Bill moves Indiana chiropractors closer to goal of primary care physician status

In 2015, the American Chiropractic Association announced "Six Elements of a Modern Chiropractic Practice Act," its ideal version of what chiropractors should be allowed to do under state law.

  1. "Chiropractic Physician" and "Chiropractic Medicine" as the Regulatory Terms of Licensure.
  2. Scope of Practice Determined by Doctoral and Post-Doctoral Education, Training and Experience Obtained Through Appropriately Accredited Institutions.
  3. Full Management, Referral and Prescription Authority commensurate with contemporary chiropractic education for Patient Examination, Diagnosis, Differential Diagnosis and Health Assessment.
  4. Full Management, Referral and Prescription Authority commensurate with contemporary chiropractic education for the Care and Treatment of Neuromusculoskeletal and Other Health Conditions or Issues.
  5. Full Authority for the Delivery of Information, Advice, Recommendations and Counseling Regarding General Health Matters, Wellness and Health Optimization.
  6. Full Authority and Adaptable Requirements for the Management and Training of Health Care Teams and the Participation in Collaborative or Integrative Health Care Groups.

In other words, the ACA's goal is full primary care scope of practice for all chiropractors. If Indiana Senate Bill 437 passes, they will have achieved almost all goals, short of prescription authority.

The average Indiana legislator reading SB 437 would likely be wholly unaware of the huge expansion in practice scope or its implications for patient care in reading the bill. But if you've followed the chiropractic industry for over a decade, as I have, you learn how to read between the lines. Let's see how SB 437 aligns itself with the ACA's goals.

"Chiropractic Physician" and "Chiropractic Medicine" as the Regulatory Terms of Licensure.

The bill allows chiropractors to call themselves "chiropractic physicians."

Scope of Practice Determined by Doctoral and Post-Doctoral Education, Training and Experience Obtained Through Appropriately Accredited Institutions.

The bill authorizes a huge expansion of chiropractic practice, including sophisticated diagnostic testing and diagnosis and treatment of virtually any disease or condition. (We'll return to the particulars in a moment.)The only limitation is that the chiropractor learned, in the language of the bill, "a therapy" he uses

"in a chiropractic college or chiropractic program in a university that has been accredited by the Council on Chiropractic Education [CCE] . . . or approved by rules of the [state chiropractic] board . . ."

With this provision, the state will essentially default to CCE-accredited chiropractic schools to determine what chiropractic scope of practice can include by what they teach. And make no mistake: it is the goal of the CCE that all chiropractic students be educated and trained as primary care physicians.

The inclusion of the phrase "or approved by rules of the board" jibes with the ACA's goal of including "post-doctoral" education as a metric for scope of practice. The ACA has created several "specialty councils" which award "board certification" in "specialties" like "chiropractic internist" and "chiropractic pediatrics." Educational courses for "board certification" are conducted in hotel meeting rooms and on chiropractic school campuses in weekend seminars. Whether any actual clinical training is involved is unclear. Yet, by virtue of being associated with a chiropractic school (like the "board certification" in chiropractic pediatrics), chiropractic scope of practice would automatically be extended to whatever the chiropractor was taught during this ersatz "specialty" education.

Full Management, Referral and Prescription Authority commensurate with contemporary chiropractic education for Patient Examination, Diagnosis, Differential Diagnosis and Health Assessment [and] . . . for the Care and Treatment of Neuromusculoskeletal and Other Health Conditions or Issues

SB 437 does not give chiropractors prescription authority, but they come close to getting everything else the ACA wants in the way of "full management [and] referral . . . authority." Here's how.

Indiana chiropractors can already diagnose and treat the non-existent chiropractic subluxation, and that provision stays.The bill prohibits chiropractors from treating (but not diagnosing) infectious diseases, endocrine disorders, or atypical or abnormal histology, but otherwise allows them to diagnose and treat an unlimited array of diseases and conditions. Under SB 437 they can,

"evaluate and examine individuals to determine the presence of, or absence of, and diagnosis of physical or physiologic injuries, conditions, or disorders of the body."

What is striking is how hard the bill tries to avoid coming out and saying the word "disease" while at the same time clearly meaning exactly that.

They will also be able to "treat injuries, conditions, and disorders" with "the administration or dispensing of supportive therapies" and "any other therapeutic procedure or service (emphasis added)." It's hard to get any more inclusive than "any other." (Remember, the only limitation being that they learned this "therapy" in a chiropractic school.)

Given these broad parameters, while never saying the words "dietary supplements" (which includes vitamins, minerals, herbs, enzymes, and glandulars) or "homeopathic remedies," clearly chiropractors will be able to recommend and "dispense" (translation: sell) these and other dubious remedies to their patients. This is reinforced in a provision allowing chiropractors to give "nutrition" advice. The bill also allows chiropractors to "use filiform needles for the treatment of muscle pain," or dry needling.

If you're thinking it's a stretch to interpret SB 437 as an attempt to vastly expand chiropractic practice, the bill's provisions on diagnostic testing will erase your doubts. Chiropractors will be able to

"order, perform, and interpret laboratory, radiological, electrodiagnostic, or any other diagnostic studies . . . including the ordering of advanced imaging of all parts of the human body." (Emphasis added.)

Again, with the "any other." The only limitation is that they cannot "penetrate the skin with a needle or other instrument" except for blood analysis, or "conduct invasive diagnostic tests or analysis of body fluids, except urinalysis." Nothing prevents them from ordering these tests, however.

In sum, while chiropractors might not be able to perform the full range of diagnostic testing themselves, they will be able to order, and in some cases perform, any diagnostic test an MD can order: MRIs, PET scans, mammograms, EKGs, barium enemas, colonoscopies, hearing studies, pap smears, genetic testing, thallium stress tests, coronary artery cath studies, obstetric pelvimetry, pneumoencephalograms, xenon 127 pulmonary ventilation scan. . . you name it.

And that's the legit tests. For the more quackery-minded chiropractor, there's ALCAT testing, breast thermography for cancer screening, "functional" lab testing, IgG food "sensitivity" testing, salivary testing for hormones, MTHFR genetic testing (quack version), lab tests for heavy metals and "toxins."

To mimic the language, if not the actual skill, of real primary care, SB 437 authorizes chiropractors to

"manage, coordinate, or delegate patient care functions including initiating referrals, to specialists for concurrent, additional, or alternative services or care the chiropractic [sic] believes is most suited for the individual's chiropractic condition."

I am not sure what limitation, if any, the term "chiropractic condition" puts on the chiropractor's authority to manage a patient's care. Given the extremely broad scope of practice this bill allows, I am chalking it up to poor drafting, not an intent to curb a chiropractor's authority to diagnose and treat virtually any disease or condition.

Full Authority for the Delivery of Information, Advice, Recommendations and Counseling Regarding General Health Matters, Wellness and Health Optimization.

The ACA got all it wanted on this one. The bill allows chiropractors to "counsel and instruct individuals regarding general health matters," including

"activities of daily living, diet, weight management, ergonomics, exercise, hygiene, nutrition, risk factor screening, wellness, and good health habits." 

Chiropractors, of course, have no business counseling patients on "risk factor screening" other than telling patients to see their primary care physician for advice. 

So, basically, the ACA gets most of its wishes granted in this bill, save prescription privileges. (The bill doesn't really address number 6 on their list.) Ohio just passed a bill, signed by the governor a few days ago, putting into place the last bit of authority chiropractors need to act as primary care physicians "without drugs or surgery." Indiana shouldn't make the same mistake. Senate Bill 437 should die in its first committee.

Points of Interest 01/15/2017
Points of Interest 01/14/2017