An unfortunate side effect (if you will) of states licensing of “CAM” practitioners is their ensuing insinuation of themselves into the nooks and crannies of the American health care system. Sometimes this is voluntary, such as their inclusion as providers of health care services in medical practices and other institutional settings in the form of integrative and quackademic medicine. Where voluntary action is not forthcoming, CAM practitioners and integrative medicine proponents are not shy about petitioning the state legislatures and Congress to wave the wand of legislative alchemy. “Poof!” and they appear. One example of this is the legislative mandates that their goods and services be covered by private insurance. Another is including CAM providers in publicly-funded health insurance, such as Medicare. And next year we will see the effects of the non-discrimination provisions of the Affordable Care Act begin to unfold.
Two bills currently before the U.S. Congress invoke the magic of legislative alchemy by expanding the availability of CAM to military veterans and funding CAM research at the expense of legitimate research. One deals with chiropractic, the other with CAM in general. As we saw last week, one of this country’s foremost supporters of integrative medicine, Wayne Jonas, M.D., recently testified before the Senate Committee on Veterans’ Affairs in favor of these bills. I think any fair review of his testimony would find it unpersuasive and I hope the Committee will agree.
Chiropractors have already forced their way into the Veterans Administration (VA) medical system. For our readers not familiar with the fragmented American health care system, in addition to having a combination of public and private health insurance, or, in some cases, no health insurance at all, we have an entirely separate system of medical care solely for the military that includes its own hospitals and out-patient clinics. Military veterans have had access for some time to chiropractors at a limited number of these VA hospitals and clinics. According to the American Chiropractic Association (ACA), the “military’s medical bureaucracy continues to try to impose new barriers to chiropractic care.” This meant the ACA had to get its supporters in Congress to pass several bills to speed up implementation of the 1995 law requiring the current limited chiropractic benefit. The subtext I read in all of this is that the Veterans’ Administration, or at least those in charge of medical care, was not particularly thrilled with having chiropractors working in their facilities and has dragged its feet in implementing the law.
Perhaps one reason for resistance is the fact that under the current law
chiropractic care and services available . . . shall include a variety of chiropractic care and services for neuro-musculoskeletal conditions, including subluxation complex.
VA health care providers, such as medical doctors, nurses and physical therapists, were undoubtedly aware that there is no such thing as the chiropractic subluxation or “subluxation complex,” the latter being one of the many terms chiropractors have adopted to make it appear they have refined their “theory” when the real purpose is to paper over the fact that these subluxations don’t exist.
As part of continued efforts by the ACA and the International Chiropractors Association (ICA) to expand benefits even further, Sen. Richard Blumenthal (D-CT) and 7 co-sponsors (including, of course, Sen. Tom Harkin) have introduced Senate Bill 422, the “Chiropractic Care Available to All Veterans Act of 2013.” A similar bill, House Bill 921, has also been introduced.
As I learned from reading Dr. Paul Offit’s fine new book about alternative medicine, Do You Believe in Magic?, Sen. Blumenthal has a soft spot in his heart for quackery. And he doesn’t mind using taxpayer money to support crank theories. As Attorney General of Connecticut, he sued the Infectious Diseases Society of America (ISDA) and the American Academy of Neurology (AAN) for antitrust violations because both groups reached the same conclusion regarding the non-existence of Chronic Lyme disease.
According to Blumenthal, both groups’ reasoning in reaching the same conclusion “at times used strikingly similar language.” He smelled a conspiracy. In his view, the guidelines “improperly ignored or minimized consideration of alternative medical opinion and evidence regarding Chronic Lyme disease.” Apparently, Blumenthal knew so little about science he didn’t realize that when the same evidence is reviewed by two different groups it is perfectly reasonable for them to come to the same conclusion. Nor did he realize that, in reviewing evidence, it is not appropriate to consider any quack theory that comes along, no matter how ludicrous. The irony is obvious: Blumenthal was willing to accept Chronic Lyme disease despite the lack of evidence that it exists. He then turned around and sued the doctors’ groups for relying on good evidence to support their conclusion that it didn’t.
In any event, SB 422 would expand chiropractic “care and services” to all veterans’ medical centers by the end of 2016. The bill would also add chiropractic to rehabilitative services for veterans, which already include
such professional, counseling, and guidance services and treatment programs as are necessary to restore, to the maximum extent possible, the physical, mental, and psychological functioning of an ill or disable person.
Of course, any physical rehab services veterans need are now being provided by physical and other therapists, so this is completely duplicative of what is already available. As the American Physical Therapy Association’s (APTA) website says:
More than 1,000 physical therapists are employed by the Veterans’ Health Administration providing rehabilitation services to our nation’s veteran population. The need for physical therapist services is expected to increase with the aging of the veteran population and due to the complex impairments associated with the returning veterans from Iraq and Afghanistan. APTA supports measures that aim to help meet this growing need for physical therapist services.
Unfortunately, according to the APTA, “chiropractors have initiated action at . . . the Veterans Health Administration” to limit what PTs can do by seeking “to prohibit PTs from using TJM [thrust joint manipulation].”
In addition, preventative health services, which now include, among other things, periodic medical and dental exams, immunizations, and mental health services, would include “periodic and preventative chiropractic examinations and services.” Now there’s a real opportunity for mischief.
