“Here’s an idea that will probably cause some of my physician colleagues to get their knickers in a twist: it may not be a bad idea to find a good chiropractor to act as your primary care physician.” So says long-time integrative MD, David Edelberg, in a newsletter for WholeHealth Chicago, his multi-disciplinary integrative medicine practice.
If one’s knickers are twisted by Dr. Edelberg’s assertion, they’ll look like macraméafter one reads the recently published study of primary care chiropractors serving an HMO population in Dr. Edelberg’s Illinois backyard.
Since 1999, the Chicago-based Alternative Medicine Integration Group (AMI) has offered members of HMO Illinois, a Blue Cross company, the option of picking DCs as primary care physicians (PCPs). HMO Illinois members can choose DCs and others credentialed to offer natural, non-pharmaceutical medicine. From the start, AMI’s network included DCs. More recently, AMI added integrative MDs and DOs.
The AMI study, published in the May 25 edition of the Journal of Manipulative and Physiological Therapeutics, challenges conventional thinking. Compared to Blue Cross norms, plan members who chose natural health care had 60% fewer hospital admissions, 59% fewer hospital days, 62% fewer outpatient procedures, and 85% lower drug costs. Reduced drug and hospital use had no adverse impact on clinical outcomes.
Did the non-pharmaceutical PCP model truly reduce the need for expensive services or is the AMI population healthier to begin with? James Zechman and Richard Sarnat, MD, AMI co-founders, say the AMI population has every bit as much morbidity; they will examine these questions further in a future project.
Then there’s the deeper question: What do we mean by a PCP chiropractor? Search for clarity on this, and you’ll end up in the thick of a divisive contention within the chiropractic profession itself. Call it intra-disciplinary subluxation.
Both the American Chiropractic Association (ACA) and the International Chiropractors Association (ICA) assert that DCs are PCPs. Yet the ICA typically opposes practitioners adding additional modalities to their practices. Only the ACA uses “physician” language, as do over half of all state chiropractic licensing statutes.
The ACA characterizes a DC PCP as being: “a) a primary care/direct access practitioner; b) health information resource; c) health and wellness advocate; d) disease and injury prevention manager; and e) spinal care specialist.” As part of a push to get DCs included in the National Health Services, the ACA memo’d the Department of Health and Human Services citing data from the AMI project.
James Winterstein, DC, President of National University of Health Sciences, was part of AMI’s original advisory board. Most DCs in the AMI network were graduates of NUHS’s “broad scope” chiropractic programs. The school has a long history of educating DCs in modalities beyond manual therapies, with nutrition topping the list. Dr. Winterstein estimates that half of the 16 chiropractic colleges are similarly broad in their training.
That said, organizations pushing a broad, physician-level role for DCs have gathered little support among the nation’s roughly 70,000 DCs. Dr. Winterstein and Reiner Kremer, DC, DABCI, co-founded the American Academy of Chiropractic Physicians (AACP) in 1999, “to promote the concept of the chiropractic physician.” Yet the group never drew more than 75–150 people, and is presently “in a state of hibernation.”
An entity with a similar mission is the American Board of Chiropractic Internists (ABCI), a specialty society of the ACA. Cindy Howard, DC, DABCI, president of the Board’s parent organization, the Council on Diagnosis and Internal Disorders, explains that ABCI offers a 300-hour training over 26 weekends during a 3-year period. It covers pharmacognosy, biology of natural medicines, and conventional diagnostics.
“The program focuses on what we can do for these conditions, in a most conservative way,” according to ABCI past-president, Brian Wilson, DC, DABCI. The training culminates in a three-part exam, two written and one on clinical practice. Those who pass become diplomates of ABCI, and use the “DABCI” designation. Those taking the course do much of the program at home, though clinical and diagnostic components require in-person, hands-on training. Three classes are currently running, with “30–50 students in each class.”
Asked how she justifies a 300-hour course as compared to the three-year, full-time, residential training required of a board-certified MD-internist, Dr. Howard notes that because DCs, “have no access to hospital settings,” requirements are fewer. The ABCI program does not cover inpatient procedures. While a portion of the course covers commonly used drugs, DABCIs do not need the extensive pharmacy training MDs get.
Dr. Wilson explains the differential this way: “We are training people for a more conservative approach. We have different purposes and different outcomes (than MDs). But we can certainly talk the same language.”
Isn’t a DC-PCP similar to a licensed naturopathic physician? Yes, said Dr. Howard. But, naturopaths, “are only licensed in 14 states. People want this kind of care everywhere.”
Public demand hasn’t yet prompted too many DCs to take the ABCI course or otherwise retrain. Like the now inactive AACP, ABCI has not gained much ground inside the chiropractic profession. Dr. Howard estimates there are just 250 active DABCIs today.
ACA does not support ABCI financially. A continuing education partnership between the two failed to launch. ABCI’s website is outdated. Funding for new initiatives is limited. All in all, DABCIs probably aren’t causing much sleep loss at the American College of Physicians or the American Academy of Family Physicians. But why not?
Why, with half the DC schools teaching broad scope, are neither the AACP nor the ABCI drawing much interest? Winterstein and Kremer both pointed to the influence of insurance coverage. Chiropractic coverage is typically limited to musculoskeletal conditions. “People will do what they get paid for,” Dr. Kremer said. For many DCs, scope of practice is constrained by scope of reimbursement. Sound familiar?
Dr. Winterstein views this as an erosion of chiropractic’s former role. In many towns, especially in the Midwest, DCs were once general practitioners. Dr. Kremer agrees: “The consumer doesn’t think of the chiropractor as beyond back care anymore.”
Yet, the AMI data strongly suggest DCs can provide good quality, less invasive primary care, and significantly reduce cost. That HMOs and insurers are not rushing to explore this model is intriguing. Is it that the data were not in a more conventional journal? Is it that anything which so challenges conventional care is still suppressed? Would interest be stronger if this were a network of MDs? Or is it that because insurers work in a cost-plus environment—the higher the tab, the higher their profit—they have little real incentive to reduce costs?
While the directions of these questions can be dismaying, Dr. Winterstein directs his consternation not at insurers, but at his profession’s failure to promote broad-scope: “Chiropractic is shooting itself in the foot at a time when more people want a kind of care that is safer and more natural and more cost-effective.”
For more information about the ABCI chiropractic internist training, and the issue of DCs as primary care physicians, visit:
- For DABCI: http://www.rollanet.org/~internis/ dabci/
- For American Academy of Chiropractic Physicians: www.aacp.net/
- For National University of Health Sciences: http://www.nuhs.edu/
- The ACA view of the chiropractor as primary care providers: http://www.acatoday.com/content_css.cfm?CID=235
John Weeks, a veteran of integrative medicine publishing for 23 years, is the publisher-editor of the Integrator Blog News & Reports (www.theintegratorblog.com), a journal focusing on the practical challenges and opportunities in advancing integrated health care. The journal is meant to help integrated care’s diverse leadership see the trends, data, perspectives, and policy actions that may assist them in achieving their shared mission. Johnweeks@theintegratorblog.com
