chiropractic standards

The Death of Chiropractic? A Look Into Chiropractic Standards of Care

The Death of Chiropractic?

A Look Into Chiropractic Standards of Care

The Mercedes 80s

Most chiropractors are familiar with this phrase. If you’re not, let me summarize. In the 80s and 90s insurance was paying hand over fist for any and all chiropractic treatment. It was not uncommon to see $20 for heat or ice packs and treatment plans with 30-60 visits. Wellness care was also being reimbursed and DCs were getting paid with little to no denials. Ahhhh life was good. Until… the insurance company knew it was getting screwed and changed the rules. Yes, they changed them to the extreme to benefit their profits but can you blame them? That’s what happens when we can’t effectively validate the need for chiropractic standards of care beyond simple pain relief.

You may be quick to vilify them for their greedy practices but the truth is that they weren’t entirely wrong to do this. Hear me out before you start calling me a heretic or insurance sympathizer. The VAST majority of the care going on at this point was entirely subject based. Care wasn’t prescribed purely for pain like most chiropractic care is now. It was also provided on a philosophically (wellness) basis as well, especially because insurance was footing the bill. I’m not saying that a regular wellness adjustment isn’t good or even that they shouldn’t be covered. I am questioning the existence of research or measurable evidence that differentiates or validates wellness care objectively. At this time we were going primarily on dogma like “Above Down Inside Out”. While these mantras still exist, they are limited in their effect because the insurance companies are wise to the game.

There is truth to these types of philosophical statements but there certainly isn’t enough detail to make it scientific and objectively measurable. Take that to a regulatory board and see how much it helps validate care to prevent a malpractice suit. Well, apparently all you old timers did and look what happened. Many of you are fine and will triumph that if you do enough spinal screenings and “educate” enough of the public that you can make a ton of mon… cough cough. I mean heal the masses. The question is what are you educating the public about? Is it dogma and philosophy or research and objective evidence? How’s that working out for the profession because I haven’t seen any significant uptick in chiropractic usage by the public?

Yes, we are helping people reduce their overall pain and helping them avoid drugs but we’re also, in part, responsible for the downward spiral of the profession. Our philosophy is certainly rooted in truth but it’s not being practiced that way. We end up using philosophical sales pitches that can convince some of the public but not the government and the insurance companies. And they need to. Why? Because the middle class can’t afford to pay out of pocket the way they used to.

The cost of insurance is skyrocketing and the coverage is plummeting.

The people are demanding that they get something out of the overpriced insurance they are being forced to buy. This is even truer in North Carolina. We have allowed ourselves to be the foothold into a managed care group that prevents us from reliving the Mercedes 80s. Again I don’t blame them. However, there are numerous attacks on chiropractic by PTs and MDs trying to whittle away our scope of practice. They can already adjust and now PTs want the ability to do so without a MDs approval. It is laughable that they have to go to an MD with literally ZERO education in spinal adjusting to be able to adjust. They should have been required to ask for our permission but alas we are not viewed as the experts in the spine. Why is that?

The fact that the foundation of our profession can be used without our permission should be an eye opener for you. If you really think chiropractic isn’t at risk, you’re wrong. Look at the changes in the last few decades. Despite the internet allowing practically any information to be available on hand 24/7/365, chiropractic is not seeing any significant change in usage. We’ve seen massive influence and positive change in other natural treatments but not chiropractic. Before I answer why that is let’s look at an example of another natural form of treatment that has seen positive changes in public opinion.

Regardless of your opinions on marijuana, it is undeniable that the public opinion has seen a MASSIVE shift in current years. Recently a story by CBS News came out showing that legalizing marijuana is at an all-time high. This plant is now legal in more states than it is illegal in and the trend is only going to continue. Why? NORML (National Organization for the Reform of Marijuana Laws) has done an outstanding job of educating the public and lobbying for reasonable legislation. How were they able to do this? Constant public education using objective research while dispelling erroneous and misleading medical “research”. Chiropractic can certainly relate to these kinds of problems. #WilkVsAMA

For decades most of the people using cannabis believed it was safe and had beneficial effects. Most of them were cast off as stupid hippies or fewer minorities and ignored. Then the drug war put hundreds of thousands in jail. Fast forwarding to the age of information and now all that anecdotal information Cheech and Chong were talking about was validated and proven with research. We see benefits for seizures, inflammation, digestive disorders, Tourette’s, pain, appetite, depression, PTSD, CANCER and much more. How do we know? Objective measurable research.  It was undeniable that cannabis made people feel better but now the evidence is not only available to the public but also being used to lobby our politicians. This has resulted in a practical 180 in public opinion, usage, and change in regulation.

Compare this to a 2013 exploratory survey on chiropractic where 527 surveys from the public were completed. These surveys gave some insight into the public’s knowledge and opinion of chiropractic. Here are some of the most notable results.

