Today, we continue our annual review of Legislative Alchemy – the deliberate incorporation of pseudoscience into health care via legislation – with a look at 2018 state bills (some carried over from their introduction in 2017) aiming to expand chiropractors’ scope of practice.
State chiropractic practice acts are the granddaddy of all Legislative Alchemy. The first were passed in the early 1900s, making the detection and correction of non-existent subluxations the legal basis for distinguishing chiropractic from medical practice and saving chiropractors from arrest on charges of the unauthorized practice of medicine. Since the 1970s, when Louisiana became the last state to legalize chiropractic practice, chiropractors’ efforts have focused on practice expansion and state-mandated insurance coverage, to the point of their lobbying for primary care physician status, just without the pesky and time-consuming education and training. (We have extensively covered the “DC as PCP” campaign on SBM; posts are collected here.) Along the way, chiropractors have managed to pick up an extraordinarily varied scope of practice, including, depending on the state, obstetrics, pelvic (including PAP smears) and breast exams, electrolysis, acupuncture, visceral manipulation, thermography, colonic irrigation, and semen analysis, among dozens of other diagnostic and treatment methods.
The DC as PCP
Sometimes attempts at rebranding DCs as PCPs take a head-on approach, with bills dramatically increasing the scope of diagnostic testing and treatments the chiropractor can employ. Others are more subtle, as we shall see.
Indiana’s House Bill 1384 and Senate Bill 160 are exemplars of the former. State law formerly defined “chiropractic” as the diagnosis and treatment of “interference with normal nerve transmission”, i.e., traditional subluxation-based chiropractic. As originally drafted, these bills would allow examination and treatment of all human ailments as long as no surgery or prescription drugs are used, and removed prohibitions on the use of ionizing radiation, conducting invasive diagnostic testing, and analysis of bodily fluids. Prohibitions on the treatment of infectious diseases, endocrine disorders, or atypical or abnormal histology were also eliminated. As originally drafted, chiropractors would be able to use any therapy to treat any “injury, condition or disorder” as long as the therapy is taught in a chiropractic college or in an approved postgraduate program. (While “post-graduate” may imply clinical training, as in medicine, that is not the case with chiropractors; these “post-grad” programs are often taught in hotel conference rooms and may not include actual patient care.)
Fortunately, subsequent amendments trimmed some of these privileges. The final bill, signed into law by the Governor, reinstated prohibitions on use of ionizing radiation, and treatment of infectious diseases, endocrine disorders, and abnormal histology, although chiropractors can apparently diagnose and treat any other injury, condition or disorder. The provision allowing anything taught in a chiropractic college or post-grad programs was removed. Nevertheless, chiropractors will be able prescribe and sell dietary supplements to patients to treat illness under the guise of “nutritional counseling”, use dry needling, and will have expanded use of diagnostic testing to “prepare a proper chiropractic diagnosis”, whatever that means. The authority to diagnose and treat phantom subluxations remains, no doubt necessary to retain the support of “straight” chiropractors.
Indiana chiropractors have thus gained several new options for rebranding. The legal authority to use diagnostic testing and prescribe dietary supplements gives chiropractors a green light to become so-called “functional medicine” practitioners. If you want to see how that works for patients, look no further than Dr. David Gorski’s Monday post on one chiropractor’s pseudoscience-filled “functional medicine” discourse. Or, chiropractors can essentially practice naturopathy, with all of its attendant quackery. Or – yet another option – they can become “chiropractic internists“. Either way, as a bonus to the bottom line, chiropractors can sell the supplements they prescribe to patients.
Similar bills “modernizing” chiropractic practice are pending in New York (Assembly Bill 8541, Senate Bill 7247), both stuck in their respective chamber’s Higher Education Committee, where they have yet to be taken up. Current law permits the detection and correction of fictional subluxations. These bills expand the use of that fiction by permitting chiropractors to diagnose “the human body” for “any human disease, pain, injury, deformity or physical condition” [emphasis added] and treat by – you guessed it – detecting and correcting subluxations. The bills would also allow chiropractors to call themselves “physicians” who could, with vaguely described additional training, engage in “wellness care” and give dietary and nutritional advice, including dispensing dietary supplements. Expanded lab testing, electrodiagnostic testing and manipulation under anesthesia are included as well.
