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Direct Access and Dr. Michael McLean's Article...The Rest of the Story
By Dr Rick McMichael
Dr. McLean is once again...twisting the VA story to the details of his liking. In his recent article carried by none other than the personal communication tool of Terry Rondberg, The Chiropractic Journal, he constructs his story in an obviously misleading fashion, including numerous inaccuracies and false innuendo...only to later contradict himself in the same article. Let's take a closer look at the rest of this story.
1) Dr. McLean states two times that three ACA members on the VA Chiropractic Advisory Committee (CAC) voted "to make chiropractic available only by referral" and even bolded the "only by referral" part.
Dr. McLean states "the ACA stated they (the three ACA DCs) voted for 'referral only'...."
Dr. McLean then states "the CAC DCs have voted 4-2 for 'referral only'...."
| No one on the CAC voted for "referral only" or "only by referral". Nine of eleven members of the CAC voted for access "in consultation with" the VA PCP and other VA providers. Again Dr. McLean has chosen to use his words and not the words of the Recommendations! (Recommendations 9 and 10 are included at the end of this article for the reader's review of exact Recommendation language sent to the Secretary). | |
Dr. McLean skirts an important part of the CAC recommendations sent to Secretary Principi...by continually stating that the CAC voted for access to chiropractic care "by referral only" or "only by referral". The Recommendation 9 which he refers to says, "in consultation with...", as noted above. Those are not only completely different words, anyone with a dictionary will find they have quite different meanings...meanings that are very important in the context of this chiropractic integration into the VA healthcare system:
Consultation...a deliberation between physicians on a case or its treatment; the act of consulting or conferring
(The terms 'by consultation with' strongly infers that the providers will engage in a 'conference' regarding the patient and how the patient will be best served...including chiropractic care. This further implies a congenial discussion regarding the patient, and working together for the best of patient care.)
Referral...the act, action, or an instance of referring
(The term 'referral' infers a one-sided action on the part of the referring provider. This term conjures up the fear of the 'medical gatekeeper'. This is the fear that Dr. McLean is attempting to foster on our profession, even though he knows that we, the CAC DCs, have been strongly advised that the VA healthcare system's reliance on the PCP (to coordinate all care of veterans) is NOT a "gatekeeper" system, but rather a more congenial consultative/conferring team approach to healthcare.)
| "In consultation with" is not the same as "by referral only". | |
| Direct Access WAS recommended by the CAC in Recommendation 10. A couple of paragraphs after Dr. McLean states (and re-states) that the CAC voted for access "only by referral" and for "referral only"... he writes," I must point out that the CAC did recommend direct access for any Veteran who had previously had chiropractic care while in the military." Dr. McLean attempts to act like this does not count for anything and that it is ok to continue to promote the false statement that anyone on the CAC voted for access to chiropractic "only by referral", or that Veterans will be able to access chiropractic care "only by referral". As stated by Dr. McLean himself, direct access is an important inclusion in the CAC recommendations...for Veterans who had previously had chiropractic care while in the military. Dr. McLean knows that the number of Veterans in this category is growing by the day, as more and more military personnel are treated at a growing number of military sites across the country...now some 40 sites and expanding. Three years ago there was no permanent chiropractic benefit for military personnel...now there is, and DCs are serving our military men and women admirably, around the country. | |
2) Dr. McLean's original article in The Chiropractic Choice (ICA paper) stated, "… ACA votes for MD referral" and proclaimed that ACA members were "against direct access". This was absolutely inaccurate, as our responses have pointed out. Now, in the TCJ article, Dr. McLean says, "Firstly, let me assert I have not accused the ACA of 'voting for medical referral'. I know too many good and principled ACA members to believe the association would support that."
Question: So, if this is true, why did Dr. McLean allow the truth to be distorted in the headlines and the content of his original article...which blatantly accused the ACA of the very 'wrongdoing' that he now asserts he does not believe is true?
Interestingly, Dr. McLean then goes on (later in his article) to state, "I believe the ACA Board must disavow the actions of these three (ACA members). Otherwise, the ACA consents by its silence to this disastrous precedent, and can no longer plausibly deny responsibility for this stance."
