Chiropractors are neither “internists” nor “primary care doctors.”
Last week, Florida became one of a handful of states allowing chiropractors to enter into direct primary care agreements with their patients. This bit of legislative alchemy is part and parcel of efforts to rebrand chiropractors as “primary care physicians” who are, in the words of the National University of Health Sciences (a chiropractic college), “ready to diagnose, treat and manage a wide range of patients and conditions.”
Florida’s new law defines chiropractors, as well as MDs, DOs, and nurse practitioners, as “primary care providers” and “primary care services” as:
screening, assessment, diagnosis, and treatment of a patient conducted within the competency and training of the primary care provider for the purpose of promoting health or detecting and managing disease or injury.
We’ll return to this rebranding campaign and state laws permitting direct primary care agreements between chiropractors and their patients in a moment. First, let’s look at the bigger picture: What are direct primary care (DPC) agreements and why are physicians and other health care providers pushing this sort of legislation?
What is “direct primary care”?
According to the American Academy of Family Physicians, which supports DPC:
The direct primary care (DPC) model gives family physicians a meaningful alternative to fee-for-service insurance billing, typically by charging patients a monthly, quarterly, or annual fee (i.e., a retainer) that covers all or most primary care services including clinical, laboratory, and consultative services, and care coordination and comprehensive care management. Because some services are not covered by a retainer, DPC practices often suggest that patients acquire a high-deductible wraparound policy to cover emergencies.
Direct primary care benefits patients by providing substantial savings and a greater degree of access to, and time with, physicians.
Patients pay a flat fee to their physicians, around $50 to $150 a month, for covered primary care services, which vary from practice to practice. (You can see examples of family practice DPC agreements here and here.) The physician accepts these payments in full for the services provided and does not bill a health insurer, freeing her from hassles like preapprovals and the prodigious paperwork involved in filing claims, leaving, proponents say, more time and energy for patients. However, as long as the patient’s insurance policy allows it, the patient can file a claim for reimbursement with his health insurer, as with any other out-of-network provider.
These claims of benefit are not without their critics. One concern is that, by reducing the number of patients each primary care physician sees (one goal of the DPC model), the supply of primary care physicians will be further reduced. And, at this point, it remains to be seen whether the DPC model can deliver on touted cost reduction and outcomes improvement.
As an NPR report on a failed chain of DPC clinics noted last year:
Some who analyze the use of health care are concerned that the approach encourages the “worried well” to get more care than they need. They describe unlimited primary care as a blunt instrument that doesn’t necessarily improve the odds that patients will get evidence-based services that improve their health. Others argue it’s important to find a way to provide cost-effective primary care within the health insurance context, not outside it.
Another problem with DPC agreements is that they can be construed as contracts of insurance under state law. That is where bills like the one recently passed in Florida come in: Proponents want to make sure providers won’t run into hassles with state insurance regulators. (There are also issues of compliance with the Affordable Care Act, Medicaid, and Medicare that must be worked out.)
So far, 24 states have passed some version of DPC legislation, although there is considerable variation. (Bills are pending in other states.) Some states, like Michigan and Kansas, permit “medical retainer agreements,” which:
means a contract between a health care provider and an individual patient . . . in which the health care provider agrees to provide routine health care services to the individual patient for an agreed-upon fee and period of time.
These are open to a broad range of providers, including chiropractors, but services are not specifically defined as “primary care.”
Proponents of DPC, however, prefer legislation tailored to a narrower category of practice, specifically focused on direct primary care. The DPC Coalition, an organization promoting direct primary care, has drafted model legislation that not only permits DPC agreements without running afoul of state insurance regulations, but also provides important consumer protections by requiring that covered services be spelled out, indicating the circumstances under which the physician and patient can terminate the agreement, and defining “primary care.”
The model legislation includes this provision:
Direct primary care practices may not decline to accept new direct primary care patients or discontinue care to existing patients solely because of the patient’s health status.
Interestingly, although Florida’s new DPC agreement law tracks the model legislation, this provision was excluded. One legislator’s attempt to add it by amendment during deliberations failed. Other states also fail to include the model provision, a protection that could negatively affect the DPC provider’s bottom line.
Some states, like Louisiana and Kentucky, specifically limit DPC agreements to MDs and DOs. Nebraska allows nurse practitioners as well, but limits DPC to those specializing in general practice, family medicine, internal medicine, or pediatrics.
Unfortunately, in addition to Florida, Virginia, Washington State, and Wyoming, specifically permit chiropractors to contract with patients to provide direct primary care services, although Virginia and Wyoming, unlike Florida, don’t specifically define what they mean by “primary care.” Tennessee includes chiropractors in its DPC law, it makes clear that chiropractors are not considered primary care providers.
The DC as PCP
A faction of the chiropractic profession is aggressively promoting the idea that chiropractors are competent primary care practitioners, an idea that we have exposed as nonsense many times here on SBM . Chiropractors do not have the education and training to practice primary care. In fact, in what little clinical training they do have, they may never have seen a pediatric or geriatric patient, a complicated medical case, or have had any experience diagnosing and treating conditions commonly seen in primary care practice. Their clinical education is a tiny fraction of the training a family practice physician undergoes. Chiropractors are traditionally anti-vaccination, which is the antithesis of good primary care.