Fortunately, a Utah bill allowing chiropractors expanded privileges, including ordering diagnostic evaluations, imaging studies, and lab tests, and prescribing durable medical equipment, failed. It would also have permitted chiropractors to prescribe and sell dietary supplements, “cellular components”, and homeopathic remedies. As I noted in my last post, on naturopathic “doctor” licensing and practice expansion, state legislation continues to include homeopathic remedies in health care practitioner scope of practice, ignoring the FDA’s declaration that all homeopathic products on the market are there in violation of federal law for failing to undergo pre-market FDA approval, subjecting them to immediate regulatory action.
Stealth DC as PCP
Other legislative attempts to rebrand DCs as PCPs are more subtle. A favorite tactic is to mandate the inclusion of chiropractors among health care practitioners authorized to perform school physicals for student athletes, thereby falsely implying to the public that they have the education and training to examine and diagnose the undifferentiated patient. Of course, it’s a handy practice-building device as well, allowing the chiropractor to impress upon the patient, and perhaps the patient’s parent, the importance of “chiropractic care” for the entire family.
Wisconsin is an excellent example of how an organized pushback against such ill-advised legislation can be effective in voting it down. Per Assembly Bill 260 and Senate Bill 232, as originally drafted, chiropractors could have performed physicals for student athletes, including college athletes. A “certificate in health and physical examinations” would be required, but the education and training for the certificate would be solely up to the state chiropractic board. Many groups opposed the bills, including the Wisconsin Medical Society, specialty medical societies, the state nurses’ and athletic trainers’ associations, hospitals, and insurance industry representatives. The Medical Society rightly pointed out that chiropractors aren’t qualified to examine students for cardiovascular problems or mental health and substance abuse issues, among others. (SBM’s own Dr. Harriet Hall, herself a retired family physician, has explained why chiropractors aren’t qualified to perform these school physicals as well.) The bills also permitted something called “chiropractic acupuncture”, which was understandably opposed by acupuncturists. In the end, the bills were stripped of these provisions, although, as finally passed and signed by the Governor, chiropractors will be allowed to employ nurses and to perform federal motor vehicle safety physicals.
Bills were also introduced in North Carolina and California allowing chiropractors to perform physicals for participation in student athletics. With the legislature set to adjourn on December 31st, the N.C. bill is stuck in the same committee to which it was assigned in 2017. The language of the California legislation (which included naturopaths as well) has been revised and now addresses a different subject (guns, but not DCs or NDs) altogether.
Bills preying on the young in a different manner were introduced in Illinois and Maryland. Both failed. In Illinois, by defining chiropractors as “physicians” for the purposes of a statute addressing student athlete concussions, chiropractors would have been allowed to evaluate students for concussions and sign off on their returning to play. They would be included on “concussion oversight teams”, tasked with developing student concussion policy. Of course, chiropractors are not properly educated and trained to treat brain injuries and “chiropractic neurology” is grounded in pseudoscience.
Maryland House Bill 623 and Senate Bill 164 were essentially chiropractic practice building disguised as a public health initiative. These bills permitted county education boards to implement a policy allowing chiropractors to perform scoliosis exams on students. Routine screening for scoliosis is controversial. The Scoliosis Research Society, American Academy of Orthopedic Surgeons, Pediatric Orthopedic Society of North America and American Academy of Pediatrics (AAP) believe that “screening examinations for spine deformity should be part of the medical home preventative services visit for females at age 10 and 12 years, and males once at age 13 or 14 years” and do not endorse routine screenings of the type described in this bill. Chiropractic treatment of scoliosis, which can result in delay of effective treatment, is not recommended by the Scoliosis Research Society and spinal manipulation for scoliosis is generally not covered by insurance. Even the General Assembly’s own staff analysis noted that the AAP recommends against this type of routine screening, perhaps contributing to the failure of both bills.
