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Legislative Alchemy: Chiropractic 2013

Via the magic of legislative alchemy, chiropractors are already licensed health care providers in all 50 states. Thus their legislative efforts tend to focus on expanding their scope of practice and forcing public and private insurers to cover their services, in some cases at the same rate as medical doctors. Those efforts continue in 2013 with 65 bills impacting chiropractors introduced so far. Of those including substantive provisions (as opposed to, say, simply raising fees), only one is not to their advantage.

New Mexico chiropractors are once again attempting expansion of their scope of practice. In 2008 and 2009, the New Mexico legislature created a new iteration of chiropractor, called “the certified advanced practice chiropractic physician.” A certain faction of the chiropractic industry is attempting to rebrand chiropractors nationwide as primary care physicians and this was a signature event in those efforts. With 90 hours of additional education, these advanced practice chiropractors can administer a bevy of dubious remedies, such as bioidentical hormones.

The new law also permitted prescription of dangerous drugs and controlled substances and administration of drugs by injection, but only if on a formulary approved by the state pharmacy and medical boards. The chiropractic board didn’t like having to get approval from pharmacists and medical doctors, so they went ahead and added what they wanted to the formulary, ignoring the other boards despite their own attorney’s advice that they couldn’t do this. This got them into a couple of court battles with the pharmacy and medical boards. The International Association of Chiropractors (ICA), the traditional, subluxation-only chiropractic faction, jumped into the fray to oppose this power grab. The ICA believes chiropractic should remain drug and surgery free.

To rid themselves of annoying pharmacy and medical board oversight, chiropractors again appealed to the legislature last year and got a bill introduced which would, among other things, let them control their own formulary. That bill passed the New Mexico House but not the Senate.

NM chiropractors go for more

Which brings us to this year. The chiropractors are back with a new bill (Senate Bill 471) and a new attempt to expand chiropractic scope of practice and play at being real doctors. Toward this end, the bill liberally sprinkles the word “medicine” throughout the chiropractic practice act, so that a chiropractor (both advanced practice and the plain vanilla kind) would no longer be engaged in the practice of “chiropractic,” but rather of “chiropractic medicine.” Similarly, existing authority to sell “herbs,” “supplements’” and “homeopathic remedies” is transformed into authority to sell “herbal medicine,” “nutritional medicine,” and “homeopathic medicine.” How very grand!

Not only would chiropractors locate and remove subluxations to restore health and treat disease (so old school!), their scope of practice would now include, but not be limited to,

diagnosis and treatment of a condition for which the chiropractic physician [sic] has been educated and trained.

Exactly who would decide whether a chiropractor has been “educated and trained” sufficiently to diagnose and treat a particular condition is not specified.

The bill appears to do away with the limitation on invasive diagnostic procedures to those permitted by chiropractic board rule. (I say “appears to” because the limitation is deleted in one portion of the bill but remains in another. This bill is no model of careful statutory draftsmanship.) Here’s what the board already authorizes chiropractors to perform (as opposed to order – that’s a different list) to date:

The collection and testing of human fluids, such as saliva, blood, urnine, vaginal and seminal fluids, hair, feces, and conventional radiography.

MRI, CT, nuclear scans, ultrasonography; thermography, B.E.A.M. [apparently, Brain Electrical Activity Mapping], EEG, EKG, ECG and surface or needle EMG.

Imagine what chiropractors will do without such limitations, as loose as they are.

But wait, it gets worse

If, up to this point, the words “outrageous,” “dangerous,” “crazy,”  and similar descriptives have occurred to you, wait ‘til you see what’s next:

Chiropractic medicine shall exclude operative surgery and prescription of controlled substances except where permitted by statute or rule.

In other words, no operative surgery or controlled substances unless the chiropractic board says it’s ok.