That has not stopped them from establishing ersatz “specialties” like chiropractic internist and chiropractic pediatrics, designations awarded after taking courses in hotel conference rooms. Nor has it stopped them from pushing for scope of practice expansion, sometimes successfully, to include diagnosis and treatment of non-musculoskeletal conditions. Some chiropractors have become certified in so-called “Functional Medicine”, which massively misinterprets and abuses lab test results (including the misuse of genetic testing) in the service of selling dietary supplements to address putative “deficiencies.”
In a recent survey of chiropractic websites, about a third of chiropractors were claiming they treat allergies and asthma. But that’s not all. Chiropractic websites and other promotional material, including those of chiropractic professional associations, promote chiropractic diagnosis and/or treatment of ear infections, bedwetting, colic, Tourette syndrome, ADHD, breech babies, autism, diabetes, breast and cervical cancer prevention and detection, and endocrinology. A series of articles in an American Chiropractic Association publication (republished here and thoroughly demolished by Harriet Hall here) recommends that chiropractors employ diagnostic methods like fasting metabolic panels, lipid profiles, high sensitivity CRP to assess the level of endothelial inflammation and the risk of a cardiovascular event, hemoglobin A1c (HbA1c) profile, auscultation, thyroid palpation, assessment of bowel sounds, palpation of the abdomen, prostate exams, and rectal exams. This same series suggests that chiropractors can “co-manage” metabolic syndrome, diabetes, hypertension, hyperlipidemia, obesity, arthritis, osteomalacia, osteopenia, osteoporosis, malnourishment, and depression.
DPC is not for DCs
Allowing chiropractors to enter into medical retainer agreements is a bad idea; allowing them to offer direct primary care agreements is even worse.
A medical retainer agreement is the perfect vehicle to promote the thoroughly discredited notion that everyone, including infants and children, would benefit from regular “spinal checkups” and spinal “adjustments” to promote health and prevent disease, or “wellness care.” It has the added benefit to the chiropractor’s bottom line of avoiding insurance company limits on number of treatments and out-and-out refusal to cover quackery like the Webster technique, neuroemotional technique, cranial manipulation, and numerous other bogus diagnostic methods and treatments chiropractors offer and insurers reject for lack of evidence, not to mention basic biological plausibility.
But the direct primary care agreement can offer the chiropractor all this and more. In addition to signing patients up for quack treatments, the DPC agreement presents the chiropractor with the opportunity to claim that he or she is in fact capable of acting as a primary care physician. Don’t believe they would do this? Then look at these claims from the American Chiropractic Association’s Council on Diagnosis and Internal Disorders:
State medical societies and medical professional organizations appear to be oblivious to the fact that chiropractors are promoting this sort of nonsense. A call to the Florida Medical Association (FMA) pointing out the flaws of including chiropractors was met with the response that the Florida chiropractic practice act would limit their scope of practice. The FMA doesn’t seem to realize that the practice act allows a chiropractor to use any diagnostic method taught in a chiropractic college (which means the legislature has defaulted to the colleges to decide the scope of practice) and treat virtually any disease or condition with dietary supplements (“foods, food concentrates, food extracts”) and non-prescription “items” (which would include homeopathic remedies) in addition to the “adjustment” of “vertebral subluxations.”
According to the Institute for Functional Medicine, there are already several chiropractors practicing functional medicine in Florida. There are “chiropractic internists” practicing here as well. That should tell the FMA pretty much all it needs to know about the generous terms of the chiropractic scope of practice law in Florida.
Curiously, even the bill’s sponsor, who testified in person in favor of his bill, appeared unaware that chiropractors were included. In response to a question from the committee, he replied that the bill covered only “general practitioner primary care” providers and “only primary care physicians.” (The questioner was asking about other medical specialties, like OB/GYN.)
The DPC agreement bill was one of the most heavily lobbied bills in Florida’s 2018 session, with a whopping 108 lobbyists signed on to argue one side or another, clearly indicating that substantial financial interests were at stake. Appearing in favor of passage at the single House committee hearing on the bill were lobbyists from the Florida Academy of Family Physicians, the American College of Physicians, and the Florida Medical Association. Only one person spoke against it and his objection had nothing to do with chiropractors.
Not surprisingly, the Florida Chiropractic Physicians Association, an organization promoting the:
advancement of the chiropractic physician to the level of true primary care physician, with full prescriptive rights and the opportunity to specialize . . .
appeared at the hearing voicing its approval.
Naturally, the Florida Chiropractic Association (FCA) is thrilled about the new law, because:
The FCA sought to include DC’s [sic] in this statute not only to provide a new business opportunity and better access to chiropractic care, but, also to express clearly in state statutes that chiropractic physicians provide primary care services.
Its announcement of the new law added:
Your FCA is now busy developing a host of new materials to assist you in better understanding this new, exciting concept and how you can best put it to work in your practice. Marketing and promotional guidelines, sample legal agreements, and new educational opportunities are among the many items on our drawing board all aimed at helping you take full advantage of this new law. Be sure to watch for our coming updates.
You can bet we’ll be watching to see just how far chiropractors will exploit this new law in rebranding themselves as primary care physicians.
