Response to the Draft Recommendations

of the Chiropractic Advisory Committee

U.S. Department of Veterans Affairs

Submitted by the

American Chiropractic Association

# 

# August 22, 2003

# Introduction

The American Chiropractic Association (ACA) welcomes the opportunity to
provide its formal response to and comments on the Department of
Veterans' Affairs (DVA) Recommendations of the Chiropractic Advisory
Committee. As the largest chiropractic association in the United States
and the leading advocacy organization for doctors of chiropractic and
millions of chiropractic patients across America, the ACA played a
leadership role in the effort to enact Section 204 of Public Law
107-135, and in the creation of the DVA Chiropractic Advisory Committee.

The advisory committee has worked hard and is now poised to provide the
Secretary with valuable information regarding how best to integrate
chiropractic care into the DVA system. This process has been an
important part of correcting a previous track record of neglect and
misunderstanding, and overcoming unfortunate historical biases toward
the chiropractic profession. At the same time, the ACA wishes to express
disappointment with some of the recommendations and comments in this
draft report, and the failure of certain advisory committee members to
properly recognize specific legislative directives and the overall
intent of Congress and the President in establishing a permanent
chiropractic health care benefit in the DVA system. The final report
should be -- as Congress and the President envisioned -- a
forward-looking effort to ensure that America's veterans finally have
access to the chiropractic care they need and deserve. It should not be
permitted to become a vehicle for expressing views based on an
antiquated bias or determined lack of knowledge about chiropractic care.

ACA is pleased to offer this response to the draft recommendations and
respectfully requests that the changes proposed herein will be
incorporated into the final Report of the Chiropractic Advisory
Committee.

**Comments of the ACA**

**Page 3, Line 18-19:**

The draft Advisory Committee Report states that **"The goal of VHA's new
chiropractic care should include: Patients have appropriate access to
chiropractic care."**

ACA believe the key to developing an effective policy on chiropractic
care in the veterans healthcare system is the guarantee of direct
access. Therefore, ACA recommends to the Committee that the Report
should say "direct access" rather than "appropriate access" to
chiropractic care. Direct access remains a high priority to ensure that
America's veterans are provided with the access to chiropractic care
they need and deserve -- which, unfortunately, the DVA has failed to
provide in the past.

Ensuring direct access to doctors of chiropractic is extremely important
to the proper utilization of chiropractic care. Patients often
experience difficulty accessing chiropractic care when a referral from a
medical doctor or nurse is required. Although they are skilled and
trained professionals, medical doctors and nurses typically receive no
professional training during their formal education relating to when it
is appropriate to refer to doctors of chiropractic.

Furthermore, medical doctors have failed to demonstrate basic competency
in musculoskeletal. It is therefore reasonable to conclude that medical
school preparation in musculoskeletal medicine is inadequate.

**Page 4, Line 42:**

The draft report states that **"Chiropractic state licensure criteria is
not standardized across all states nor has the same examination always
been used by all states. As a result, some members of the Committee
expressed concerns that licensure may not be adequate to assure the same
level of training as those programs meeting the standards of a
recognized accrediting body."**

Since 1974, the Council on Chiropractic Education (CCE) has been the
agency recognized by the U.S. Department of Education as the specialized
accrediting agency for chiropractic education. The CCE sets the
standards for the curriculum, faculty and staff, facilities, patient
care and research. Moreover, language from HR 2414 (108^th^ Congress),
which was incorporated into HR 2357 and approved by the U.S. House of
Representatives, states the educational qualification of chiropractors
and models them on those used for other professions in Title 38.
Therefore, the ACA states that this comment is fundamentally flawed and
urges it be removed from the final report.

**Page 5, Line 39**

The draft recommendations, under the Scope of Practice, states that
**"doctors of chiropractic shall provide patient evaluation and care for
neuro-musculoskeletal conditions including the subluxation complex
within the boundaries set by state licensure, VHA privileging and the
doctor's ability to demonstrate educational training and clinical
competency in the areas necessary to provide appropriate patient
care."** The ACA advises the advisory committee that doctors of
chiropractic are trained and educated at chiropractic colleges
accredited by the Council on Chiropractic Education. It appears that
some members on the Committee are questioning the capabilities of
chiropractors. The ACA believes that the inclusion of this statement
represents a bias and prejudice of certain health care physicians on
this advisory committee.

**Page 10, Lines 24-31**

The Committee Report states that **"some members believe permitting
direct access to chiropractic care may lead to patients attempting to
use that access to circumvent the primary care backlog."** To conclude
that by allowing direct access would lead patients to circumvent the
process is baseless and the ACA believes that this statement
demonstrates lack of knowledge and understanding regarding chiropractic
care. Another member expressed concerns "**that establishing a policy
where veterans may self-select chiropractic care may represent a
mechanism for doctors of chiropractic to function as primary care
providers."** Statements such as this one further illustrate the
inherent bias faced by doctors of chiropractic and lack of discernment
about the chiropractic profession.

**Page 10, Dissenting Recommendation:**

The ACA concurs with the dissenting recommendations that **"VHA
facilities should establish processes that will ensure patients are
adequately informed about treatment option, including chiropractic
care."**

**Page 12, Line 33:**

The Report states that **"One member voiced concern that this might
create a large pool of people who would attempt to circumvent VHA's
normal referral process by applying for service connected benefits in
order to continue to receive chiropractic care without a primary care
provider."** Again, statements like this one shows the blatant bias this
particular committee member has about chiropractic. Under no
circumstance would a large pool of people attempt to circumvent VHA's
process. It only reinforces what ACA has believed for some time that
certain members are afraid of direct access. This statement and the
statement on page 10 should not be included in the final report.

**Page 13, Line 36-43:**

The ACA believes that the DVA should draft and submit to Congress
legislation that would ensure that such limitations for reimbursement
for chiropractic services under Federal occupational health programs are
eliminated. The ACA would welcome the opportunity to work with the DVA
and other Federal agencies, and Congress on such legislation.

**Page 14, Line 15:**

Doctors of chiropractic are trained and understand when they should
refer patients to the appropriate physicians for care, and the ACA sees
no justifiable reason for pointing out the three areas on page 14, Line
15 in which chiropractors should screen patients. Again, this
recommendation suggests a lack of knowledge by certain members of the
Advisory Committee regarding the extensive training and capabilities of
Doctors of Chiropractic.

**Page 15, Line 39-42:**

The ACA does not agree with the rationale surrounding this
recommendation because it believes it goes in the opposite direction of
the intent of P.L 107-135, Section 204. The ACA strongly believes that
mandatory referral requirement should not apply to chiropractic care
within the DVA system and ask that the Advisory Committee remove this
sentence from its Report.

**Page 23, Appendix A Conditions Commonly Seen By Doctors of
Chiropractic**

The ACA would recommend that Advisory Committee include in the final
report the following items:

-   Elbow

-   Feet

-   Knee

-   Shoulder

-   Wrist

**Page 28, Appendix C Chiropractic Equipment Requirements**

The ACA would also like to urge the Advisory Committee to include in the
final report the following items:

-   Adjusting Table

-   Head Rest Paper

-   Stool

-   Writing Surface (desk)

## Submitted by the

## American Chiropractic Association

### Government Relations Department

> **1701 Clarendon Blvd., Arlington, VA 22209**
>
> **(703) 276-8800**
>
> **August 22, 2003**