CHAPTER XII

SYNOPSIS, RESEARCH PRIORITIES, AND POLICY ISSUES

Daniel C. Cherkin, PhD; Robert D. Mootz, DC

A. Synopsis of Monograph

In the past several decades, chiropractic has undergone a remarkable transformation. Labeled an "unscientific cult" by organized medicine as little as 20 years ago (Getzendaner, 1987), chiropractic is now recognized as the principal source of one of the few treatments recommended by national evidence-based guidelines for the treatment of low back pain, spinal manipulation (Bigos, 1994). In the areas of training, practice, and research, chiropractic has emerged from the periphery of the health care system and is playing an increasingly important role in discussions of health care policy.

This monograph documents the dramatic growth of the chiropractic profession, which now represents the third largest group of doctoral-level health professionals in the United States after medical doctors and dentists. By the year 2010, it is expected that there will be more than 100,000 practicing chiropractors, about 1 chiropractor for every 6 medical doctors (Cooper, 1996). Recent studies have found that about 7 percent of Americans had visited a chiropractor in the prior year (Eisenberg, 1993) and that chiropractic is one of the most popular sources of care for chronic back pain (Murt, 1986). Although most chiropractors practice in metropolitan areas, a substantial fraction practice in small towns and rural areas (Goertz, 1996).

All 16 chiropractic colleges in the United States are now accredited and monitored by the federally recognized Council on Chiropractic Education. Chiropractic students receive about the same number of total hours of education as medical students, although the former obtain less than half as many hours of education in clinical settings (Coulter, submitted). Chiropractors have been licensed to practice in all 50 States and the District of Columbia for more than 20 years. Licensing boards in all States require successful completion of the National Board of Chiropractic Examiners’ basic science examination and almost all States also require passing scores on clinical sciences and clinical competency examinations. All but 5 States require at least minimal continuing education to maintain or renew a license. Although the scope of practice for chiropractic varies by State and most States administer their own examination, expanded and enhanced competency assessment by the National Board of Chiropractic Examiners is bringing more standardization to chiropractic licensure.

More than 80 percent of American workers in conventional insurance plans, preferred provider organizations, and point-of-service plans now have health insurance that covers at least part of the cost of chiropractic care (Jensen, in press). It is only in health maintenance organizations that a majority of enrollees still lack chiropractic coverage. Even though most employer plans are no longer mandated to cover chiropractic (as they had been in the early 1980s), most plans have chosen to continue to include chiropractic benefits. In addition, nearly all workers’ compensation systems, personal injury protection insurance, and Medicare cover chiropractic services.

Chiropractors are beginning to be integrated into mainstream activities of the health care system. There is a small, but growing number of chiropractors practicing in collaboration with medical doctors and other health professionals, and medical referrals to chiropractors are becoming more common. As chiropractic services have moved into the mainstream of health services, it has been necessary for the profession to develop measures to ensure accountability. Chiropractic has responded by developing a variety of practice guidelines, parameters, and technologies to improve practice and permit evaluation of its quality.

Chiropractors have also begun to participate in policy and research roles. For many years, chiropractors have served as claims consultants and health administrators. Some now hold positions on industrial insurance boards, health care commissions, and on the staffs of medical directors. A small but growing number of chiropractors have pursued postgraduate training in public health, some entering careers in research. Recent major studies of the appropriateness and effectiveness of spinal manipulation have included chiropractors as co-investigators or advisers. Although hampered by a lack of research training and research infrastructure, some in the profession have recognized the importance of evidence-based research and are currently undertaking a major effort to identify an agenda for chiropractic research in the areas of basic science, clinical research, education, health services, and outcomes research (Hawk, 1997).

There is growing evidence for the safety and effectiveness of chiropractic’s primary treatment technique, spinal manipulation, at least for low back pain. The risk of a serious complication following manipulation of the lower back appears to be very low (Shekelle, 1992). Complications associated with neck manipulation are also extremely rare, but may be more common and severe than lower back complications (Hurwitz, 1996). Recent syntheses of the literature have concluded that spinal manipulation appears to be effective for at least some types of low back pain (Koes, 1996; Shekelle, 1992), although it is not known which, if any, of the numerous manipulative techniques employed by chiropractors, osteopaths, physical therapists, and allopathic physicians are superior. In addition, patients seeking care for back pain from chiropractors tend to be more satisfied than patients treated by medical doctors (Cherkin, 1989; Carey, 1995; Kane, 1974). However, studies have yet to adequately determine if chiropractic care is more cost effective than medical care for back pain. Furthermore, the value of spinal manipulation for neck pain and headache or for other neuromusculoskeletal problems is not as clear, as fewer scientifically rigorous studies have been published on these topics.

