Editor's note: The following article / interview appeared originally in the January 2013 issue of Health Insights Today, a newsletter published by Cleveland Chiropractic College – Kansas City. It is reprinted with permission from the college.
Anthony Lisi is the director of the chiropractic program for the Veterans Health Administration (VA) and section chief of the chiropractic service at the VA Connecticut Healthcare System in West Haven, Conn. He serves on the VA's Interdisciplinary Pain Management Workgroup and as manager of its Chiropractic Field Advisory Committee. Dr. Lisi is also an associate professor of clinical sciences at the University of Bridgeport College of Chiropractic. He is a member of the Integrative Medicine Committee at the Yale School of Medicine, the Clinical Care Working Group of the Academic Consortium for Complementary and Alternative Healthcare, the Military/Veterans Affairs Committee of the American Chiropractic Association and the Committee on Graduate Education of the Council on Chiropractic Education.
In this interview, Dr. Lisi explains the growing role of chiropractic care within the national health care system serving American veterans, including its history, current status and future possibilities; as well as noting the value of the VA chiropractic program to the chiropractic profession at large.
Ten years ago, there were no chiropractors employed by the Veterans Health Administration. Currently, there are DCs working in staff positions at over 40 hospitals or other facilities that provide health services for military veterans. What changed and why? The change was legislation that was enacted, first in 1999 and then follow-up legislation in 2001, that required the VA to provide chiropractic services to veterans. This legislation was put forth by a number of veterans service organizations, as well as chiropractic professional organizations, and was the result of many years of lobbying Congress to reach that point.
In short, as a result of the 2001 legislation, the VA was authorized by Congress to make chiropractic services part of the standard benefits provided to veterans and to provide these services at a minimum of one site in each of its 21 geographic regions, with the stipulation that the other sites could either be at on-station clinics or by another mechanism [whereby] non-VA providers are used to supplement the care the VA provides on-station.
How would you characterize the access of veterans across the country to chiropractic services under this arrangement? In some cases is there just one VA facility providing chiropractic for a large region? I'd say it's a work in progress. We have added a new service to a large health care system. When adding anything to a large system, there is a period of uptake that varies. Some sites are early adopters of a new technology or a new service. Others tend to take a slower approach. What we're seeing now is an evolutionary process; we still have a way to go but we have been increasing our reach each year since the program has been in existence, starting in late 2004.
You are the national director of the VA chiropractic services. In that role, are you able to facilitate greater consistency of delivery across the country and greater access for veterans who might benefit from chiropractic care? Yes, absolutely. That's one of the core functions and responsibilities of my job, in my role working for central office. We have several ongoing efforts in program assessment and development aimed at improving access for veterans across the country and minimizing variation. And I should say that is consistent with VA goals in other disciplines as well.
For the reader who may not be familiar, VA is a very large organization and even though it is coordinated nationally through central office in Washington, each region and each facility within a region has some latitude in the way central office policy is implemented. That is part and parcel of the way VA works in every area. The goal is to minimize variation when it comes to things like quality or access, yet to allow some variation as part of the expected differences in the ways that various facilities implement different programs and policies.
Please describe the role of the chiropractor within the VA. What conditions do chiropractors treat and how have they been integrated into the VA health care team? By policy in VA, chiropractors are licensed independent providers. They are physician-level providers that are often considered in the same classification as podiatrists and optometrists. We are privileged to diagnose and treat musculoskeletal conditions, consistent with current law. The national directive specifies broad policy, and then the local facilities grant privileges to individual DCs consistent with their training, licensure and competencies.
As to being part of the team, chiropractors have been integrated into facilities in different ways. In some cases, they're working in physical medicine and rehabilitation departments, and in other cases they might be in primary care or medicine departments, and others might be in pain management or spinal cord injury departments. The clinical services would be coordinated differently based on the different administrative structures.
They are part of the team in that they are able to receive and send consultations to any other provider within the system. Their documentation and communication with other providers is part of the standard electronic medical record in VA. In addition to clinical work, chiropractors have also made inroads integrating into other areas in these facilities. This might involve membership on hospital committees on quality improvement or hospital educational activities or research activities with colleagues at the hospital or at other facilities. In general, the opportunity exists for any DC in the VA to integrate in many instances where there are congruent interests and abilities at the facility.
As I understand it, specialty care in the VA is by referral from a primary care physician (PCP), who is an MD or DO. Initially, there was concern among some chiropractors that this would limit access to DCs. Has that been the case? In VA, primary care providers as well as dentists can be accessed directly by the patient. Any other provider is on referral from either the PCP or from another provider in the system.So there's vertical referral from primary care to specialty, but there's also horizontal referral between specialties.
Is chiropractic defined as a specialty? Yes. Chiropractors can receive consults from either primary care or from other specialties like neurology or orthopedics. And DCs can send consults to those other practitioners as well.
To answer the other component of your question, there has been no concern among the chiropractors in VA that the referral process is a problem. In fact, all the chiropractic clinics in VA are robustly used and their use has increased each year over time. There's been no shortage of consultations or referrals to the chiropractic clinic from providers at any of the sites in which chiropractic clinics have been implemented.
I realize that for many chiropractors in the private sector, the thought that access would be determined solely by referral is quite troublesome, but in VA we have seen that the referral policy helps improve the chiropractor's integration as part of the team. The process of sending and receiving consultations to and from other providers, and communicating on the cases, is part of building team-based care. I think if you ask any DC who has worked in the VA for any amount of time, they would not want to change that.
Would you say that the demand for chiropractic services exceeds the current supply of chiropractors within VA? When we talk about demand and capacity, I wouldn't be able to generalize across the board. The optimal capacity at any given site starts as an unknown entity. When a site started a clinic, many times the simple first step was to start with one chiropractic clinician. Over time, as that clinic develops, the activities at the site are tracked in terms of performance. Tracking the use and utilization and outcomes helps to determine whether the staffing level is currently correct or needs to be right-sized in any direction.
I can tell you that the trend is that at any of the sites that have started with one clinician, the clinic has gotten quite busy. At many of these sites, the clinic has then expanded by adding a second clinician or in some cases even a third. That's part of the natural evolution. Across the board in VA, we think that demand is still greater than the capacity we've put in place so far. We're working to correct that. There are reasons to view this more as an evolution as opposed to a revolution. There isn't really one switch that can be turned to put everything in place in a short time.
Are the chiropractors within the VA federal employees? Yes, the vast majority are employees. A small number are on contract appointments. There's also a small number of clinicians who may actually be employees of an affiliated academic institution who are granted privileges at a VA facility. This is consistent with the way the VA does business in medicine and other disciplines as well.
Dr. Daniel Redwood, the interviewer, is a professor at Cleveland Chiropractic College – Kansas City. He is the editor-in-chief of Health Insights Today (www.cleveland.edu/hit), associate editor of Topics in Integrative Healthcare, and serves on the editorial board of the Journal of the American Chiropractic Association. Visit Dr. Redwood's website and health-policy blog at www.redwoodhealthspeak.com.
Learn more about the current status of chiropractic in the VA in part 2 of Dr. Redwood's interview with Dr. Lisi, scheduled to appear in the July 1 issue of DC.
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