In what may be one of the first analyses of its type in the indexed literature, Richard Cooper and Sandi Stoflet of the Health Policy Institute at the Medical College of Wisconsin have examined trends in the per capita supply of "alternative medicine clinicians" in the United States. The results and the implications are interesting and important. The paper, "Trends in the Education and Practice of Alternative Medicine Clinicians," was recently printed in Volume 15, Number 3 of the journal Health Affairs, a publication that focuses on health policy.
The authors focused on the professions of chiropractic, oriental medicine, and naturopathy. They estimate that while the supply of medical physicians will grow by only 16 percent by the year 2010, the supply of "alternative clinicians" will increase 88 percent.
They note the explosive per capita growth of chiropractic doctors from six per 10,000 population in 1970 to 19.2 per 100,000 in 1994. This figure is close to 10 percent of the current per capita supply of medical physicians (212 MDs per 100,000 population). They also describe the curiously wide disparity of state by state distributions. For example, West Virginia has 7.3 chiropractors per 100,000 while Colorado has 45.6.
Based on current and projected enrollments in chiropractic institutions and other factors, the trend predicts there will be 33.2 chiropractors per 100,000 population by the year 2010. In fact, the actual number of chiropractors will double. Although growth in medical physicians will be much slower, there will still be a per capita increase to 247 per 100,000.
So what are we to make of these projections? First, there is no doubt that this paper will cause discussion both inside and outside the chiropractic profession. And well it should. Health policymakers and economists are still concerned with the perceived oversupply of medical physicians, because national expenditures tend to rise as a function of per capita supply. In the current cost cutting environment, there is great pressure to stabilize growth in the number of medical doctors, or at least to cause a decline in the number of medical specialists. Now that alternative/complementary professions are becoming increasingly popular and integrated into payment plans, policymakers will begin to wonder and analyze how the supply of these kinds of clinicians will affect the health care marketplace as well. This is precisely the point made by the authors of this paper. Obviously, when policymakers seriously start to deliberate about the "optimum" number of alternative/complementary clinicians needed by the nation, it will affect chiropractic.
Within chiropractic, the notion that the supply of chiropractors requires serious debate is a fairly recent development. Historically, growth was the explicit and obviously correct goal to establish the profession and make chiropractic services available to the patients that needed and desired them. In the changing health care marketplace, with the evolution in reimbursement patterns, and the growth of managed care, etc., the chiropractic profession, itself will have to come to grips with its own reality.
One of the curious paradoxes that must be understood is that the overall success of the chiropractic profession as a whole may not necessarily mean optimum success for every individual chiropractor. On one hand, the profession is increasingly successful; a higher proportion of patients seek chiropractic care every year. For back pain alone, chiropractors treat one-third of all patients. The scientific success of spinal manipulation is genuinely if begrudgingly accepted. And while major inequalities certainly still exist in reimbursement systems, it is nothing like a quarter century ago.
On the other hand, there are many anecdotal reports that chiropractic practices are suffering. Revenue is down, and the overhead expense and workload of running a chiropractic business is becoming increasingly complex and time-consuming. It is small comfort that medical physicians are making the same complaints. Chiropractors that perceive themselves as having a tough time wonder whether the profession is truly successful if they can't make the living they want.
Whether or not the national supply of chiropractors is a major factor in individual financial success, or whether there are other factors that play a larger role is, at this point, simply a debate without much data. And, as is often true in chiropractic, the discussion will be horribly complicated by different opinions about the scope of diagnosis and treatment to which chiropractors should aspire. For example, individuals that believe chiropractic should grow until every person in the population is under maintenance chiropractic care will have a different take on this issue than those who believe only patients with acute low back pain should receive chiropractic. Those who see the future of chiropractic as integrating with the rest of the so-called health care industry will have a different perspective than those who think integration is a sell-out of principles. The chiropractic educational community may take a global long-term perspective, while the trade associations may be forced to deal with short-term exigencies to maintain membership and political clout. In short, it is not a simple discussion.
The authors of the paper described above have raised a potentially emotional and divisive issue. This author hopes the debate can be kept at a reasonable level. To do that, chiropractic leaders must recognize that there is now a much needed role for health services researchers, economists, and health policy makers to design studies so that good decisions can be made for the future based on data, not dogma.
William Meeker, DC, MPH
Davenport, Iowa
