Robert Mootz on October 30 - 31, 2000

This section is compiled by Frank M. Painter, D.C.
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Comments on Appropriate Roles the Federal Government Can Play Concerning Complementary and Alternative Medicine

Robert D. Mootz, DC
Associate Medical Director for Chiropractic
Washington State Department of Labor and Industries


Presentation before the White House Commission on Complementary and Alternative Medicine
Seattle, Washington
October 30, 2000

Ladies and Gentlemen, thank you for allowing me the honor to briefly present some of my observations regarding appropriate and constructive roles the Federal Government can play concerning complimentary and alternative medicine (CAM). The perspectives I offer come from the following three vantage points: thirteen years in private practice as a doctor of chiropractic; eight years in academia and research; and six years as the first doctor of chiropractic to hold a full-time policy and research position within a government agency.

As you know, recent studies have shown that Americans make nearly twice as many visits to practitioners of alternative medicine than they do to practitioners of family medicine. They spend more money out-of-pocket for CAM services than they do for out-of-pocket hospital payments. Further, the past decade has seen an exponential growth in the use of alternative medicine. Chiropractic care and massage are the most utilized of all CAM approaches with nearly 15% of the US population visiting a chiropractor every year accounting for a third of all visits to CAM providers. Additionally, patient satisfaction data has also consistently demonstrated higher levels of satisfaction with many CAM approaches such as chiropractic care for people who have low back pain.

Obviously, the marketplace is already incorporating CAM approaches and providers into the “mainstream” in terms of preference, utilization, and expenditures. However, government and the health care system at large often proceed as though CAM merely represents some kind of “fringe” practice or a passing fad. From my perspective there are three key areas that the Federal government has both an interest and obligation in, as well as ability to constructively influence the future of CAM and health care to meet the need for all Americans:


1. Federal support of research and education

The CAM professions and their institutions need to develop and enhance their own educational and research missions, particularly research capacity and infrastructure development. Education and research are obviously the domain of the respective professions for they have the most knowledge and passion regarding it. Federal support need only be patterned after what exists currently for other disciplines.

Other than qualification for some federal student loan guarantee programs, government support of CAM educational institutions is nearly non-existent. This creates an incentive that fosters tuition dependence and focuses curriculum on basics that neglect important but costly residency and apprentice training, development of multidisciplinary exposure, collaboration with universities, and deters development of a culture of scholarship. Two distinct needs are related to this:

·   Educational development grants, infrastructure grants, support for post graduate fellowships and advanced degree programs are examples of the kinds of support widely available for medicine, osteopathy, dentistry, and psychology programs but exclude CAM professions such as chiropractic, acupuncture or naturopathy.

·   Level the playing field for students in legitimate CAM training programs in terms of student loan repayment options. Defaults need to be decreased though additional deferment options available to other health professions such as post-graduate residency and fellowship programs.

Barriers to research in CAM exist at many levels. Key barriers include: inadequate scientific career training; limited science related career opportunities; bias, isolation from and ignorance of chiropractic with the wider science and health care communities; and inadequate representation in government research and policy circles. There are several distinct needs in this area:

·   Post-doctoral training programs and incentives for CAM related scientists

·   Establish incentives for dual degree training (e.g., MPH) for matriculates and graduates of CAM programs.

·   Establish incentives for more partnerships, consortia, and collaborations between CAM institutions and universities. For example, joint conference sponsorships similar to the DHHS Health Resources and Services Administration (HRSA) funded geriatrics program (GRECC Symposium) with St. Louis University School of Medicine and Logan College of Chiropractic.

·   Fund and establish more clinical research centers at CAM institutions.

·   Reduce bias at the National Library of Medicine so that CAM related headings can be improved and CAM journals are included in indexing.

·   Consider training support options in chiropractic and CAM disciplines to the same extent as supported in dentistry, medicine and other disciplines in order to reduce the climate of tuition and encourage development of widespread legitimate research cultures within CAM institutions.

·   Consider the need for special support to “prime” scientific activity at CAM institutions, e.g., expansion of the Centers of Excellence programs being funded at HRSA.