Recent guidelines published by the Federal Agency for Health Care Policy and Research (AHCPR) concluded that spinal manipulation was one of only three treatments for acute low back pain for which there was at least moderate research-based evidence of effectiveness (Bigos, 1994). Commonly used back pain treatments such as muscle relaxants and various forms of physical therapy lacked even moderate amounts of evidence, largely due to the absence of research. The AHCPR guidelines, in conjunction with appropriateness criteria for the use of spinal manipulation for low back pain (as well as neck pain and headache) developed by multidisciplinary expert panels, have legitimized the use of spinal manipulation as a relatively safe and effective treatment for back pain (Bigos, 1994; Shekelle, 1991; Coulter, 1995).

Through persistent efforts at self-improvement and successful legal and legislative initiatives challenging organized medicine’s antichiropractic stance, the chiropractic profession has begun to resemble the more mainstream health care professions in many respects. The metamorphosis from fringe to mainstream is not quite complete but appears inevitable. The main question is no longer, "Will chiropractors enter the mainstream of healthcare?" but "What role will chiropractors play in the health care system of tomorrow?" The answer to this question will be determined by the complex interplay of decisions and actions made by policymakers and by the chiropractic profession itself.

Because the information necessary to make informed decisions about many important issues is often unavailable, there is a clear need for focused research. Priorities for policy-relevant research concerning the role of chiropractic are discussed in the following section.

B. Research Priorities

Before policymakers can make informed decisions about the most appropriate role for chiropractic within the system of health care, there is a need for research that more completely answers questions about effectiveness, cost, and safety. These issues are interrelated and all are likely to be affected by the way in which chiropractic is integrated into the broader health care system. Important priorities for research are listed in Table 29 and discussed below.

Table 29. Priorities for Research on Chiropractic

Utilization and delivery options Comparisons of access, patient outcomes, and costs under different delivery models (e.g., direct access vs. medical referral to chiropractic care Determination of how the availability of chiropractic services affects the use of other medical care resources (e.g., radiology, physical therapy)

Effectiveness Randomized controlled trials (RCTs) comparing different manipulative techniques for specific clinical problems (e.g., short-lever, high velocity manipulation vs. flexion-distraction manipulation for low back pain patients with radiculopathy) RCTs comparing spinal manipulation with other physical medicine approaches (e.g., specific exercise protocols, mobilization procedures) for common musculoskeletal problems Evaluation of the long-term effects of spinal manipulation on the prevention of musculoskeletal problems Comparison of costs and outcomes associated with different frequencies and durations of manipulative treatment (e.g., 5 visits vs. 10 visits for low back pain) Inclusion of economic outcomes in studies of effectiveness of chiropractic care Determining if spinal manipulation affects nonmusculoskeletal

1. Effectiveness

Despite the large number of randomized trials evaluating spinal manipulation for low back pain, critical reviews have generally lamented the poor quality of most of these studies and the inability to generalize the findings to current manipulative practice (Koes, 1991 and 1996; Shekelle, 1992). Although the most thorough reviews have concluded that there is evidence that spinal manipulation is effective for some patients with low back pain, it remains unclear which subsets of patients are most or least likely to benefit or which forms of manipulative care are most useful. As with many other interventions for low back pain, there remains a need for high quality studies to evaluate the effectiveness of spinal manipulation for specific patient populations, defined in terms of their history, presenting complaints, age (e.g., children or the elderly), and neurological findings. Studies of spinal manipulation for patients with sciatica and with chronic and recurrent back problems would be especially useful. Future studies will be particularly valuable if they compare different types of spinal manipulation with physical treatments that are already in common use, such as McKenzie physical therapy and massage. Direct comparisons of chiropractic with other conservative approaches such as encouraging return to normal activity and nonsteroidal anti-inflammatory drugs would also be helpful.