To get the full import of this provision, it must be read together with the proposed expansion of chiropractic scope of practice to include “treatment of a condition for which the chiropractic physician has been educated and trained.” Under existing law, the chiropractic board attempted to include drugs on the formulary for uses which, according to the medical board, were not within the chiropractic scope of practice. This is what got them into a tussle over the formulary. That scope is currently defined in the traditional manner as “locating and removing interference with the transmissions or expression of nerve forces in the human body by the correction of misalignments or subluxations” and “the administering of all natural agents to assist in the healing act,” e.g., herbs, homeopathic products, and the like.

The “we are primary care physicians” faction of chiropractors thought this cramped their style. So if this bill passes, any chiropractic school can “educate and train” chiropractic students in whatever it pleases – say, psychiatry or gastroenterology – and the scope of practice will be practically unlimited, at least in New Mexico. You can bet the chiropractors will try this trick in other states.

The bill is confusing on operative surgery as its provisions are conflicting. The ICA thinks it “potentially” allows operative surgery so we’ll go with that interpretation. I don’t know if this is yet another example of bad drafting or the drafters are just being sneaky.

Thus, under this bill, the chiropractic board, which consists of four chiropractors and two public members, could decide on its own to allow chiropractors to perform operative surgery, “potentially.” There are no requirements in the bill which the board must follow in determining who is qualified to practice surgery or which surgical procedures can be performed, as long as the chiropractor is “educated and trained” in the subject. Chiropractors are forbidden from “procuring, aiding or abetting a criminal abortion,” the implication being that they can perform legal abortions if so “educated and trained.”

Under current law, an “advanced practice” chiropractor must complete 90 clinical and classroom hours and pass a test in addition to the usual requirements for a chiropractic license. The chiropractic board is given sole authority to develop a formulary for the prescription, administration (including by injection) and dispensing of certain substances such as herbal and homeopathic “medicines,” vitamins and minerals, glandular products, live cells products, enzymes, amino acids, lidocaine and procaine for the “advanced practice” chiropractor. To this list the bill adds carbohydrates and sugars. Any substances not listed in the bill can be added to the formulary by the chiropractic board if the pharmacy board approves. Gone is the requirement for medical board approval.

To prescribe, administer or dispense legend (prescription) drugs or Schedule III through V controlled substances, an advanced practice chiropractor must, in addition, hold a prescription certificate. This requires completion of a “primary care clinical rotation” at a chiropractic college or other accredited “institution of higher education or professional school.” The rotation consists of 500 hours of “clinical and hands-on instruction” in clinical pharmacology, evidence-based clinical assessment, clinical pharmacotherapeutics, primary care case management or (not “and” but “or”) patient safety and standards of primary care under the supervision of an M.D., D.O., nurse practitioner or advanced practice chiropractor. No exam is required.

So, let’s see. After what would equal a little more than 6 weeks of a medical residency, all of which could take place in a chiropractic college outpatient clinic, an advanced practice chiropractor could prescribe, administer and dispense Schedule III – V drugs if the chiropractic board wants them on the formulary and the pharmacy board agrees.

Just to further scare you out of your wits, here are a few of New Mexico’s Schedule III – V drugs that caught my untrained eye: anabolic steroids, codeine, testosterone, hydrocodone (Vicodin, Lorcet), morphine, opium, lysergic acid, pentobarbital (Nembutal), alprazolam (Xanax), chloral hydrate, clonazepam (Clonopin), dextropropoxphene, (Darvon, Darvocet), Diazepam (Valium), Esopiclone (Lunesta), phenobarbital (Luminal, Donnatal) and tramadol.

You can see where this is going. Together with the expansion of the scope of practice, this certificate will be a ticket for the advanced practice chiropractor to do pretty much anything a real primary care M.D. or D.O. can do.

So far, the only sponsor of this bill is Senator Cisco McSorley (D). Perhaps some of you might want to drop Sen. McSorley a line with your thoughts on his bill.

Before we move on to other areas, one other practice expansion effort is underway, this time in Texas.  Currently, the chiropractic scope of practice includes

objective or subjective means to analyze, examine, or evaluate the biomechanical condition of the spine and musculoskeletal system of the human body

House Bill 1169 would add to the end of that sentence

. . .  or the condition of another system of the human body that is affected by the musculoskeletal system.