So, Dr. McLean 'firstly' attempts to recant the blatantly inaccurate and misleading headlines and content of his original article (which accused ACA of voting "for MD referral", when the truth was that NO association had a vote on the CAC). He asserts he did "not accuse the ACA of voting for medical referral" in one paragraph, and then in the following paragraph attempts to pin the "responsibility" on ACA again!
| As stated previously, in some detail (refer to ACA website for articles that explain the CAC truth), NO association had (or has) a vote on the CAC. Although individual members may belong to a particular association, the CAC members have been carefully instructed that their service on the CAC is as individuals. As individuals, CAC members have a responsibility to make recommendations to Secretary Principi on the details of the chiropractic integration, details that they believe will result in a successful integration of the chiropractic benefit into the Veterans Healthcare System (VHS). | |
Each of the CAC members has reviewed input from the DVA, various stakeholders and interested parties. Each of us has asked questions and debated the issues at the CAC table. Each of us has struggled with the magnitude of the issues and decisions before us. Each of us has worked to draft the most positive recommendations possible...that we believe will lead to a successful integration of chiropractic care into the VHS, which follows a PCP model of healthcare delivery.
Each of us voted our own conscience on the issues. ACA members on the CAC were not directed how to vote on any issue, including access. We all knew that ACA leaders and members would want direct access; we did too. ACA gave strong testimony for direct access. To insinuate otherwise is just an outright distortion of the truth. This was NOT an ACA vote...each of us voted for what we felt was best for Veterans, with all the available information considered.
3) So, then Dr. McLean attempts AGAIN to spin his story against ACA. He states, " It is disingenuous to deny responsibility for the actions of ACA leaders because they were not official ACA representatives but then put out an official defense of their actions."
So, to Dr. McLean, any association that supports the position of its members is responsible for their actions? And the ACA should disavow the actions of its members on the CAC?
What if the association did want direct access (as ACA did), but the association respects the members who serve on the CAC for creating the strongest "majority" recommendation possible? What if the association recognized the complexity of the issues involved and looked beyond the most-desired direct access objective to the accomplishment of the primary GOAL...a successful integration of chiropractic in the VA, which is a PCP model of care?
Dr. McLean's opinion that ACA is 'responsible' for the votes of Doctors McMichael, Phillips and Vaughn just does not hold water. His attempt to cast aspersions on Dr.Phillips, Dr.Vaughn, and me and to impugn the ACA in the process is unprofessional and divisive. We should all speak to our positions on the issues and omit the personal attacks.
| The ACA did not vote "for medical referral", or for "only by referral", or against "direct access". The ACA is NOT against direct access and has done more to support direct access throughout our healthcare system that any other association. Let's remember that the ICA and WCA supported a bill (despite broad chiropractic opposition) that would have resulted in the loss of "physician" status, along with any hope for parity compensation levels and other parity treatment under the law. | |
Direct access is best supported by doctor/physician status, built on the provider's education, training and experience to diagnose the patient, set a care plan, and manage, co-manage or refer the patient appropriately. WCA representatives, at pre-CAC meetings with the VA, testified that DCs were not educated or trained to diagnose...that diagnosis was a 'duplicative' service that chiropractors did not desire to perform, and that DCs were not skilled enough to provide. Maybe someone could explain how this fits the picture of a profession that expects to be given direct access to patients in a major healthcare system.
FIVE of the DCs on the CAC (including the three ACA members) voted for direct access on the original draft of Recommendation 9 (on access). Most of us realized, however, that we needed a "majority" recommendation, not a "dissenting opinion" of the minority, to have a reasonably good chance for it to be accepted and implemented. Those who understand the political hurdles and beaurocratic realities at this level clearly know that we needed at least one more vote to gain a "majority" recommendation and preferably two or three more votes to gain a reasonably strong recommendation. When we could not gain those additional votes for our dissenting recommendation (direct access), it became critical for us to gain modifications to the "majority" recommendation that would be sent to the Secretary. We could not leave the vote at 6 to 5, in favor of the original draft Recommendation 9, which stated that "Access to chiropractic care should require referral from the patient's primary care provider…."