Research on the effectiveness of spinal manipulation for other musculoskeletal problems such as neck pain and headache is even more limited and inconclusive than that for low back pain. Because chiropractors commonly treat patients with these conditions, research in this area should be considered a high priority. Although the evidence suggests that chiropractors rarely treat nonmusculoskeletal conditions (e.g., otitis media, hypertension, dysmenorrhea) (Hurwitz, in press), these conditions fall within the scope of chiropractic practice in many States and are believed by some chiropractors to respond to spinal manipulation, other manual methods, or other drugless approaches within a chiropractor’s practice scope. There is a clear need for research to determine if chiropractic methods are effective for these problems.

In addition to treating patients with specific problems, some chiropractors attempt to prevent recurrences of a problem (e.g., low back pain), to prevent the development of other illnesses, or to enhance general health. It is not known if such prevention-oriented activities are in common use. Because they are not covered by health insurance, preventive care, health enhancement, or "maintenance" visits may represent only a small fraction of most chiropractors’ practices. However, if chiropractors are to function in primary care roles, as has been suggested by some observers inside and outside of the profession, it will be important for research to determine if chiropractic approaches can in fact prevent recurrences of musculoskeletal problems, prevent illness, or enhance health.

2. Cost and Cost-Effectiveness

In addition to the evidence indicating that spinal manipulation is effective for some patients with low back pain, there is ample evidence that patients who choose chiropractic care find it very satisfying (Cherkin, 1989; Carey, 1995; Kane, 1974). However, these benefits come at a cost and it is not yet clear if chiropractic care is more cost-effective than the various forms of conventional medical care (e.g., medications, physical therapy, exercise programs) or alternative care (e.g., massage or acupuncture) used to treat back pain. It is also not known how many manipulative treatments are necessary to achieve satisfactory outcomes. For example, it may be that a regimen of 5 chiropractic treatments per episode of back pain is as effective as a regimen of 10 treatments, and therefore twice as cost-effective. Determining the relative cost-effectiveness of chiropractic care compared with other commonly used treatments for low back pain and the number of chiropractic treatments necessary to achieve satisfactory outcomes should be considered high priorities for future research.

Finally, whether chiropractic care is used in addition to or in place of medical care is still not clear. The answer to this question will depend in part on if and how chiropractic services are integrated into a particular system of health care. For example, if access to chiropractic services requires an initial evaluation and referral by a medical doctor, this might increase the number of physician visits over the number that would have occurred had direct access to chiropractic been an option. If patients were granted equal access to chiropractic and physical therapy, however, one might expect that increased use of chiropractic would be accompanied by decreased use of physical therapy.

3. Safety

Although available evidence suggests that the risk of a serious complication following spinal manipulation is very low, this information is based on collections of published case reports (Assendelft, 1996; Shekelle, 1992). Because many complications attributable to spinal manipulation might never be reported, estimates of complication rates based on case reports will inevitably underestimate the true incidence. However, the estimated risk of complications following lumbar manipulation is so low that even if there were 100 times as many serious complications as reported, the true risk would still be very small. Because the risks of cervical manipulation appear to be higher and more devastating, however, it would be helpful if future research could identify subsets of patients at risk of complications from cervical manipulation and determine if there are specific manipulative techniques that should be avoided or modified.

Another safety issue derives from concerns that chiropractors might fail to diagnose patients who have a serious condition that requires urgent medical attention. Although the incidence of this problem is unknown, it appears to be more common in the United States than in Canada (Henderson, 1994). Where chiropractors serve in portal of entry roles into the health care system, it will be important for research to determine the extent to which delayed access to urgent medical treatment occurs.

C. Key Issues Affecting the Future Role of Chiropractic in the United States

A fundamental question confronting both the chiropractic profession and public and private sector health care policy planners centers around how chiropractic should fit into the evolving American health care system. Over the past few decades, the profession has enhanced its image by strengthening its education programs, increasing the quality and quantity of its research, and collaborating with other disciplines in clinical settings (Mootz, 1995a). The profession has also effectively used political, legislative, and legal measures to secure a broader and more integrated role in the health care system (Getzendaner, 1987; Mootz, 1995b; Wardwell, 1992).

However, concerns about the ability of chiropractors to play a larger role remain. Although chiropractic and medical students receive a similar number of hours of didactic education, chiropractors still lack the opportunities available to medical doctors in clinical training through clerkship, residencies, and fellowships. Furthermore, the lack of interdisciplinary clinical experiences has impaired the abilities of both chiropractic and medical physicians to learn about what the other has to offer.