2. Consistency in Federal programs with the national trends and priorities

The Federal government is incredibly far behind the curve of social norms in its own health care programs. Chiropractic care for example, is a core benefit in personal injury protection coverage, most workers’ compensation programs, and in health indemnity plans. Although managed care exclusions exist, meaningful chiropractic benefits can be found in a majority of insurance plans. On the other hand, Medicare, Medicaid, Veterans and Military Benefits, and Federal Workers’ Compensation programs all have highly restricted coverage or exclude chiropractic care altogether. Even many managed care programs have not restricted or established the kinds of non-clinical, arbitrary and discriminatory policies on chiropractic care that exist in most Federal programs, although many are increasingly relying on these Federal programs as a template to justify such exclusions.

At the state level, patient’s bill of rights legislation, court precedent and innovations such as Washington State’s “every category of provider” laws are establishing that consumers and tax payers want CAM services and they want their social institutions for health care to get along. On a social level, the potential for improvements in quality of life, satisfaction with care, and demonstrated cost efficiency in various circumstances have been documented with a number of CAM approaches. Chiropractic care for the people who have low back or neck problems, and headaches are just one example of how inclusion of CAM approaches (even within existing condition-oriented health plans) offers direct tangible benefits to consumers and taxpayers alike.

CAM needs resources for quality improvement and CAM practitioners can improve their practices just like the rest of health care. The need for health services research and policy development that both explores CAM and includes CAM in government health policy circles is obvious. For example, there is only on DC employed within all of the health care agencies of the federal government and this is only within the past year or so at the National Center for Complementary and Alternative Medicine. Further, as far as I have been able to find out, my policy and research position within the Washington State Department of Labor and Industries is the only such position in existence at the state level. Many examples of benefits to both the state agency, the chiropractic profession and to the business and labor constituencies have accrued as a result. For example, the joint research between the Washington State Chiropractic Association, the Department, and the University of Washington led to the adoption of an evidence-based fee schedule for chiropractic services. This has provided more robust coverage for chiropractic care, helped reduce administrative burden on doctors and department staff, and has made constructive progress in policy development without adversity, litigation, or excessive expenditure of resources by government or the community at the Legislature.

The precedent set by such neglect of policy roles for CAM professions at the federal level permeates to state and local government as well. Although there is progress with DCs in ad hoc and advisory roles, more needs to be done, not only in chiropractic, but for many of the CAM professions. The value and contributions of such participation not only benefits respective CAM disciplines, it brings new perspective and insight to existing policy development efforts. I have seen this first hand in my work at the state agency level.


3. Degree of integration and role of CAM within conventional health care delivery

One of the most important points to be made regarding integration of CAM within conventional delivery models is that a distinction must be made between the incorporation of certain CAM procedures into conventional medical practice and the integration of CAM providers into patient care pathways. An example from my discipline is the procedure of spinal manipulation compared to chiropractic care.

The procedure of manipulation has been used by many disciplines including medicine, osteopathy, and physical therapy for many years. In these settings it may be applied as an ancillary modality with the context of overall medical management, usually focusing on increasing joint range of motion and reducing pain. Although manipulation for specific conditions has a positive benefit, chiropractic management is truly distinctive, considering how body structure impacts physiology and function generally. Clinical outcomes and patient satisfaction with chiropractic care have been demonstrated. Management approaches and non-specific effects of care are acknowledged as important variables in both clinical care and scientific research, yet these issues are routinely neglected in conventional delivery and research settings.

Overall management perspectives, lifestyle approaches, and doctor-patient relationships are pivotal in health care. Tossing a few CAM modalities into general family practice is not the same as integrating practitioners in a constructive clinical environment who bring unique and extensive training, skills, and perspectives to the decision-making table. Consider the reverse: having a chiropractor incorporate suturing and NSAID medication into her or his practice seems unlikely to serve as a replacement for family practice medicine.

Here in Washington State provider choice is law, both in general health insurance and in workers compensation. The point is that integration of CAM is not a medical profession issue, it is a social and marketplace issue. Exploring integration will require gradual exposure, training, and scientific research to accomplish. This exposure must involve all parties as the convention science and medical communities have to move as far in their understanding of CAM approaches as CAM providers have to move in there understanding and skill in conventional methodologies and rationales. There are no simple “fixes.” Rather, there is a need to continue to level the playing field, provide all interested parties with necessary tools for constructive engagement and bring reasoned appraisal both to discussions on integration and policy development at government levels.


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