Statement

Disagree

Neutral

Agree

A Doctor of Chiropractic (D.C) degree program (education and training) is on a par with a Medical Doctor or Doctor of Osteopathy degree program
90%
4%
6%
A Doctor of Chiropractic degree program (education and training) is on a par with a massage therapist, acupuncturists and personal trainer degree programs
10%
3%
87%
I would be interested to hear more about how Chiropractic care can help me if I was approached by a D.C. in a shopping mall.
88%
12%
0%
D.C.’s take x-rays to assist them in diagnosing conditions
41%
7%
52%
D.C.’s are wealthy and earn in excess of $150,000 annually
20%
20%
60%
Chiropractic care and Physical Therapeutics are basically the same thing
14%
2%
84%

 

In order for Chiropractic to survive, we must first unify to validate and differentiate our profession. It’s clear that we have dropped the ball on educating the public. More to the point we need to do a better job educating ourselves. The foundation of our practice, the subluxation, is still an arguable topic. That’s pathetic. If we can’t agree on what a subluxation is, how to measure it objectively how to fix it then how can we expect the public to respect our profession beyond the hippies in the 70s smoking weed? So, what do we do? I’m glad you asked.

 

STEP ONE: Universal OBJECTIVE Normal

First, we have to research and show what a normal spine looks like. If you can’t measure it, you can’t prove it exists. Then we utilize this objective model to compare our patients to. Would you trust an MD if he diagnosed you with diabetes or cancer based on philosophy and not objective tests? If there were hundreds of different ways to determine diabetes and each has their own treatment protocol would the public trust medical doctors?

Many of you may not like this idea and I have a suspicion why. Let’s be honest, it easy to play the insurance game. You can see more people and make more money when you do what you’re told and focus ONLY on pain. Some of us don’t even prescribe a unique treatment plan and just tell the patient to come in “when they need to”. Who’s the doctor in that interaction? If our profession can’t grow beyond this we will eventually die. I’m not saying that we only utilize one technique. We do need to admit that most chiropractic techniques are only pain and subjective based and not capable of measuring normal or making objective changes to a spine in a consistent manner.

STEP TWO: Determine Most Effective Treatment

Once we can objectify a normal spine we can then use research to determine what techniques and methods of treatment are most effective.  This step is a much longer and ever growing process. Without a measurable normal, the only way for a patient to know if they are “healthier” is how they feel. PERIOD. Sprinkle all the philosophy you want on it but at that point, a chiropractor is on the same level as a physical therapist, massage therapist, yoga teacher or Crossfit instructor in the eyes of the public. Why shouldn’t they be able to adjust? Seriously why? It’s not like an adjustment carries a lot of risks. We may have more education in adjusting but MDs have NONE and they are still the gatekeepers for PTs to be allowed to adjust… at least for now.

Until we start using objective research to validate our treatment as more effective and necessary we will never be utilized or reimbursed for treatment beyond subjective complaints. We are slowing losing our place at the table with insurance under the current treatment model. We also run the risk of losing the adjustment to PTs or others professions. The more they can devalue our care the less they have to pay for it.

This is why we have been relegated to a managed care system that penalizes or kicks us out of network if we attempt to treat past their guidelines in an attempt to follow our own. They know we don’t agree on what a subluxation is and how to treat it. Because of this, we have no strength to stand up to them and fight for our patients’ rights to have access to the corrective structurally focused care patients need. Remember kids, Daddy Insurance doesn’t like it if you play for more than six visits or you’ll be punished.

STEP THREE: Use Objective Measurements To Validate Care

I know I’m coming dangerously close to starting a technique war but so be it. I agree that essentially all of the chiropractic techniques have value. The problem is that the value of most techniques isn’t proven beyond symptomatic changes. Why are these symptomatic changes better than other treatments from P.T.s or message therapists? How is it that we can then say we are better than other treatments that can improve the same symptoms we can? What are we really doing that these other treatments can’t?

If you are already following these steps then that’s an easy question. Structurally focused chiropractic care compares your spine to a research validated a normal model, treats accordingly and measures on reevaluation to show the objective changes via x-ray. Why? Because research shows that the effects are longer lasting and more effective and that an abnormal spinal structure has consequences.  It also validates care for problems beyond just pain. If we stay in the traditional model we will never break past the 80/10/10, “just hit ‘em with a shovel” mentality.

This generalized adjusting does help improve symptoms for people. It does not differentiate us from other symptoms based professions like physical therapy. Chiropractors need to be better than that.  We won’t be if we are ONLY willing to treat within the inadequate guidelines insurance and managed care require of us. We don’t have to abandon insurance but we do need to show an objective need for structurally focused chiropractic care. If we continue on the current path, we will never reach beyond the very limited influence we currently have.

