Vermont is a rural state with a population of some 650,000 and fewer than 100 chiropractors actively practicing. It is a state that is in a unique position to change its health car delivery system.
Since Governor Howard Dean, MD, succeeded Governor Richard Snelling in 1991, health care reform has been one of his primary agendas; the speed with which health care reform is moving through the state legislature is staggering. The 1991 state legislature passed Act 160 which set the stage and direction for creating the Health Care Authority administrative agency. The act required that by November 1, 1993, a Health Care Authority Board, appointed by the governor, "would submit a report to the general assembly recommending universal access plans." The plans are based on the concept of regulated multi-payers or single payers.
The Health Care Authority (Authority) over the following year and a half set out to design a universal access system, relying on recommendations of its own committee, the Health Policy Council, the Hospital Data Council, and several other smaller committees. The Authority held public hearings throughout the state. The chiropractic profession was conspicuously excluded from membership on any of these appointed committees despite multiple requests for representation. The only avenue of influence that chiropractic enjoyed was in the public arena. It was discouraging to see the Vermont Medical Society, major insurance companies, and Vermont hospitals granted ready access to the Authority and its staff while the chiropractic profession was treated as an unwanted guest at the party.
Fortunately Vermont is a small state and the public still enjoys easy access to the political system. Grassroots efforts by chiropractic patients and the profession were imperative at the early stage of public hearings. Both the Board of Chiropractic Examiners and the Vermont Chiropractic Association and its lobbyists were instrumental in providing the Authority with documentation from chiropractic studies. The British Medical Journal report, the RAND study, the National Board of Chiropractic Examiner's Job Analysis of Chiropractic, the Stano study, various workers' compensation studies, and perhaps the most influential piece, the Manga report, were presented in both private and public meetings.
It became apparent throughout these early efforts, by the overwhelming response of public support, that the Authority would not be able to disregard the chiropractic profession. However the profession was disappointed with their final recommendations. The Authority's proposals have now been submitted to the 1994 legislative session. The Speaker of the House has set up a special legislative committee for health care reform to receive bills and take testimony. This special committee will circumvent the need for health care legislation to go through the multiple committees that would have been otherwise necessary. The Vermont Senate will deal with health care bills via the regular committee process.
The present plan as submitted by the Authority recommends a health care delivery system composed of several large, competitive HMOs called integrated systems of care. Every insured will have a primary care physician who will control referrals to specialty care practitioners. Chiropractic physicians have been deemed "specialists." Full paid access will be available only if referral is made by a primary care MD gatekeeper in almost all instances. The plan has allowed for direct access to the chiropractic physician only for treatment of lower back pain for the initial visit. Following the initial visit, a plan of treatment would have to be designed with the patient's primary caregiver. This concession which they offer us is extremely disappointing for a number of reasons:
- The referral requirement does not adequately reflect or recognize the chiropractor's training, expertise, or broad scope of practice under Vermont law.
- It creates a cumbersome routine for patients, duplicating evaluations, as patients must first visit their primary care provider prior to entering the chiropractor's office. Vermont MDs routinely refer to other specialized care providers such as orthopedists, neurologists, physical therapists, etc., but not DCs. The chiropractic profession argues that general medical practitioners are poorly trained to handle neuromusculoskeletal complaints, and as Dr. Cherkin's studies have revealed, MDs are commonly frustrated with these patients. Despite the overwhelming body of evidence about the appropriateness of chiropractic care, MDs continue to reject referrals as an appropriate treatment option. We do not think that these attitudes will significantly change in the immediate future.
- Also of concern is the great bottleneck that will occur at the primary care level. Vermont suffers from a lack of primary care physicians. The patient may have to wait days before seeing a primary care provider just to request a referral to a chiropractic physician. This is an unacceptable delay to treatment. We strongly recommended utilizing the chiropractic physician as the primary gatekeeper for neuromusculoskeletal complaints, thereby helping to alleviate the bottleneck and decreasing the time it takes the patient to get to the appropriate care.
- There is also significant concern about which major insurers will remain in the market. Blue Cross/Blue Shield of Vermont and Community Health Plan presently provide medical insurance for more than 60 percent of Vermonters. Historically, they have poorly utilized the chiropractic physician, and insurance coverage has been limited at best. Blue Cross/Blue Shield of Vermont covers chiropractic services only if the insured has a separate rider which in most cases pays up to $200 per year. Community Health Plan has no allowance for chiropractic services. The Authority's common benefit plan does allow for out of service referral but at a significant out-of-pocket cost to the patient.
So, where does health care reform go from here? The 1994 legislative session, which runs from January through mid-April, will consider no less than four proposals for universal health care. The special House legislative committee on health care reform is presently taking testimony in committee. They have the recommended plan by the Health Care Authority, and the governor's proposed bill. What they will do with these bills and what will come out of this committee is yet unknown, but undoubtedly some legislative reform will be enacted in 1994.
What does this mean to the rest of the profession? It is apparent that a strong grassroots political effort must be maintained to educate legislators about the benefits and significant cost savings that will be realized by the inclusion of chiropractic. We must educate policy makers not to the philosophy of chiropractic, but convince them of the potential cost saving of shifting from medical modalities. Vermont is a state that many national leaders are watching. It is important to note that Vermont has a democratic governor who is a medical physician internist. He is attempting to lead his state into being one of the first with universal access to health care. Governor Howard Dean has been extremely active in Washington with the Clinton administration in developing its national health care plan allowing states maximum flexibility in creating state plans. A member of the governor's staff served for many months in Washington on the health care transition team. He is also co-chair of the National Governors' Association Committee on Health Care Reform.
With a democratic president who is attempting to secure universal access to health care on a national level, I believe the administration is encouraging Vermont to go forward with a plan which President Clinton's administration can use as an example during the upcoming congressional debates. I believe that Congress will decide on a national health care policy only after various approaches have been experimented with at the state level. If Vermont develops a plan which appears successful, then the characteristics of that plan may well be adopted in a national health care scheme. For these reasons, what is happening in Vermont has national implications for chiropractic.
The solutions that we propose would seem reasonable if viewed with an unbiased eye.
- The chiropractic physician should be designated and used as a primary care provider for neuromusculoskeletal disorders with direct access and without MD gatekeeper interference.
- There should be antidiscriminatory language in any health care plan permitting all providers to participate that are willing to abide by reasonable guidelines.
- The chiropractic profession must refine and use current practice parameters and guidelines such as the Mercy Guidelines to determine treatment protocols.
- Government must embrace the findings and proposed solutions of the Manga report and incorporate them to better utilize the chiropractic physician in a cost effective manner.
We the chiropractic profession must continue to educate the political decision makers and show them that without changing the present system there will be no cost savings in health care reform. The chiropractic profession can make such an enormous impact on health care reform, but we must view this not as a battle, but as an opportunity to enhance access to chiropractic physicians for every American.
Vernon Temple, DC, DABCO
Bellows Falls, Vermont
Dr. Temple is president of the Vermont Board of Chiropractic Examiners, a diplomate of the American Board of Chiropractic Orthopedists, and a fellow of the International College of Chiropractic. He maintains an active practice in Bellows Falls, Vermont and coordinates an out-patient chiropractic program at Grace Cottage Hospital in Townshend, Vermont. He is co-founder of a consulting group working with managed care, ICEs, impairment ratings, and second opinions in the New England area. Dr. Temple has served as a National Board of Chiropractic Examiners' Test Committee member, and a national board state delegate. He is currently District III director-elect for the Federation of Chiropractic Licensing Boards.