The personnel, institutional, and financial resources available for chiropractic research are sparse and will need to be enhanced if chiropractic research is to gain credibility in the medical community. Recent access to small but significant amounts of Federal funding has allowed several university-based clinical trials involving chiropractors to be initiated (Mootz, 1995a) and has demonstrated the feasibility of collaborative research. The recent effort by the chiropractic profession to identify research priorities and to address the inadequacies of the research infrastructure has the potential to lead to actions that significantly improve the productivity of chiropractic research (Sawyer 1997; Brennan 1997; Nyiendo 1997; Mootz 1997; Adams 1997).

There are a variety of perceptions both inside and outside the chiropractic profession regarding chiropractic clinical competency, appropriate scope of practice, determination of appropriateness of care, identity regarding "primary care" delivery relationships, operational definitions and models of the "chiropractic lesion," and how to work within and outside of typical medical delivery settings. Chiropractic’s future role will be determined by decisions made within the profession, as well as by policy-planning efforts by health care administrators, public and private sector policymakers, and other health care professionals. Key policy issues are summarized in Table 30 and discussed below.

1. Issues Within the Chiropractic Profession

Professional Clinical Identity

For both philosophical and economic reasons, chiropractors have desired to maintain a direct access, "portal of entry" role for patients coming into the health care system. Most patients appear to seek chiropractic services for musculoskeletal problems, primarily low back pain (Hurwitz, in press). However, partly because the profession has evolved outside of mainstream medicine, chiropractic has positioned itself not only as an alternative source of health care, but also as a separate profession with a distinct health care philosophy. This has created an identity crisis within chiropractic. The profession is unclear about whether it is a comprehensive, holistic alternative to medicine or a clearly defined musculoskeletal subspecialty. This philosophical quandary is complicated by the advice of external health care observers who have emphasized the need for chiropractors to enhance and maintain an identity as primary care providers in order to remain competitive (Coile, 1995).

In fact, chiropractors’ practices include several characteristics considered to be consistent with a primary care role. They are directly accessed by patients, frequently coordinate care


Table 30. Key Policy Issues

General Health Care Questions Policy Makers Must Address Are side effects of a given intervention acceptable? ß What is the cost of an intervention compared to readily available alternatives? ß Does the intervention improve meaningful health outcomes? ß What are the demands from various constituencies (e.g., patients, providers) for an intervention?

Specific Issues Internal to the Chiropractic Profession Resolution of professional clinical identity: musculoskeletal specialist vs. primary care provider ß Resolution of professional social identity: special interest vs. community resource ß Clarification of existence and clinical significance of the "manipulable spinal lesion" (vertebral subluxation)* ß Nature and extent of integration of chiropractic into mainstream health care training, practice, and research ß Increased attention to quality and cost-effectiveness of chiropractic services

Specific Issues External to the Chiropractic Profession Determination of which chiropractic services (if any) will be covered by insurance and for which patient populations ß Determination of rational methods for integrating chiropractors into the health care system ß Methods for assuring quality and accountability of chiropractic services ß Identification of mechanisms for controlling costs of chiropractic care ß Consideration of support for research examining risks and benefits of spinal manipulation

*This is a policy issue because various statues, rules, and policies explicitly require documentation of such lesions before spinal manipulation can be performed or covered by insurance.

with other providers, may obtain special studies, develop continuing relationships with patients, and emphasize prevention strategies, especially related to injury prevention (Jamison, 1991; Bowers, 1995). However, because chiropractors do not offer a comprehensive array of medical treatment strategies, advocacy of primary care provider status for chiropractors has been a controversial topic (Nelson, 1993; Bowers, 1995). Some within the profession believe that many chiropractors can function in "community-oriented" primary care roles (Bowers, 1995) consistent with the recent Institute of Medicine’s updated definition of primary care: "the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of health care needs, developing a sustained partnership with patients, and practicing in the context of community" (Donaldson, 1994).

There are a number of reasons why some chiropractors feel capable of filling such community-oriented "primary care" roles, including their training in examination and diagnosis, chiropractic's strong record in risk management and professional liability, and their history of routinely referring patients to medical doctors (Bowers, 1995; Mootz, 1994). Additionally, historic obstacles such as organized medicine's policies that prohibited medical doctors from accepting patients from a chiropractor (Getzendaner, 1987) have caused chiropractors to view themselves as the primary source of care for many of their patients. Still, limitations regarding clinical training in multidisciplinary settings, scope of practice, and comprehensiveness of services provided by chiropractors will need to be overcome before those outside the profession will be comfortable with the idea of chiropractors as primary care physicians (Bowers, 1995).