So, we went to work at the CAC table to modify the "majority" recommendation in every way possible to optimize what would go to the Secretary. We changed the original language of "should require referral from" to "in consultation with". We noted that veterans who desired chiropractic care should see a doctor of chiropractic for evaluation and care. We drew language from our original recommendation that clearly noted our ongoing concerns relative to past and present bias of some VA providers against DCs and chiropractic care. We went further in the Rationale for Recommendation 9 and included, "As local facilities' experience with integrated doctors of chiropractic matures they may wish to explore protocols for direct access at their facility." We made these very substantive changes to the "majority recommendation that would be sent to the Secretary. We believed that showing the Secretary the CAC could work together to produce a high-consensus recommendation on access would give the integration of chiropractic the best chance for success.
| The entire CAC voted together on every Recommendation but #9. These Recommendations strongly encourage the integration of DCs into the VHS as full members of the VA healthcare team. DCs will be treated similar to other specialists in the VHS. We believe that many Veterans will access DCs for chiropractic care. Our DCs will be busy and very much appreciated by Veterans and eventually appreciated by the DVA. Recommendation 9 will allow our DCs to enter the system without being singled out as 'non-team-players'. Our DCs will be given the best opportunity to accomplish a successful chiropractic integration for the benefit of Veterans who need and desire chiropractic care. | |
It is time for our profession to pull together? Is it possible for Doctors McLean and Fischer to be respectful toward their CAC colleagues, with whom they disagree? No one has disparaged them for not voting with the remainder of the CAC. We supported their right to offer a dissenting opinion. Must they continue to impugn the judgement of their CAC colleagues? Must they continue to claim ACA is responsible for how 3 members voted? Must Dr.McLean continue to twist the words of the access recommendation to his own devises? I believe it is time, really far past time, for our profession and its members to grow up, cease the innuendo and one-upmanship, and learn to work together. Quit oversimplifying complex issues. Quit attempting to impugn colleagues we know are acting with purpose and forethought...even if their opinion is different than ours. Quit attempting to raise fear in the profession, even on the eve of an historic integration into the VA. Quit working to turn opinion against the association, which was most responsible for passage of the legislation that made chiropractic care a permanent benefit in the DoD and the VA in the first place. I think it is time that we begin a NEW DAY for veterans in the VHS… AND a NEW DAY for our brothers and sisters in the chiropractic profession. ACA is committed to that goal. I hope others will join ACA in celebrating all the good things included in the CAC Recommendations sent to Secretary Principi, and that we will move forward to work together to make the chiropractic integration a tremendous success for the benefit of Veterans nationwide. I can assure you that the ACA will not rest until this integration is successfully completed. If VA physicians refuse to work with doctors of chiropractic in a congenial manner, treating DCs as important providers on the VHS healthcare team; or if we find that Veterans continue to encounter VA physician bias, causing unreasonable barriers or delays to chiropractic care…the ACA will be back on the HILL, asking for legislation to demand full and direct access to chiropractic care. At that point, everyone should be very happy that ACA has one of the top 25 grassroots lobbying organizations in the country. But, for now, we have chosen to take the high road…allowing our VA physician colleagues to assume the virtue of doing the right thing for Veterans by supporting the chiropractic integration "in consultation with" their chiropractic colleagues.
Thank you for taking the time to learn...the rest of the story.
Rick McMichael, DC
VA CAC Member
Recommendation 9: Access to Chiropractic Care
Access to chiropractic care should be in consultation with the patient's primary care provider or another VA provider for the condition(s) for which chiropractic care is indicated. 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 a doctor of chiropractic for evaluation and care.
Veterans who have been referred to and have received care from a doctor of chiropractic should continue to have access to the doctor of chiropractic for the continuation of care or treatment, consistent with facility policy for specialty care access.
Recommendation 10: Continuity of Care for Newly Discharged Veterans
Newly discharged veterans who have been receiving chiropractic care through the Department of Defense while on active duty, or who have service-connected neuromusculoskeletal conditions, or who are newly returned from a combat zone, or who have applied for service-connection for the neuromusculoskeletal condition for which DoD provided chiropractic care, should have direct access for continued chiropractic care at a VHA facility. Veterans accessing chiropractic care in this manner should be assigned a primary care provider at the earliest possible time.
Please refer to ACA's website (www.amerchiro.org/government/VA/) for additional information on the Department of Veterans Affairs Chiropractic Advisory Committee and the 38 Recommendations sent to Secretary Anthony Principi.
