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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'...."
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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). |
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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.)
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"In consultation with" is not the same as "by referral only". |
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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. |
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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!
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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). |
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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.
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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. |
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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.
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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. |
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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.acatoday.com/level2.cfm?T1ID=14&T2ID;=36) for additional information on the Department of Veterans Affairs Chiropractic Advisory Committee and the 38 Recommendations sent to Secretary Anthony Principi.
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