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Integration of Chiropractic Medicine into 
Medicaid Reform

I. Introduction

The New Mexico State Legislature had mandated that the Health and Human Services Committee focus on developing the scope of the health care study for Medicaid reform. In past legislative initiatives, the State Legislature has included chiropractic medicine in the reform but has failed to fund it.

With a physician shortage in New Mexico and with our state classified as “under-served," it is time for legislators to take a bold stand and revise Medicaid legislation by:

· Using Doctors of Chiropractic (D.C.) as primary care physicians. Primary care does not mean full service but, instead, means first choice health care. Chiropractic Physicians are trained to serve as primary care providers.
· Allowing patients direct access free from the requirement of medical referral. The Medicaid patient should be able to choose Chiropractic medicine for primary care.
· Allowing the Chiropractic Physician to receive equitable reimbursement for services rendered. RAND, a prestigious nonprofit research organization has conducted several studies of chiropractic medicine. Dr. Paul Shekelle, a medical doctor and a researcher for RAND, stated: “Instead of thinking of chiropractic as an alternative or some kind of therapy separate from other health care, we really should consider it equivalent.” (Studies on Chiropractic, 2000, National Board of Chiropractic Examiners)

II. Trends in Alternative Medicine

In 1998, the Journal of the American Medical Association published an article, “Trends in Alternative Medicine Use in the United States, 1990-1997," which was the result of a national survey.


· Chiropractic therapy was the leader in total visits per 1000 (30.5%) for all types of alternative therapy visits and led the nearest therapy (massage at 18.1%) by 12.4%. Examples of other alternative therapies that registered a frequency of use well below that of chiropractic are as follows: relaxation techniques - 16.4%, self-help groups - 12.7%, energy healing - 6.4%, commercial diet - 4.4%, and acupuncture - 0.9%.
· The percentage of users paying entirely out-of-pocket for services provided by alternative medicine practitioners did not change significantly between 1990 (64%) and 1997 (58.3%) (P=0.36).
· Extrapolations to the US population suggest a 47.3% increase in total visits to alternative medicine practitioners, from 427 million in 1990 to 629 million in 1997, thereby exceeding total visits to all US primary care physicians by 39 million in 1990 and 242 million in 1997.
· An estimated 15 million adults in 1997 took prescription medications concurrently with herbal remedies and/or high-dose vitamins (18.4% of all prescription users).
· Estimated expenditures for alternative medicine professional services increased 45.2% between 1990 and 1997 and were conservatively estimated at $21.2 billion in 1997, with at least $12.2 billion paid out-of-pocket.
· This exceeds the 1997 out-of-pocket expenditures for all US hospitalizations. Total 1997 out-of-pocket expenditures relating to alternative therapies were conservatively estimated at $27.0 billion, which is comparable with the projected 1997 out-of-pocket expenditures for all US physician services."


“Alternative medicine use and expenditures increased substantially between 1990 and 1997, attributable primarily to an increase in the proportion of the population seeking alternative therapies, rather than increased visits per patient.”

III. Cost Effectiveness of Chiropractic Medicine

The publication, Dynamic Chiropractic, published an article, “Chiropractic More Cost-Effective Than Medicine Under Managed Care." Doug Metz, DC, Chief Health Services Officer, and Craig Nelson, DC, MS, Senior Health Services Research Scientist headed the study, conducted by American Specialty Health and Health Benchmarks, Inc.

The four-year study compared the experiences of 1.7 million patients in a California managed-care plan-- 1.0 million members without chiropractic coverage and 700,000 with chiropractic coverage. Patients were divided into six groups, based on whether they enjoyed chiropractic coverage and whether they received chiropractic or medical care for their neuromusculoskeletal (NMS) conditions.


· Lower total health care costs – Patients with chiropractic coverage had 12 % lower costs than patients without chiropractic coverage. Much of this reduction was attributable to favorable patient selection.
· Fewer inpatient hospital stays – Per 1000 patients, those with chiropractic coverage had 9.3 stays vs. 15.6 stays for those without coverage.
· Fewer MRIs – Per 1000 patients, those with chiropractic coverage had 43.2 MRIs vs. 68.9 MRIs for those without coverage.
· Fewer low back surgeries – Per 1000 patients, those with chiropractic coverage had 3.3 low-back surgeries vs. 4.3 low-back surgeries for those without coverage.
· Fewer radiographs – Per 1000 patients, those with chiropractic coverage had 17.5 radiographs vs. 22.7 radiographs for those without coverage.
· The inclusion of chiropractic benefit attracts a slightly younger and slightly healthier subscriber.
· Most of the chiropractic care provided was a direct substitution for medical care.
· The cost/episode of chiropractic care for back pain and neck pain is much lower than for medical care.


The inclusion of a chiropractic benefit results in a much more conservative back pain episode (less surgery, in-patient care and advanced imaging) than in groups without a chiropractic benefit.