Regardless of one's views about whether or not chiropractors should be considered primary care physicians, it is clear that they possess many of the characteristics of medical specialists. They have a clientele presenting with a narrow range of musculoskeletal health problems and most of their care focuses on mechanical musculoskeletal interventions. This musculoskeletal specialist view of chiropractors poses a hazard for the profession. Specifically, because treatment of musculoskeletal problems often is provided by physical and occupational therapists following referral by a medical doctor, there is a concern that chiropractors may be viewed by some policymakers as a duplication of existing medical management options. However, given that more than 90 percent of billable manipulation services have been provided by chiropractors (Shekelle, 1992), an argument can be made that chiropractors provide a unique service. Because of the fundamental nature of these "clinical identity" issues, the chiropractic profession needs to clarify its role and strive to ensure that both training and practice are consistent with that vision.

Professional Social Identity

Due to their historical exclusion from participation in the mainstream of health care delivery, chiropractors have functioned outside of medical referral networks, institutional settings, and multidisciplinary group practices. As a result, they have had to rely on individual patient referrals and marketing efforts to attract patients. Although advertising and marketing are now also commonplace in medicine, medical marketing strategies tend to have an institutional focus on issues of perceived importance to patients (e.g., availability, clinical competence, location) while many chiropractic promotional efforts often seem aimed at vindicating and reinforcing professional philosophies. Some of chiropractic’s promotional strategies have misrepresented the evidence, thereby alienating opinion leaders outside the profession and undermining the profession’s efforts to improve its credibility and acceptance.

The profession is also likely to confront a credibility challenge if its colleges and research foundations, as well as its trade associations, are perceived to be little more than "special interests." In order to be perceived as a community resource rather than a special interest (Mootz, 1996), the profession needs to establish a credible and supportable clinical identity. Marketing and patient education should focus on prevention, wellness, rapid resolution of disorders, and self-reliance for common health problems, perhaps like dentistry has done with dental caries.

The profession also needs to improve the quality, effectiveness, and efficiency of its care. Cost of care is of primary concern to policy planners and the community at large. Efforts need to be undertaken to determine the types, amounts, and durations of chiropractic care that are most cost-efficient and appropriate for different clinical circumstances. This will require the chiropractic profession to pay increased attention to practice variation. Gaining a better understanding of the causes of variations in practice, determining which of these variations are inappropriate, and finding ways to minimize undesirable variations should become professional priorities.

The Effect of Spinal Structure on Health

Chiropractors have long emphasized the importance of the effect spinal structure can have on human physiology (particularly the nervous system) and the beneficial effects of spinal manipulation (Gatterman, 1995). The idea of a manipulable "spinal lesion" is not unique to chiropractic; lay practitioners, osteopathic physicians, and others also advanced a variety of spinal lesion models near the turn of the 20th century (Gatterman, 1995). Historically, chiropractic terminology has characterized a spinal lesion as a "vertebral subluxation," although other terms have become more popular in recent years (e.g., spinal dysfunction, vertebral subluxation complex). Regardless of the syntax used to characterize it, the condition remains poorly defined and is inadequately supported by current research.

There has been abundant conceptualization about subluxation in the chiropractic literature, but no professional consensus on a particular model and little hard data regarding the reliability and validity of its clinical identification and pathophysiologic impact (Gatterman, 1995; Osterbauer, 1996). Although chiropractic has functioned successfully without more clarity about the existence and nature of the manipulable lesion, a better understanding of this issue would enhance full acceptance by other health care professionals. In particular, chiropractic researchers should focus on the following aspects of the vertebral subluxation: reliability of its identification as a clinical entity, its prevalence and incidence within healthy and unhealthy populations, its relationships to recovery and function, and refining the pathophysiologic and psychosocial models used to characterize it.

Resource Development and Allocation

In the past, many chiropractors developed strong collaborative alliances with patients, sympathetic legislators, and key individuals within the legal and labor communities (Mootz, 1996). More recently, chiropractic scientists have begun to collaborate with others in the greater academic and research communities. However, although interdisciplinary clinical relationships are evolving (Triano, 1994), it is still rare for chiropractors to function in medical group settings. Furthermore, unlike medicine, dentistry, and other professions, very little public funding exists for chiropractic research.

