Chiropractors' frustrations and disappointments with the lack of substantive health care reforms for the past two decades are palpable. The profession had good reason to be hopeful for public and private sector reforms favorable to chiropractic. After all, there has been a steady flow of empirical evidence of its efficacy and cost-effectiveness, as well as more evidence for its clinical practice, safety and patient satisfaction. Recently, there is proof chiropractic can be successfully integrated with other health care professions, including medical doctors in primary care settings and in hospitals.
Chiropractic care is relatively cheaper because of the savings generated by lower use of drugs, imaging, diagnostic tests and hospitalization, along with reduced lost days of work. By contrast, there still is very little hard evidence of the medical profession's effectiveness in treating a range of musculoskeletal conditions, plenty of evidence they get far too little education in diagnosing and treating such illnesses and injuries, and truly worrying levels of safety due to their heavy reliance on drugs, hospitalization and surgery. Medical management of musculoskeletal conditions, particularly back pain, is relatively costly. Furthermore, the poor and low-income populations who have the greatest need for chiropractic have the least access to such care.
Evidence-Based Health Care Reform?
This situation suggests that despite the incessant talk about "evidence-based medicine," and by extension, evidence-based health care reform, the reality is very different. Reforms that fully or even adequately reflect the evidence are rare. As likely are reforms perversely contrary to the extant evidence. A good number of professions including dental nurses, dental hygienists, nurses, optometrists, pharmacy assistants and chiropractors have all been victims of such perverse health care reforms. More often, health care reforms do not seem to be based on evidence. Most often, evidence for reform elicits no action from the public and private sector authorities who have the mandate to plan and implement health care reform.
The gap between evidence and reform simply means those who are empowered to undertake health care reform do not consistently serve the public interest unless they truly are compelled to do so. Instead, they succumb to the desires of powerful political and economic interests. Public and private authorities are cowardly and diffident to taking on the dominant professions, the pharmaceutical industry and hospitals. To put it simply, the gap is explained by politics. It is by no means unique to health care .One can readily observe such gaps in virtually every area of public policy.
David and the Goliaths
Speaking metaphorically, the chiropractic David is up against the medical Goliath and the pharmaceutical Goliath in every country. In some countries it is worse than in others, as there are other Goliaths to contend with as well. For instance, in the U.S., there is the hospital Goliath and the private insurance Goliath. An impartial and fair media is a rarity almost everywhere. The medical profession is well-connected to the centers of power (pharmaceutical firms, insurance companies, workers' compensation systems, and of course, governments) and influence (media, universities). Comparing chiropractic with medicine alone could lead one to despair about ever getting the kinds of reform advocated by health economist and policy experts. There is not one single slingshot that can topple the medical Goliath, let alone the other giants colluding and cooperating with medicine.
Does this mean chiropractors should give up the fight and that it can never win the reforms it desires? Not at all, but it does mean it will be a long and hard struggle that requires a sustained strategy involving a variety of slingshots well within the capacity of the profession.
The Slingshots
This list of slingshots is not exhaustive and is not ranked in terms of relative importance. Each is doable and will be more or less important in different jurisdictions.
- Maintain a high level of professionalism. This includes a respect for and enforcement of a professional code of ethics, a substantive belief in evidence-based clinical guidelines, maintaining and possibly raising the standards of education and training, a visible effort to do more scientific research, and a willingness to work in interdisciplinary settings and health care delivery organizations. Many health care professions including medicine are losing their once-high reputation. Chiropractic can not afford such a loss.
- Become engaged in the wider health care system and not limit oneself to issues mainly relevant to chiropractic. The profession must be seen as a player in the whole health care system. In practical terms, this means assessing and commenting on many health care reforms or developments. By all means, speak up about the many problems with the use of drugs in treating a variety of health problems; comment on the lack of safety and iatrogenic problems of medicine; the misinformation or lack of information that affect patient choice of care; the need for consumer choice in accessing caregivers or therapies; the plight of the poor, the elderly and other groups who do not have access to care, and so on. In doing all of this, make sure you always are speaking for the public interest and, more importantly, that what you say is defensible.
- Fight harder to get more private and public insurance coverage of chiropractic care in every jurisdiction. Greater coverage adds legitimacy to the chiropractic profession, improves access to care, saves the health care system substantial sums and improves health outcomes. Chiropractors are beginning to fret about an oversupply of chiropractors; solving the supply problem is not at all easy and may even be unwise. It is far better to seek ways to enhance the demand for chiropractic care.
- No profession can avoid the politics of health care. Chiropractors must do more in this respect at all levels of government. Lobbying is an inescapable part of government decision making. For a relatively small profession, this obviously is a huge and costly challenge. One way to rise to the challenge is to ask for greater participation of the rank-and-file members in the effort. Another is to continue the effort to unite the profession. Yet another is to build coalitions with other health care professions.
- Marketing chiropractic is necessary and the joint responsibility of individual practitioners and the associations representing the profession. It is important to discover what works best, as not all marketing is productive or effective.
- Consider making legal challenges to the medical profession under the extant competition acts, or in some jurisdictions, health care acts. The medical profession will not voluntarily concede any turf. Likewise, legal action might be taken against governments and workers' compensation boards by individual patients who may well ask why a duly licensed and regulated profession is kept out of a government-funded insurance system.
- Keep spreading the chiropractic message and growing the profession internationally. Greater recognition and growth of the profession adds to its capacity to do the things mentioned here, such as research.
- The medical profession is quite representative of the racial, ethnic and cultural groups that make up the larger society. Most professions are likewise representative; chiropractic is not. If it wants to make inroads to the many groups that don't even know what chiropractic is, let alone use chiropractic, then embracing diversity is well worth promoting.
- The profession needs a media strategy with a view of getting more balanced, factual and impartial coverage.
Persevere and remember the very struggle itself is a source of great satisfaction.