ACA RESPONDS TO MISLEADING ARTICLES IN RECENT ICA AND WCA PUBLICATIONS
The American Chiropractic Association (ACA) is compelled to respond to recent front-page articles carried in the December 2003 issue of The Chiropractic Choice published by the International Chiropractors Association (ICA) and the January 2004 issue of The Chiropractic Journal published by the World Chiropractic Alliance (WCA).
These two articles are sensational in their reporting and omit important facts and complexities involved in the Department of Veterans Affairs' Chiropractic Advisory Committee process and the recent recommendations sent to Secretary Anthony J. Principi. The ICA specifically accuses ACA of "voting for MD referral" and both articles profess that ACA members are against direct access to chiropractic care. These two articles give the uninformed reader an inappropriately negative take on the VA Committee's recommendations, which are quite positive and herald a new day for veterans and the chiropractic profession. The American Medical News recently reported, "Chiropractic care at the Dept. of Veterans Affairs could expand dramatically, if the final recommendations of the VA chiropractic advisory committee are followed."
The recent ICA article seems particularly intent on misrepresenting the facts and damaging the ACA when it wrongfully blames the ACA for voting on a committee recommendation they do not agree with. The ICA headline, "…ACA votes for MD Referral" is the most egregious, since ICA knows this is just not true. Dr. McLean and the ICA know that the ACA, ICA and WCA have NO standing or votes on the VA Committee. It has been made perfectly clear by the VA that the committee members were chosen to share their personal expertise in drafting recommendations for Secretary Principi, NOT as representatives for any organization. Each VA Committee member voted their personal conscience in light of all the facts and information presented to them. They voted for what they thought would best serve our nations veterans and the chiropractic profession. The ACA certainly did not vote "for MD referral" as the ICA alleges and did not vote on any of the other committee recommendations.
ICA knows full well that the ACA and its members are NOT "against direct access" in the VA or any other institution or entity. Direct access is a principle the ACA fights for every day with insurance companies, regulatory agencies, in the courts and in Congress. The ACA Chairman testified before the VA Committee in favor of direct access. The ACA members on the VA committee simply voted for what they believed would best serve veterans in this integration into the VA Health System.
VA Committee members Dr. Michael McLean (quoted in ICA article) and Dr. Leona Fischer (author of WCA article) are also fully aware that their fellow committee members, Drs. Reed Phillips, Rick McMichael and Cindy Vaughn, are NOT "against direct access" in the VA or anywhere else. These committee members voted for Doctors of Chiropractic to be treated like all other specialists in the Veterans Health System (VHS).
Here are a few important facts: The three ACA members on the committee voted FOR direct access on March 30, 2003. A 5-6 vote made direct access a dissenting recommendation, lacking the consensus of other committee members or even a simple majority. A minority recommendation was very unlikely to gain acceptance and be implemented by the VA. The three ACA members then worked with the committee to craft the strongest possible, high-consensus recommendation on access. They gained compromise language that deleted "referral by" the PCP in favor of "by consultation with" the PCP and other changes. The committee recommendations also included "direct access" for veterans who have received chiropractic care in the Military Healthcare System while on active duty.
Never did any of the ACA members vote "for MD referral", but rather, "Access to chiropractic care should be by consultation with the patient's primary care provider or another VA provider who is currently treating the patient..." In fact, none of the ACA members ever voted "against direct access" since no vote was taken on the dissenting recommendation offered at the September 2003 meeting.
The committee's chiropractic members were counseled by VFW's Michael O'Rourke (VFW represents millions of veterans) to work with other VA providers to allow veterans the best and most workable access to chiropractic care in the highly structured Veterans Health System. O'Rourke counseled that by working within the VHS our doctors of chiropractic would be kept very busy with patient care.
Project Manager Sara McVicker, who Dr. Leona Fischer describes as "a Godsend," also encouraged the DCs to work within the VA system that is based on PCP coordination of veterans' care. We agree with Dr. Fischer's remarks about Ms. McVicker, "Her professionalism, attention to detail and knowledge of the system have been extremely valuable to us and greatly appreciated." Drs. Phillips, McMichael and Vaughn chose to heed the sincere counsel of McVicker and O'Rourke (based on their extensive VA knowledge and experience), while Drs. McLean and Fischer chose to ignore it.