DC as PCP via DPC
Another back door to rebranding chiropractors as primary care physicians is state legislation allowing DCs to enter into direct primary care agreements with their patients. This year, Florida’s Governor signed a bill doing just that, an effort that one chiropractic lobbyist admitted was aimed at positioning chiropractors as primary care physicians.
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.
As I opined in a previous post, allowing DCs to enter into DPC agreements is a bad deal for patients. Their lack of education and training for primary care practice has been extensively documented here on SBM. Yet, as I pointed out in that post,
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.
And just look at these amazing results claimed for “upper cervical” chiropractic for any number of conditions. (This is apparently what passes for research among chiropractors.)
This overreach can now be embodied in a binding DPC agreement, obligating the patient to pay a monthly fee to a provider not qualified to perform the covered services or offering treatments that confer no benefit and possible harm. The Florida Chiropractic Association (FCA) has drafted a form DPC agreement for its members (one I’d love to see but have not been able to get my hands on). It’s already caused one kerfuffle: The Florida Chiropractic Physician Association was busted for pirating the FCA’s form, which did not sit well with the FCA, legal action being threatened.
Alabama’s Governor signed a bill allowing chiropractors to enter into what is called a “direct payment agreement” with patients, avoiding the term “primary care”. However, these agreements have their own problems, permitting chiropractors to contract with patients to provide so-called “wellness care” or “maintenance care“, that is, regular spinal “adjustments” to rid the body of putative subluxations, although (unsurprisingly) it has never been shown this routine “maintenance” improves health.
Taxpayer-funded DC as PCP
Currently, Medicare covers “manual manipulation of the spine to correct a subluxation as demonstrated to exist,” meaning that taxpayers pay millions of dollars annually for chiropractors to find and treat a condition that, in fact, does not exist. Not only that, a number of federal probes into overpayments to chiropractors have found that chiropractors regularly, and illegally, bill Medicare for what investigators later determine is “maintenance care”, which is not covered by Medicare.
To exacerbate the problem, Rep. Erik Paulsen (R-MN) has introduced H.R. 7157 in Congress. It will amend the Medicare law to cover not only phantom subluxations, but also
all physicians’ services furnished by doctors of chiropractic within the scope of their license.
Presumably as a sweetener for passage, and allegedly to help solve the huge overpayment problem, chiropractors whose billings are “aberrant” are excluded from this coverage.
So, in exchange for punishing “aberrant” chiropractors, Rep. Paulsen wants to dump every diagnostic method and treatment allowed chiropractors under state law into Medicare coverage and let taxpayers pick up the tab. Surely the U.S. Treasury would come out much better by simply continuing to pay the “aberrant” chiropractors for maintenance care.
Fortunately, H.R. 7157 has no co-sponsors, Congress is (to put it mildly) otherwise engaged, and time is running out. Even the American Chiropractic Association (ACA), which launched an all-out campaign promoting the bill, admits its chances are nil. As the ACA makes clear, however, they plan to be back in the next Congress with a new bill.
In addition to scamming patients by convincing them they are afflicted with illusory subluxations, chiropractors, sometimes in cahoots with “holistic” veterinarians, have ventured into animal chiropractic, convincing pet owners their animals are suffering as well. Reliable evidence that this benefits your pet in any way is notably lacking. This year, Colorado, which previously legalized animal chiropractic, has a new law removing the requirement that the poor creature be cleared by a veterinarian before being subjected to animal chiropractic performed by a chiropractor. The law adds a requirement that the chiropractor undergo a whopping nine hours of course work on contagious, infectious, and zoonotic diseases, plus two hours of continuing education. In better news, bills (Senate Bill 746, House Bill 1911), legalizing the practice of animal chiropractic by veterinarians and chiropractors failed in Missouri.
Legislatures will be cranking open the statehouse doors for new sessions as early as January. You can bet chiropractic lobbyists will be back, promoting bills to expand scope of practice and rebrand DCs as PCPs. We’ll be watching.