Which leads me to wonder: considering the vertebrae-centered chiropractic belief system, what wouldn’t be “another system of the human body that is affected by the musculoskeletal system?”

Informed consent, finally?

In Oklahoma, Senate Bill 451 provides

Chiropractic physicians in this state shall obtain informed, written consent from a patient prior to performing any procedure that involves treatment of the patient’s cervical spine and such informed consent shall include the risks and possible side effects of such treatment including the risk of chiropractic stroke.

Needless to say, the Oklahoma Chiropractors’ Association opposes the bill. Chiropractors do not believe there is such a risk, a subject Harriet Hall, Mark Crislip and I have all written about on SBM.

Discrimination?

Washington State already has a law prohibiting the state and its subdivisions (such as counties) from

in any way discriminating against licensed chiropractors in performing and receiving compensation for services covered by their licenses.

To make the point, schools would be forced to include them in sports physicals per an amendment to the law:

Licensed chiropractors must be allowed to perform sports physicals for school athletes and physical examinations required for commercial driver’s licenses.

As Harriet Hall, herself a Washington resident, pointed out:

Physicians and properly trained, experienced PAs and NPs are qualified to do these exams. Chiropractors and other alternative providers are not, even with special certification and training.

As noted in my recent post on naturopathy, chiropractors are seeking to avoid exclusion, which they equate with discrimination, from Oregon’s Coordinated Care Organizations (CCOs) through a bill that would force CCOs to accept them as primary care providers. The CCOs, which provide care for Medicaid patients, were merely trying to follow a legal mandate to save money by requiring providers to practice evidence-based medicine and excluding those who don’t. Never underestimate the power of a state legislature to take away with the right hand taxpayer money the left hand is trying to save.

Insurance

The majority of chiropractic bills introduced so far seek greater public and private health coverage for chiropractic services. Pending bills would, among other things,

  • include or expand coverage of chiropractic services in Medicaid or other taxpayer-funded health insurance programs;
  • prohibit coverage limitations on chiropractic services unless there are similar limitations on physician services or require coverage of services on same basis as a physician;
  • require coverage for any service within the scope of chiropractic practice;
  • prohibit larger copayments for chiropractors than for physicians.

There is considerable financial pressure on chiropractors and thus an urgent need to increase income, even if it means singing up for low reimbursement programs like Medicaid. The total number of ambulatory visits to chiropractors decreased by 3 percent from 2002-2008. Quackwatch recently analyzed chiropractic income based on data from the U.S. Department of Commerce:

These figures indicate that between January 1992 and December 2007, the average gross income per chiropractic office rose at less than half the rate of inflation, which is equivalent to a loss of 20% in purchasing power. Since the cost of running the offices increased during this period, the purchasing power of the chiropractor’s take-home pay was even lower.

And just this week Scripps-Howard News Service published a news report revealing the large number of defaults still outstanding on government health care provider student loans. A complete list of the 930 providers (see bottom of report) reveals that chiropractors hold a distinct majority on the list.

Conclusion

Instead of ditching the subluxation and becoming an evidence-based provider of care for musculoskeletal problems, chiropractors appear to being going in the extreme opposite direction. They are attempting to become primary care physicians but with far less education and training than M.D.s, D.O.s, P.A.s and nurse practitioners have in diagnosing and treating the broad range of conditions seen by primary care providers. They compound the problem by using quack remedies like homeopathy. If they can fool some of the public some of the time with this nonsense, I don’t think it will be for long. As is true of “naturopathic doctors,” very few patients will see chiropractors for primary care even when their scope of practice permits it and insurance pays for it. And it will just compound the problem the public has figuring out just what it is chiropractors do.

Posted in: Chiropractic, Herbs & Supplements, Homeopathy, Legal, Pharmaceuticals, Politics and Regulation

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