If you want to be treated like an adult, or even, a “real doctor” then act like it. Stop minimizing the potential of chiropractic care and allowing our profession to be pinned to only short term subjective changes. We have to start asking more of our doctors and our schools. We have to hold a standard for our care that extends beyond the insurance guidelines. Oh, wait. We do. Many of you may not know but we have our own guidelines that validate chiropractic care that extend beyond the insurance and pain based guidelines.

The problem is that sucking off the insurance tit is easy.

I understand that it’s not easy to learn new things. I’m not asking you to. We need to show our DCs and the public that there is more to chiropractic than insurance care. I’m asking that we show the world that we’re more than on par with a massage therapist. We need to stop expecting ONLY the least (insurance care) from our DCs and start expecting more options (evidence based care) from them. If you want to offer one or both that’s fine but when we ignore the need for structurally based care because we don’t want to fight insurance companies or we don’t want to learn new things then our profession dies.

Like it or not that is a real possibility. New chiropractors are coming out of school with a quarter of a million in debt or more and the potential to make about $60,000 a year on average after five years of experience. The sad reality is that this number used to be higher despite skyrocketing college debt. I honestly think that it’s worse than that given the huge number of fellow DCs that I see surrendering their passion for chiropractic to be real estate agents or jumping to some other profession they didn’t pay hundreds of thousands for just so they can pay the bills. We are still recovering from the worst economic downturn since the great depression. Couple that with more stringent regulations and it is a VERY different climate compared to the Mercedes 80s wave some of you are still riding.

This is likely why we see such an embarrassing hodgepodge of unrelated services being offered by chiropractors. Whether it’s hair removal, detox foot baths or a $30,000 laser, there is always some fringe hardware that resembles a Dianetics E-meter in most chiropractic offices. Look, I’m not saying that all of this stuff is of no use. I am saying that most of it only further supports the view that chiropractors live in the subjective. We are not viewed as experts of the spine but philosophical massage therapist. This will NEVER change if the majority of our chiropractors are educating patients solely based on philosophy or insurance guidelines and not chiropractic guidelines.

Regardless of what other treatments you offer in your office, chiropractors need to be unified on four chiropractic standards of care.

  • First, is that there is an objective normal spinal model that can be measured via x-ray.
  • Second, structurally focused chiropractic can make reproducible corrections to an abnormal spine.
  • Third, there is research that validates these measurable changes as essential and necessary to better overall health.
  • Fourth, chiropractors are the only healthcare professionals capable producing these changes.

 

Up to this point, our main tool for preventing others from stealing the adjustment and eroding our profession is to discredit them. This is a mistake. If you haven’t figured out the answer let me state it again. We must validate chiropractic with undeniable objectivity and show ourselves we are the experts of spinal care. Let’s not focus on why they’re not as good but why we are the best. This cannot be done by educating with only philosophy. This cannot be done by offering care SOLELY based on insurance guidelines. We have equal to or more education than MDs and PTs…? So what? We have more classroom hours in x-rays and diagnosis and anatomy but no one cares regardless of how loud you scream it.

We need to show OBJECTIVELY what we can do with a spine and why it is not just different but better. This is where we come back to structurally focused chiropractic. Until this becomes the archetype for chiropractic care, we will look more and more like PT and massage, giving insurance and the public less and less reason to utilize chiropractic.

Thankfully there are some in our profession that has gotten the ball rolling.

It’s up to us to actually read and follow these chiropractic standards of care and then tell our patients about them. In an ironic attempt to be more accepted by insurance our professional guidelines have been melded with insurance guidelines. I’d venture to guess that most of you have NEVER read through the ICA Best Practices and Practice Guidelines or the Practicing Chiropractors’ Committee on Radiology Protocols (PCCRP). BUT every one of North Carolina in-network DCs probably knows how to treat in order to appease HNS guidelines. Don’t forget that the guidelines for our profession are there for the patients’ best interest. Those insurance guidelines are put in place for the insurance companies’ bottom line.

Put the burden on them. Tell the insurance companies and feel free to offer chiropractic care following “insurance guidelines” but understand that we are ethically obligated to educate our patients about the need for structurally focused care that is backed by objective research. When you show patients what a measured normal is, where they are at and that what is needed to change the structure of their spine exceeds insurance guidelines, you demonstrate the potential for chiropractic. This is the first step in putting the fault of substandard care on the insurance companies, not our profession. If you continue to ignore the research which clearly shows there is a difference between insurance care and corrective care, then YOU are part of the problem. Like it or not you will be contributing to the slow chiropractic suicide that is currently underway.

It will come as no surprise to me that many of you either don’t know or don’t even think there is a normal spine model. There is plenty of research on this. Feel free to check PubMed or look to our professions most researched technique Chiropractic Biophysics to find out more. If you don’t like or disagree with the facts then it’s up to you to provide or publish research that proves otherwise. Until then, realize that you may be part of the problem, not the solution.

 

 

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