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| ![] | # AMERICAN OSTEOPATHIC ASSOCIATION                             |
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|     | 142 EAST ONTARIO STREET, CHICAGO, ILLINOIS 60611-2864          |
|     | 800-621-1773 312-202-8000 FAX 312-202-8200                     |
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August 13, 2003

Ms. Sara McVicker

Chiropractic Advisory Committee

Primary and Ambulatory Care SHG (112)

U.S. Department of Veterans Affairs

810 Vermont Avenue, NW

Washington, DC 20420

Dear Ms. McVicker:

As President of the American Osteopathic Association (AOA), which
represents the nation's 52,000 osteopathic physicians, I am pleased to
respond to the request for comments on the VA Chiropractic Advisory
Committee draft recommendations. The AOA shares in the Committee's
desire to improve the Veterans Health Administration and provide
services to beneficiaries, which will improve both their overall health
and their access to health care services.

 

P.L. 107-135, Section 204, which created this Committee, also requires
that the Committee "provide direct assistance and advice to the
Secretary in the development and implementation of the chiropractic
health program." The AOA, overall, is encouraged by progress the
Committee is making in drafting recommendations for the implementation
of P.L. 107-135. We remain concerned, however, about several
recommendations put forth in the latest draft.

 

We support fully the Committee's recommendation to require that
beneficiaries receive a referral from their primary care physician prior
to accessing any new benefit. We feel that the role of the primary care
physician in monitoring and managing care of beneficiaries is essential
to the successful implementation and utilization of any new benefit. We
are pleased that the Committee agrees. The AOA encourages the Committee
to retain this provision in all future drafts and the final
recommendation. Its omission would create potential implementation
problems for the chiropractic benefit. Additionally, any recommendation
to remove or lessen the role of physicians as the primary provider of
health care would be viewed unfavorably by the AOA. For this reason we
strongly urge the Committee to omit any references to chiropractors
being the "managers" of care for musculoskeletal conditions.
Chiropractors may be a member of a team providing musculoskeletal care
if warranted, but to expand their role to the primary principal in such
care is not appropriate.

The AOA believes that any new benefit should be monitored for efficacy,
utilization, and cost. It is important to determine if a new benefit is
improving the health care of beneficiaries, being utilized
appropriately, and if the costs associated with providing the benefit
equate to sound fiscal policy.

The following are comments specific to recommendations made in the
Committee's draft:

### 

### **Recommendation 5: Minimum Initial Privileges**

The recommendations presented in this section are problematic as they
are not consistent with Recommendation 19. Recommendation 5 refers to
management of care, while recommendation 19 states that chiropractors
should co-manage care. The wording in this section needs to be changed
to co-management of care.

#### Recommendation 6: Other Initial Privileges 

This section refers to additional privileges, which include the ordering
of various tests. However, there is no language which clarifies who will
read and/or evaluate the results of such tests. We recommend that
additional language be added to address this question.

#### Recommendation 9: Access to Chiropractic Care

We strongly agree that access to chiropractic care should require
referral from the patient's primary care provider. This method of access
is in keeping with the primary care model that currently exists within
the Veterans Health Administration. We strongly urge the Committee to
retain this language in the final recommendations.

**[Recommendation 10: Continuity of Care for New Discharged
Veterans]{.underline}**

We agree with this recommendation. However, some additional information
is needed. In the final recommendation, a defined timeframe for
chiropractic care should be specified, as veterans will need to be
evaluated and seen on a periodic basis by their primary care provider.

#### 

#### Recommendation 16: Referral Service Agreements

We strongly agree with lines 26-29 on page 15, which state that "non
chiropractic members of the Committee believe that physical therapists,
physiatrists, or doctors of osteopathic medicine also are qualified to
provide evaluation and care". We urge that this statement be retained
and included in the final recommendations.

There are two questions in this recommendation that need to be answered.
The first refers to patient symptoms - if a patient presents with no
symptoms, how can that patient be treated? Finally, the comments state
that chiropractic care requires multiple patient encounters over a
period of time. If that is the case, how cost effective will this
treatment be within the VA system?

#### Recommendation 19: Co-management of care

We agree with the statement that "doctors of chiropractic care should
co-manage patient care for neuromusculoskeletal conditions as
appropriate".

**[Recommendation 22: Doctor of Chiropractic Staffing]{.underline}**

We suggest that the final recommendation not name a specific number of
chiropractic staff to be hired. Instead, the determining factor for the
number of hires should be based on patient volume at each facility.

#### 

#### Appendix B -- Models for Integrated Care Delivery

The AOA supports Model 3, which is integration into a specialty service
or serviceline without specific liaison to primary care.

## Thank you for your consideration of our views. If you have any questions or need additional information, please contact the Department of Government Relations at (202) 414-0140.

## 

![](media/image2.png){width="2.125in"
height="0.5145833333333333in"}Sincerely,

Darryl A. Beehler, D.O.

AOA President

C: AOA President-Elect, AOA Board of Trustees, Chairman AOA Council on
Federal Health Programs, Members AOA Council on Federal Health Programs,
AOA Executive Director, AOA Senior Staff, AOA Department of Government
Relations

##