We can safely assume that these “periodic” exams must be for the purpose of providing “preventative” services, as the purpose of this section of the law is to list what preventative services are available. And we can safely assume that these exams and services address “neuro-musculoskeletal conditions, including subluxation complex” as is also specified in the law. Finally, we can also assume that the condition to be prevented is asymptomatic, because if it were causing symptoms the law already allows a veteran to see a chiropractor.
Let us posit, then, a veteran with an asymptomatic neuro-musculosketal condition going to a chiropractor for a periodic checkup. Exactly what would the chiropractor be looking for in these exams, how would he find it, and what preventative services would the chiropractor provide? After all, absent symptoms, one does not regularly see an orthopedic surgeon or neurologist or physical therapist just to have him poke around for a neuro-musculoskeletal condition.
I suspect the primary purpose of this section of the proposed law is to give chiropractors the authority to “detect” and “correct” subluxations in a patient with no symptoms. In other words, what is known as “maintenance care” or (the newer term) “wellness care.” This is a nonsensical exercise which purports to get rid of non-existent subluxations before they cause problems. Perhaps this is why the ICA is so excited about the prospect of the bill’s passage. I suspect chiropractors employed in the VA hospitals and out-patient clinics might be reluctant to try this stunt for fear of having to explain it to the medical staff. But the law also authorizes referral to chiropractors in private practice.
Or perhaps I am underestimating the chiropractors’ motive here. Maybe this is yet another attempt to refashion chiropractors into primary care physicians.
Forcing more CAM on the VA
Another bill, Senate Bill 852, has been introduced by Sen. Bernie Sanders (I-VT) to “improve health care furnished by the [VA] by increasing access to complementary and alternative medicine.” Notice the unfounded assumption that health care will improve via increased access to CAM. The bill does have some uncontroversial provisions creating access to fitness centers for overweight veterans and a provision of “wellness care,” although the latter could simply serve as another vehicle for the entry of CAM into the system, as is the case with chiropractic “wellness care” discussed above. The bill supports further infiltration of CAM into health care for veterans in three ways.
First, “centers of innovation” will be established to figure out how to spread CAM further throughout the VA medical system. This includes such activities as training health care professionals on how to furnish CAM services, including how to make referrals to CAM providers. In one especially disturbing provision, funding research on implementing CAM services will be siphoned off from the Medical and Prosthetics Research Account. Even worse, if the research projects involve providing CAM to veterans in rural areas, funding requests receive priority status. Considering the large number of veterans returning from the Iraqi and Afghanistan wars needing prosthetics and the potential for research to improve these devices, this is absolutely unconscionable.
Second, in tandem with figuring out how to spread CAM throughout the VA, 15 centers in the VA medical system will be established “to promote the use and integration of complementary and alternative medicine services for mental health diagnosis and pain management.” For some unexplained reason, these services “shall be administered by clinicians who exclusively provide services consisting of complementary and alternative medicine.”
I can imagine the VA doctors will just love having roving bands of reiki masters, cranial sacral practitioners, reflexologists and assorted other CAM providers running around their facilities. And I wonder how these providers will be credentialed by the VA? What level of reiki training would one have to achieve to have privileges at a VA hospital?
Veterans will be able to get CAM services for mental health and pain, whether or not they are receiving “traditional” (which presumably means “conventional”) treatment. So, let’s say a veteran addicted to drugs chooses to rely solely on “auricular acupuncture”, which has zero plausibility and, not surprisingly, no good evidence of effectiveness. In the meantime, effective “traditional” treatments that could actually improve his health are eschewed. Now multiply this by the hundreds and you will have enriched auricular acupuncture providers at the expense of the taxpayer and have a lot of veterans still addicted to drugs.
Third, the bill requires a study of “barriers encountered by veterans in receiving complementary and alternative medicine from the [VA].” The study will also look at whether veterans are aware of the availability of CAM services, the “effectiveness of outreach to veterans on the availability of CAM”, and their satisfaction with CAM in primary care. Of course, none of this has anything to do with whether the treatments themselves are safe or effective.
And so it is that the attempt to infect the American health care system with implausible and unproven (or disproven) treatments continues apace. It is especially disturbing that these bills are aimed at forcing the Veterans Administration health care system to embrace CAM. It is heartbreaking to see all the young soldiers returning from two wars plagued by physical injuries and mental health issues. CAM (that is, real CAM, not plausible treatments such as exercise rebranded as CAM) will not help them one bit. And to think funds are being diverted from medical and prosthetics research is sickening.
On it goes
It appears CAM researchers have found a new cash cow in the form of the U.S. Military. Whether these bills pass or not, the NCCAM is poised to hand out money for “Non-Pharmacological Approaches for Managing Pain and Co-Morbid Conditions in U.S. Military Personnel, Veterans, and Their Families.” These “non-pharmacological, complementary, and integrative approaches” include (but are not limited to) acupuncture, and “multidisciplinary or integrated models of care” which could “include physicians, physical therapists, psychologists, or complementary therapists, etc.”
Research has suggested that some approaches hold promise for helping individuals manage chronic pain conditions and for the amelioration of symptoms but additional research is warranted.
Of course it is.