George Washington said, "Truth will ultimately prevail where there are actions taken to bring it to light." For more of the VA story, we have attached the ACA's testimony to the VA Committee, and articles authored by Dr. William Morgan (Chief of Chiropractic Services at Bethesda National Naval Medical Center) and by Drs. Rick McMichael and Cindy Vaughn (VA Committee members).
The ACA is committed to truth and honesty in reporting and will not hesitate to hold other organizations and individuals to the same standard. The type of information contained in these recent ICA and WCA articles serves to foster further division within the profession. We can do better. Honest and complete reporting by all individuals and organizations will increase understanding and improve our intra-professional relationships. Differences in opinion and strategies will occur, but we must all commit to reporting complete and accurate information. Is that really too much to ask?
Watch ACA publications for positive news regarding progress in bringing chiropractic care to veterans. The integration of full-scope chiropractic care in the VA will be a great step forward for veterans and for our profession. Along with the integration of chiropractic care in the Department of Defense (now at some 37 sites by last count), this truly does herald a new era for the chiropractic profession and our patients. It is time for us all to focus on the positives of these historic events and work together to accomplish our vision of the future, where all people have access to our care.
Is This the Hill That You Want to Die On?
By William E. Morgan, DC
Recently I heard a Marine at work use the phrase, "Is this the hill that you want to die on?" When I asked about the expression, the Marine told me it was attributed to an old grisly sergeant major who was giving advice to a young Marine officer back in Vietnam. It seems the young officer had prepared defenses for his post without thought to a fall-back position, losing his ability to maneuver and prevail in exchange for the pride of holding onto an indefensible position.
The more I considered the sergeant major's question, the more I thought about how often people place themselves in positions where they would rather die than accept defeat or admit that they are wrong.
Recently, the VA Chiropractic Advisory Committee found itself at a similar impasse. The committee is charged with developing recommendations for the Secretary of Veterans Affairs on how best to implement chiropractic services in the VA's vast health care system. When it came time to vote on whether to allow patients direct access to chiropractic care or to require a referral from a primary care provider, the vote was 6 to 5 against direct access, with little chance of a break in the standoff. Later, after the wording of the proposed rule was changed to more acceptable terms ("by consultation with the patient's primary care provider"), three doctors of chiropractic on the committee changed their votes to recommend that chiropractic be implemented just like every other specialty in the VA health care system.
While direct access to chiropractic would have been great for the profession, it was simply not possible in the VA system. There are those who say this was a defeat for chiropractic, but it is actually a victory for the millions of VA patients who will have access to chiropractic care. These veterans can now get the care they need because three chiropractors chose not to die on the philosophical "hill" of direct access.
I speak from the unique perspective of having practiced under both the direct-access and referral models of chiropractic care. The chiropractic department at Bethesda's National Naval Medical Center was initially open access, with no referrals required. A year and a half later, we switched to a system where patients required a referral from a PCM (primary care manager). The result was an increase in the number of new patients. This is particularly remarkable given the fact that, during this same time period, the number of patients eligible for care was reduced by more than 75 percent (retirees and dependents were no longer allowed to receive care).
The two staff chiropractors at Bethesda continue to receive 65-100 new patient referrals per month. The main difference that I have noticed since switching to the referral model is that we now receive more complicated cases--patients that may require coordinated care between two or more doctors. For example, a Marine who was seriously wounded by a rocket-propelled grenade was referred to us for care by his physician, and I later consulted with his surgeon to determine the extent of the patient's injuries and how best to adjust this young serviceman without causing further harm to his condition. After successful treatment, the Marine was eventually released from our hospital. If this wounded man had been in a direct-access model of chiropractic care, he would have laid in pain in his room. In this case, his physician had acted as his chiropractic advocate!
Of course, this model of care requires that chiropractors continually interact in an intellectual and cordial manner with physicians in a hospital. They also must be willing to continually educate the hospital staff. In short, chiropractors who practice mainstream chiropractic will have little trouble adapting to this model of care and should even find it rewarding.
As for those who continue to say the profession should have "died on the hill" of direct access, I can tell you from my first-hand experience that it would have been an unwise and indefensible position.
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
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