By Dr. James Edwards, ACA Chairman of the Board
I just returned from Washington, DC, where I attended the third meeting of the Veterans Affairs Chiropractic Advisory Committee and presented ACA testimony. This report will update you about the tentative agreements that have been reached and my personal impressions of the process.
Prior to this meeting, Dr Reed Phillips, chairman, submitted a working draft of how chiropractic might best be implemented into the VA system to the committee members. The document was a compilation of the sentiments expressed by members during the first two committee meetings. This third meeting concentrated on studying and revising the proposed document. Although the proposed draft is still subject to further amendment and revision, following are the areas where I believe the committee has reached consensus in regard to what they will present to VA Secretary Anthony Principi:
- Qualifications - The first portion of the proposed document dealt with contracting qualifications for doctors of chiropractic into the VA system. The committee utilized the standard language for all the Title 38 professionals that you would expect (U.S. citizen, speaks English, professional license holder, etc.). The only area of any controversy surrounded the "graduated from a CCE-accredited institution" language. Since some practicing DCs graduated before the inception of CCE, I look for protective "grandfathering" language to be included.
- Scope of Practice - In the VA, doctors may be permitted to do any number of things according to their scope, but in actual practice, they are limited to perform only those things for which they have been privileged. In addition, a doctor's privileging may not exceed that which their scope permits. Under these rules, the basic scope of chiropractic practice will include: history taking, performance of neuromusculoskeletal and associated physical examinations, performance/ordering of x-rays, providing a diagnostic impression and treatment plan, referring to other healthcare providers (when appropriate), and performing chiropractic adjustments. The "extra" scope procedures (state law permitting) will include: physiotherapy, ordering of laboratory tests, CT, MRI, ultrasound, bone scans, electro-diagnostics, orthotics, supportive bracing, taping, counseling/education on body mechanics, nutrition, lifestyle, exercise, hygiene, and ergonomics.
- Access to Chiropractic Care - The VA system, not unlike the Department of Defense, is a Primary Care Provider (PCP) driven system. However, the chiropractic members of the committee were successful in including some provisions and language that provide for limited, direct-access care. While discussions will continue on the matter, I believe there was consensus that - absent any "red flags" or overt contraindications - requests for chiropractic would be honored without a PCP referral. Also, there is language being proposed that will help ensure that patients are afforded early access to DCs for NMS conditions, rather than being subjected to 6-8 weeks of allopathic trials by their PCP before obtaining a referral.
- Full Team Membership - The draft proposal also includes recommendations for additional privileging after a year, full medical staff voting privileges for DCs at the facilities, recommendations surrounding coordination of care (the interdisciplinary "team approach" model), and a recommendation that DCs be included as appointees on other VA advisory committees, as appropriate.
- DC Staffing - Some discussion has begun regarding how best to implement doctors of chiropractic into the system. The committee tentatively agreed to recommend a minimum of two DCs at each facility providing chiropractic services. In addition, after the committee's recommendations are submitted to the secretary regarding access, scope and qualifications, another significant challenge will be to develop (and subsequently recommend) a training/teaching program on chiropractic for all VA staff, including medical doctors.
The VA Chiropractic Advisory Committee heard public testimony from the following individuals and chiropractic organizations: David O'Bryon, representing the Association of Chiropractic Colleges; Wayne Wolfson, DC, representing the Federation of Chiropractic Licensing Boards; Matthew McCoy, DC, representing the World Chiropractic Alliance; David Chapman-Smith, representing the World Federation of Chiropractic; George McClelland, DC, representing the Foundation for Chiropractic Education and Research; Ronald Hendrickson, representing the International Chiropractors Association; and myself, representing the American Chiropractic Association.
My remarks on behalf of the ACA covered two major points. First, I emphasized the importance of direct access so veterans would not be subjected to artificial barriers to chiropractic care. Second, I discussed the extreme importance of DCs being able to practice under the full scope of their state chiropractic license.
Although this meeting was much more contentious than the December meeting, as the political agendas of some members became transparent, I am still optimistic that the six chiropractic members of the committee will be able to successfully create a new "federal model." Drs. Phillips, McMichael and Vaughn continue to be the "glue" holding it all together and are to be highly commended for their outstanding work.
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