For the most part, chiropractors have had limited influence with several key health care constituencies, including public- and private-sector health policymakers and planners and health care administrators. Their ability to influence actions by health care purchasers and the business community has resulted more from litigation and political pressure than from voluntary policies of these groups. In order for chiropractic to significantly improve its educational and research missions, greater educational and research funding from Government and the private sector will need to be obtained.⁷ This will require the profession to initiate and develop strategic alliances with organizations and institutions outside the profession. Continued and expanded collaborative research between chiropractic schools and universities will be important as will establishment of corporate and community partnerships to create endowments and expanded educational and research infrastructures. Finally, because the number of chiropractic researchers is still small (Meeker, 1996), there is an urgent need for more chiropractors to be trained in fields such as public health, epidemiology, health services research, the evaluative clinical sciences, and health administration. Opportunities for both dual degree tracks (e.g., DC-MPH) and post-DC degree training should be expanded.

Gaining full acceptance and credibility within the greater academic and research communities may pose some difficulties for chiropractic researchers who have trained in a profession that has, until recently, relied on political advocacy and litigation to accomplish its goals. To maximize their credibility, and therefore their impact on future policies, chiropractic researchers will need to eliminate prior belief and conviction from influencing the results or their reporting. Although investigator bias is a problem in all professions, it presents a particular challenge to the newly emerging group of chiropractic researchers at this point in their profession’s evolution.

Responding to "Customer" Needs

There is a need within the chiropractic profession for a greater appreciation and routine incorporation of accepted, systematic processes for professional prioritization and decisionmaking. Systematic appraisals and syntheses of "customer" needs (stakeholding) could help chiropractic institutions and centers improve their internal and external relationships. Systematic incorporation of scientifically derived information into clinical practice remains a particular challenge. Many within the profession have developed strong beliefs about chiropractic's value from anecdotal personal experience alone (Keating, 1987). In some instances, this has led the profession's leadership to assume a naive attitude toward research, i.e., "Because we already know its value, the role of research is to prove it to others." Although such attitudes are not unique to chiropractic physicians (Tanenbaum, 1994), initial efforts to develop evidence-based chiropractic care guidelines and clinical consensus should be expanded. Greater incorporation of quality improvement strategies in chiropractic settings would also be of value.

2. Policy Considerations External to the Chiropractic Profession

Only a fraction of commonly used health care procedures (including those used by chiropractors) have clear and consistent scientific evidence to support their use. Even when well-designed research studies are available for a given procedure, or a specific application of a procedure, probabilistic findings as typically reported in studies are fundamentally ambiguous as they relate to policy actions (Tanenbaum, 1996). These limitations complicate the efforts of government and private-sector policymakers in making coverage decisions, prioritizing the use of scarce health care resources, and allocating research dollars among many competing demands. Examples of questions policymakers generally must answer to address these issues are listed in Table 30 and discussed below.

Several specific policy questions concern insurance coverage. A fundamental issue is whether or not insurers and managed care plans should cover chiropractic services. The chiropractic profession has demonstrated an ability to successfully influence legislation and use the court system to pass and enforce insurance equality laws guaranteeing coverage of a given service without regard to who performs the service. In recent years, managed care plans have restricted access to chiropractic services (as well as to some medical services) through a variety of controversial mechanisms. These approaches seem likely to be met with further legislative and litigation activity on the part of the profession. Market forces (e.g., consumer demand for chiropractic services) are also likely to continue to influence plans' coverage decisions.

Individual health plans face a variety of complex decisions concerning which chiropractic services to cover and for which subsets of patients. For example, coverage decisions for some types of conditions and services (e.g., spinal manipulation for low back pain or whiplash injuries) may be more readily amenable to policy actions than coverage decisions involving other services (e.g., preventive services). The populations for which chiropractic care is already commonly provided will also influence demand and appropriateness concerns. For example, the use of chiropractic services for children remains controversial and will likely require better research data and practice guidelines for making future coverage decisions. In addition, although Medicare covers spinal manipulation as long as a physical examination and x-ray precede it, Medicare has not reimbursed chiropractors for physical examinations or x-rays. Congress recently mandated elimination of the x-ray requirement beginning in the year 2000 but issues remain concerning which chiropractic services Medicare will reimburse. How chiropractic services are documented and reported for reimbursement, utilization review, and auditing purposes will also require greater clarification. On the surface, some issues may be quite straightforward, but because scope of practice can vary by jurisdiction, individual States may need to respond differently.