IV. Chiropractic Care Reimbursement for Managed Health Care, Medicare and Medicaid Patients

A. Managed Health Care

The following definition is according to Title 13 Insurance, Chapter 10- Health Insurance, Part 13
“Physician services are those services that are reasonably required to maintain good health, including, but not limited to, periodic examinations and office visits with a primary care physician, specialist and referral services provided by a licensed physician, and services provided by other health professionals who are licensed to practice, are certified, and are practicing under authority of the managed health care plan, a medical group, an independent practice association, or other authority authorized by applicable New Mexico law. [3/16/1997].”

“Nothing contained in this section or contained in the definition of ‘primary care physician’ shall preclude other health care professionals such as doctors of oriental medicine, chiropractic physicians, nurse practitioners, physician assistants, or certified nurse midwives from providing primary care, provided that the health care professional (1) is acting within his or her scope of practice as defined under the relevant state licensing law; (2) meets the MHCP eligibility criteria for health care professionals who provide primary care; and (3) agrees to participate and to comply with the health care insurer’s or MHCP’s care coordination and referral policies [6/30/1998].”

B. Medicaid

Previously Submitted Legislation to State of New Mexico
Amendment to Section 1. Section 27-2-12 NMSA 1978 Medical Assistance Programs – “Consistent with the federal act and subject to the appropriation and availability of federal and state funds, the medical assistance division of the human services department may by regulation (proposed change – “shall by rule”) provide medical assistance, including the services of licensed doctors of oriental medicine and licensed chiropractors (proposed change – “chiropractic physician”).”

C. Medicare

The Department of Health and Human Services issued a new policy directive on 1/14/2002. Section 1861 [r] of the Social Security Act provides the definition of a physician for Medicare coverage purposes, which includes a chiropractor for treatment of manual manipulation of the spine to correct a subluxation. (As a standard Medicare Part B benefit, manual manipulation of the spine to correct a subluxation must be made available to enrollees in all Medicare + Choice plans.) The statute specifically references manual manipulation of the spine to correct a subluxation as a physician service. Thus, Medicare + Choice organizations must use physicians, which include chiropractors, to perform this service. They may not use non-physician physical therapists for manual manipulation of the spine to correct a subluxation.


· Managed Health Care -- The Chiropractic Physician acts within his or her scope of practice as defined under the relevant state licensing law
· Medicare -- Chiropractic Physicians are reimbursed for spinal manipulation only.
· Medicaid -- Chiropractors are included in New Mexico State legislation for medical assistance but are reimbursed only if funds are available. To date, no funds are available.

The Chiropractic Physician is legally and clinically included in the primary care definition and should be included in the proposed Medicaid reimbursement reform as a primary care provider.

V. Introduction to Chiropractic Care

A. Approach to Patient Care

Chiropractic medicine is the third largest branch of the healing arts and, as a health care discipline, is based on the premise that good health depends, in part, upon a normally functioning nervous system for all ages.

Chiropractic medicine focuses on the relationship between structure and function coordinated by the nervous system. When the body structure (e.g., cells and organs) is functioning normally, a state of health or normal physiology exists. However, when the body’s physiology is abnormal, the potential for a disease state exists. Therefore, abnormal physiology and function predispose the body to disease processes.

Most people understand that chiropractic care is outstanding in the treatment of back pain, neck pain and headaches. Many do not know about how chiropractic medicine can help in the treatment of many other ailments.

The chiropractic approach to patient care is not disease-oriented or pharmaceutically driven. Each patient is individually assessed for anatomical, physiological, psycho-socio-economic and functional components. The following process allows for the treatment of the whole patient and results in greater doctor/patient rapport:

· Determination of a Working Diagnosis - The Chiropractic Physician determines a working diagnosis and discusses this with the patient, along with strategies for meeting his/her health and wellness needs.
· Discussion of a Management Plan - The physician and patient discuss the diagnosis and a possible management plan that includes risks, benefits and lifestyle implications of selected strategies.
· Negotiation of Management Plan - The physician and patient negotiate a plan for immediate, intermediate and long-term active/wellness care.

B. Patient Care Management

Patient Care Management

This includes non-drug, non-surgical holistic care including, but not limited to:

· Spinal adjustment/manipulation
· Mobilization
· Physical therapeutics
· Rehabilitation
· Nutritional counseling
· Psychological counseling
· Wellness activities


Most Chiropractic Physicians use a standard procedure of examination to diagnose a patient’s condition that includes:

· Consultation
· Case history
· Physical examination
· X-ray or other modern imaging tests – when indicated
· Laboratory analysis – when indicated
· Chiropractic structural examination with special emphasis on the spine, extremities, nervous and musculoskeletal system.


Touch or laying on of the hands is an important part of chiropractic treatment and contributes to healing as it communicates sympathy and produces emotional, physiological, and mental responses in patients.

