropractic bias exhibited by some VA physicians. Even the non-DC members of the CAC agreed that such bias has existed and, to some extent, likely continues to exist. Nonetheless, non-DC members of the CAC who are experienced with the DoD and VA health care systems were adamant about the need for doctors of chiropractic to work within the VA system> '> s PCP model. > > The DCs on the CAC wanted direct access as a way to > "> guarantee> "> that veterans would receive chiropractic care. In fact, we spoke strongly to this issue in committee discussions. We all felt that the availability of chiropractic care should not be dependent upon referrals by VA medical physicians, which had been shown to be difficult to get, at best. The CAC debated the issue thoroughly as the DCs on the committee searched for ways to modify the VA system for chiropractic integration or to work within the system and yet > "> guarantee> "> patients easy access to chiropractic services. Of course, we all recognize that most patients access chiropractic care directly in the civilian world. However, we were repeatedly reminded that this is not the civilian world and not pri> vate practice; it is the Department of Veterans Affairs-a very large health care system. These were very sensitive negotiations at the CAC table. > > One of our CAC members, Michael O> '> Rourke, is a very knowledgeable and well-connected veterans advocate employed by the VFW. He has been very helpful, as has our project manager, Sara McVicker, in explaining the Veterans Health Administration (VHA), how it works, and how it is changing. > > As a staunch supporter of our veterans> '> rights to access chiropractic care, Michael O> '> Rourke strongly encouraged us to agree to work within the VA system in coordination with VA primary care physicians. He assured us that this was the best way to give this new service a real opportunity to work effectively for the veterans we were avowed to serve. He asked us to consider this a new day, leave the past behind and move toward the future. This is what the majority of the CAC chose to do. > > Our CAC recommendations are directed to Secretary Anthony Principi for his review and consideration. As an > "> advisory> "> committee, charged with making recommendations to the secretary, we knew that he could accept them as a whole, modify them or reject them. We also knew that the broader our consensus, the stronger impact our recommendations would have, and the more likely that Secretary Principi would accept them as a whole. So, we revised and crafted the access language to send a strong message of high consensus to Secretary Principi. Relative to access, we agreed that doctors of chiropractic should work within the VA system, in consultation with PCPs and other providers. We noted that veterans should be able to access chiropractic care for a broad range of neuromusculoskeletal conditions and for subluxation complex, without undue delay or difficulties, despite the bias that we believe remains with some VA physicians. We also recommended that direct access to chiropractic care should be allowed for newly discharged veterans who have received chiropractic care in the military for service-connected conditions. This, we noted, would ensure important continuity of care. > > The following language is taken from Recommendation #9: Access to Chiropractic Care: > > "> Access to chiropractic care should be by consultation with the patient> '> s primary care provider or another VA provider who is treating the patient for the condition(s) for which chiropractic care is indicated.> "> > > In our CAC discussions, the DCs noted that medical gatekeepers were not appropriate for chiropractic care, and we were told the PCP> '> s function in the VA is not considered to be a > "> gatekeeper.> "> It was explained that this could be as simple as picking up the phone or sending an e-mail from the PCP to the DC--a collegial coordination of care. Our previous draft (6) of Recommendation 9 read, > "> Access to chiropractic care should require referral from the patient> '> s primary care provider> ...> .> "> We were able to gain agreement on the modified > "> by consultation with> "> language cited above, to reflect the collegial tone expected between providers in the VA. > > The language of Recommendation 9 continues: > > > "> VHA facilities should establish processes that will ensure patients are adequately informed about treatment options, including chiropractic care, when presenting to urgent care with acute neuromusculoskeletal conditions appropriate for chiropractic care, when calling to request a primary care appointment for acute neuromusculoskeletal conditions, or when receiving care for difficult, chronic and otherwise unresponsive neuromusculoskeletal conditions. Patients presenting with neuromusculoskeletal complaints who prefer chiropractic care as their treatment option should be referred to the doctor of chiropractic for evaluation and care.> "> > > An additional sentence was also added to previous draft (6) language for Recommendation 9, in the rationale, > "> As local facilities> '> experience with integrated doctors of chiropractic matures, they may wish to explore protocols for direct access at their facility.> "> > > The big picture, painted by the 38 recommendations of the Chiropractic Advisory Committee, is overwhelmingly positive. These recommendations have received unanimous approval by all CAC members (excepting the two DCs who took a minority position on recommendation #9, regarding access). A few of these positive recommendations follow: > > * Inclusion of DCs under Title 38 with other health care professionals (MD, DO, OD, DPM and DDS) > * Direct access to chiropractic care for newly discharged veterans who received chiropractic care in the military for service-connected condition(s) > * Inclusion of DCs as full voting members of medical staff > * A goal of providing chiropractic care at all major VA health care facilities, consistent with the VHA distance and travel standards for access to specialty care. > * Continuance of fee-for-service (i.e. fee basis) chiropractic care in areas where veterans do not have easy access to VA facilities with chiropractic services > * Inclusion of chiropractic in VA research projects > * Inclusion of chiropractic in VA training programs > * Comprehensive educational programs on chiropractic for VA physicians, other health care providers, ancillary personnel and the patient population > > These are only a few of the 38 recommendations that have been sent to Secretary Principi. We are hopeful that the secretary will give these high-consensus recommendations his strong consideration and initiate the chiropractic integration as soon as possible. > > These recommendations are very positive for veterans, the Department of Veterans Affairs and doctors of chiropractic. The DVA is the second-largest cabinet department in the United States, with approximately 224,000 employees and an overall budget of $59 billion. Currently, 6.8 million of our nation> '> s 25 million veterans are enrolled in the system and 4.5 million users received care in 2003 for a total of 46.5 million outpatient visits. This is a system with an annual health care budget of approximately $26 and annual internal and external research funding of approximately $1.3 billion. Doctors of chiropractic will soon be hired into the VA health care system as members of the health care team, and veterans will soon have access to chiropractic care within VA facilities across the country. This is an historic event that will produce positive ramifications for decades to come. > > Yes, our chiropractic leadership must continue to monitor the integration of chiropractic in the VA as it proceeds, and ensure that veterans who want chiropractic care can, and do, receive it. Modifications may be needed along the way; however, this is a NEW DAY> ...> for veterans and for our profession. Now, we must work together to bring veterans the best of chiropractic care. To everyone who has worked in any capacity to make this NEW DAY a reality> ...> our nation> '> s veterans thank you. > > Rick McMichael, DC > VA Chiropractic Advisory Committee Member