Skating Away on the Thin Ice of a New Day: Chiropractic Health Care as Primary Access for the Underserved

I envy today's chiropractic students for the wealth of opportunities that lie before them, unprecedented in the history of the profession: more inclusive coverage of chiropractic services under private and public insurance plans; integration of chiropractors into the health care systems of the Department of Defense (DoD) and Department of Veterans Affairs (DVA); and inclusion in the National Health Service Corps (NHSC) student loan repayment program.

Working in cooperation with other health care practitioners, doctors of chiropractic successfully integrate a balanced understanding of high-technology medical care with a highly valued "hands-on" approach to health care, based on a chiropractic philosophy that emphasizes the inherent recuperative power of the body to heal itself, and includes the primary care elements of diagnosis, appropriate case management, and promoting total health.¹ As a principle, legitimate, and established primary care profession emphasizing a natural, holistic, noninvasive, conservative, and wellness-oriented approach to health care, chiropractic is well-positioned to assume a key leadership role in serving the growing public demand for such care.

A key opportunity for expressing the full potential of chiropractic's contribution to meeting the health care needs of the American public is in delivering care to this nation's medically underserved populations. For the past 30 years, attempts to increase health work-force capacity in medically underserved areas (e.g., through federal National Health Service Corps and statewide Area Health Education Centers) have met with less-than-optimal success. More recently, we are seeing a growing awareness and dialogue among health services researchers and policy-makers about the role of doctors of chiropractic in underserved areas.² What do we know, and what needs to be known, about chiropractic health care and the needs of underserved populations?

Chiropractors in rural and underserved areas (i.e., areas with shortages of primary care health professionals) have busier, higher-volume practices than do those in other locales, regardless of the number of other chiropractors in the same market service area.³ This suggests that chiropractic health care providers may be serving in some function to fill the gap in health care system capacity in medically underserved or rural areas, or perhaps otherwise substituting for other types of health care services in response to specific patient demand in certain markets.

Chiropractors in rural or underserved areas may be more likely to be a first point of contact for the health care system for their patients; experience more active bi-directional referral relationships with MDs; be more likely to render care for nonmusculoskeletal conditions, or be more likely to provide preventive services than DCs in non-shortage areas.³ As a main source of care for many patients in rural or underserved areas, and given the "natural" congruence of prevention and health promotion strategies with a wellness-oriented model of chiropractic practice, chiropractic is increasingly being recognized for its role and value in this nation's primary health care work force.

Patients and other purchasers of health care, such as employers and insurers, seek the best value for their health care dollars. The chiropractic health care profession increases its value to individual patients and to society by providing fundamental primary care services, such as screening or early diagnosis; allowing for prompt referral and timely intervention in cases of identified medical need, such as for uncontrolled hypertension and diabetes; and in managing or co-managing health conditions within a chiropractic or integrative scope of care. The value of chiropractic health care is enhanced when chiropractic practice includes primary care services such as prevention, health promotion and health management, e.g., smoking cessation, weight management, stress reduction, exercise, and other lifestyle interventions. Doctors of chiropractic may serve as their patients' usual source of ongoing care, and Dcs render a valuable primary care service and improve overall patient safety by monitoring their patients for adverse pharmaceutical events and coordinating their care with other health professionals. This is an especially crucial service for older chiropractic patients, as noted in preventive guidelines for polypharmacy, which recommend that all clinicians evaluate and monitor elderly patients for unnecessary and excessive drug use.⁴

In addition to improving the delivery of primary care and public health services within their practices, chiropractic health care professionals can, and should, engage in the dialogue and activities of the larger public health arena. At the local and state levels, doctors of chiropractic are increasingly volunteering and being invited to contribute to public health planning and policy development. Active participation by DCs in national organizations such as the American Public Health Association (APHA) provide highly visible and effective opportunities for interacting with public health workers, health care providers, educators, administrators, policy-makers, and research scientists.

Information on chiropractic membership in APHA can be found on the Web site of the APHA Chiropractic Health Care Section: www.apha-chc.org.

References

1. Association of Chiropractic Colleges. Issues in Chiropractic: The ACC Chiropractic Paradigm. Position paper #1, July 1996.
2. Briggance BB. Chiropractic Care in California. UCSF Center for the Health Professions, 2003. Monograph online: www.futurehealth.ucsf.edu/pdf_files/chiropractic.pdf.
3. Smith M, Carber L. Chiropractic health care in health professional shortage areas in the United States. American Journal of Public Health. 2002;92:2001-2009. Article available online: www.ajph.org/cgi/content/full/92/12/2001.
4. Put Prevention Into Practice: Clinician's Handbook of Preventive Services, 2nd edition. www.ncbi.nlm.nih.gov/books/
   bv.fcgi?rid=hstat6.chapter.4489. PPiP Section 57: Basics of Polypharmacy Counseling. www.ncbi.nlm.nih.gov/books/
   bv.fcgi?rid=hstat6.section.7668#8007.

Monica Smith, DC, PhD
Associate Professor,
Health Services & Policy Research Program,
Palmer Center for Chiropractic Research