An “adjustment” means the specific manipulation of one or more spinal or other malfunctioning joints (articulations). These abnormalities within the spinal column may cause irritability within the nervous system and interfere with normal nerve supply. Once these spinal areas have been adjusted (manipulated) to restore normal movement, the resulting change may have a positive influence on the initial area of complaint or discomfort.

The adjustment is given by hand or mechanical methods. It consists of placing the patient on a precisely designed adjusting table, chair, or other equipment, and then applying pressure, using specialized chiropractic techniques, to the areas of the spine that are out of proper alignment or that do not move properly within their normal range of motion.

VI. Doctor of Chiropractic Education

A. Educational Standard

Government inquiries as well as independent investigation have affirmed that today’s chiropractic academic training is of equivalent standard to medical training in all pre-clinical subjects.

· Clinical Standard

The following standard of clinical education is from “A Natural Method of Health Care – Introduction to Chiropractic” by Louis Sportelli, D.C., 10th Edition, 2000.

- Eight-year program of undergraduate and professional college study and clinic internship prior to entering private practice.

- Areas of science studies pertinent to the health care of human beings include diagnosis, anatomy, bacteriology, pathology, physiology, biochemistry, pediatrics, geriatrics, spinal manipulation, x-ray, nutrition and physical therapeutics.

- Postgraduate and continuing education programs include diagnostic imaging, diagnosis of internal disorders, neurology, nutrition, occupational health, orthopedics, rehabilitation, physiological therapeutics, acupuncture, sport medicine and pediatrics. The American Board of Chiropractic Specialties (ABCS) certifies these specialties.

· Accreditation

- The professional accrediting agency for chiropractic colleges is the Commission on Accreditation of the Council on Chiropractic Education (CCE).

- The U.S. Department of Education and the Council recognize the Accrediting Commission of the CCE for Higher Education Accreditation (CHEA).

- The National Commission for Certifying Agencies (NCCA) has granted accreditation to the Diplomat program (DACNB) of the American Chiropractic Neurology Board (ACNB) for a period of five years through August 31, 2008. The National Commission for Certifying Agencies (NCCA) is the accreditation body of the National Organization for Competency Assurance (NOCA). Certification programs may apply and be accredited by the NCCA if they demonstrate compliance with each accreditation standard. NCCA’s Standards exceed the requirements set forth by the American Psychological Association and the U.S. Equal Employment Opportunity Commission.

- Established in 1977, NOCA is the leader in setting quality standards for credentialing organizations. The American Chiropractic Neurology Board is the first Chiropractic Credentialing Agency to receive full accreditation from NOCA/NCCA. The American Chiropractic Association had directed that its Specialty Council Certification Boards pursue NOCA/NCCA accreditation. This accreditation ensures the public and all professions that a certification board represents the highest quality and standards in a discipline.

· Credentials

The D.C. must:

- Graduate from a CCE accredited university or college or the equivalent criterion thereof.
- Pass a four-part national board exam and a physiotherapy board exam.
- Obtain a state license through examination in order to practice in New Mexico.

B. Comparison of Training of Spinal Manipulation to Other Medical Professionals

The following information is from the American Chiropractic Associations (ACA) “Policy Statement on Spinal Manipulation” (August 1999).

While chiropractors deliver 94% of all spinal adjustments, there is a wide variance in the educational levels of other professionals who attempt to perform manipulation. In an effort to determine who, by education, is best prepared to safely perform spinal manipulation, a comparison of the number of classroom hours spent in training practitioners to perform manipulation indicates:

· Medical Schools - No manipulation training is given or available for MDs.

· Osteopathic Schools – These schools generally offer spinal manipulation on an elective basis, and while other schools offer some manipulation training “scattered throughout the curriculum," when pressed for actual number of hours spent on spinal manipulation training, the responses varied between “We don’t know” and “The hours are not defined."

· Physical Therapy Schools - One study queried 10 physical therapy schools – none taught spinal manipulation. Soft tissue work and joint mobilization are taught, and manual skills are addressed. In some cases, the chiropractic form of manipulation is demonstrated. Clearly, the focus is on soft tissue work as opposed to spinal manipulation.

VII. Conclusion

It is a legitimate conclusion that by having chiropractic benefits, total health-care costs will be reduced by up to 12% by giving the consumer a choice of care. If chiropractic care is used, there will be fewer inpatient hospital stays, MRIs, low back surgeries and radiographs.

The New Mexico Legislature historically has refused to consider the cost-saving benefits that can be gained by including chiropractic medicine.

By adding the licensed New Mexico D.C. to the rolls of primary care providers within the Medicaid program, you will be adding approximately 400 currently active, licensed, qualified physicians that would help to alleviate physician shortage and improve health care access at a reduced cost to the state and tax payer.

Submitted by: Gretchen G. Peterson, D.C.
Chiropractic Physician for 15 years
Past President of the New Mexico Chiropractic Association
New Mexico Board of Chiropractic Examiners 1996-2003
New Mexico Chiropractic Association Legislative Committee Member
American Chiropractic Association Alternate Delegate for New Mexico





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