In dealing with policy issues relating to chiropractic, policymakers may be tempted to defer decisions until such time as definitive research becomes available. In the past, excluding chiropractic was frequently justified by citing an absence of supporting evidence. In fact, the effectiveness of the primary intervention used by chiropractors, spinal manipulation, has been well studied and found to be effective for some subsets of patients with low back pain. Thus, if policymakers apply the same standards of evidence to evaluate the value of medical and chiropractic services, there will be no justification for dismissing spinal manipulation as an unsubstantiated treatment for back pain. However, because physical therapists, osteopaths, and allopathic physicians also use spinal manipulation and it is not known which forms of manipulation are most effective, there is no rationale for restricting manipulative care to any single profession.⁸

Access to chiropractic services is another major concern. Chiropractors receive extensive training and have demonstrated competencies in clinical assessment and management through government-accredited higher education programs. They are licensed and regulated in all 50 States, typically maintain professional liability coverage, and have evolved as a direct-access profession, in part because they have been outside traditional medical referral loops. Given that medical practitioners have little exposure to chiropractic training or practice, a case can be made for not requiring medical referral. This problem is analogous to the issue of requiring a primary care physician to authorize referrals for specialty care within the medical profession. In any event, the referral issue has significant economic and organizational implications and will likely require more cost data and market experience before it can be intelligently addressed.

The question of how the utilization of chiropractic services is controlled also has important economic considerations. Typical insurance benefit limits include actuarial caps (e.g., a limit on the number of visits that will be covered or on the number of dollars per year for services). Risk-sharing options are also likely to evolve as the chiropractic managed care marketplace matures. A number of chiropractic managed care organizations (MCOs) currently use capitated rates, allowing more flexibility in determining which procedures are reimbursable.

Finally, policymakers in Government and planners within the chiropractic community will need to consider how to best achieve infrastructure development and needed enhancement of chiropractic training, particularly as it relates to practical training through residencies and clerkships. In order to succeed, infrastructure and facility development at chiropractic colleges will need to occur through vehicles such as educational grants and indirect cost support, rather than exclusively through student tuition, as is currently the case at all chiropractic colleges.

* * *

Despite nearly a century of adversity that included multiple efforts by organized medicine to eliminate the profession, chiropractic has thrived and attracted a large patient following. In recent years, increasing numbers of other health professionals have become supportive of chiropractic treatment. As a health care resource, chiropractors have established a presence that appears to have filled a void left by the limited success of the more traditional approaches to musculoskeletal problems.

In contrast to medical treatment of musculoskeletal problems by primary care physicians, a chiropractic encounter often includes more time listening to patients’ concerns, extensive hands-on evaluation, clear and concrete explanations that make sense to patients, hands-on treatment that often feels good and is sometimes associated with an immediate improvement in symptoms, and repeated follow-up with the doctor (Mootz, 1995b). It is not surprising that such an approach is viewed as more satisfying than standard medical treatment (Cherkin, 1989; Carey, 1995; Coulehan, 1985). Chiropractors infrequently use high-cost diagnostics, specialist referral, and hospitalization. Further, chiropractic’s principal intervention, spinal manipulation, has at least as much evidence for effectiveness as any other conservative treatment for back and neck pain. Thus, there is a clear rationale for policy planners to identify efficient strategies for incorporating chiropractic services into the health care system.

Given the chiropractic profession's history of survival and growth, its consistent political and legislative successes in adversarial situations, and its dedicated effort in recent decades to upgrade its education, research, and practice activities, both the profession and policymakers should pursue greater incorporation of quality improvement strategies in care delivery, dedication of appropriate resources for research, enhanced exposure to appropriate residencies and fellowships (e.g., in radiology, rehabilitation), and greater efforts to facilitate multidisciplinary practice. These actions will help policymakers determine the most appropriate roles for chiropractors in the health care system and will ensure that chiropractors are well prepared to serve in these roles.

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7. The chiropractic profession itself has already devoted extensive resources to training and research and does not appear capable of providing significantly more.

8. Although the best available evidence suggests that over 90 percent of spinal manipulative treatments in the United States have been performed by chiropractors (Shekelle, 1992), there has been growing interest among allopathic and osteopathic physicians and among physical therapists in learning and using these techniques.  It is therefore likely that the availability of nonchiropractic sources of spinal manipulative care will increase in the future.

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