Three years ago in this publication, Greg Stanley wrote that the current flow of DCs into the marketplace was unsustainable.1 He pointed out that the current student loan default rate in chiropractic was twice as high as all other health professions combined, and he identified three threats to our profession's ability to thrive: deterioration in insurance reimbursement, contamination of the market by chiropractic extremism, and an oversupply of new chiropractors. He identified 1992 as the watershed year that would start a long and protracted war with insurers looking to cut reimbursement for chiropractic services and all kinds of doctors finding ways of "gaming" the insurance system. Mr. Stanley was right.
For over a decade now, about 7 percent of 300 million people in the U.S. have used chiropractic services annually, which allocates only 350 active patients per chiropractor during the life of the practice when distributed among nearly 60,000 chiropractors. Those 350 patients will make an estimated 5,000 patient visits per year (25 per day over 200 working days). In California, with 9,879 chiropractors serving 7 percent of 36,961,664 residents, this creates an average practice size of only 262 patients for the lifetime of the practice (though utilization might be higher and more chiropractors may not practice).
But if 6,000 patient visits each year (30 per day over 200 working days) are considered a minimum to keep the practice doors open, then at least 500 patients need to make 12 office visits each to a practice during the year. The patient population required to draw 500 patients is slightly larger: 500/.07 = 7,143. "Luckily" for active practitioners, only half of chiropractors end up practicing2 (a sordid issue left for another time). This effectively doubles the chiropractic patient base from 5,000 to 10,000, giving each chiropractor a potential 700 active patients.
The point is this: If the chiropractic profession has not already reached market saturation, it is very close. The problems for chiropractic are further exacerbated by competition in the "natural care niche" by naturopaths, Ayurvedic medicine practitioners, homeopaths, herbalists, and traditional Chinese medicine physicians. Add in another 2,500 new chiropractors each year, and you get patient giveaways, free X-rays, and insurance fraud.
Too many chiropractors means a buyer's market of lower reimbursement on top of fewer patient visits. Wellness marketing, direct-to-consumer advertising, celebrity endorsements, and another research study on back pain has not, cannot, and will not improve chiropractic utilization. U.S. chiropractic colleges and research departments have so far stayed aloof from the fray in the trenches, but they must bear much of the responsibility for this predicament and are ethically obliged to remedy a rapidly imploding profession.
Chiropractic's Self-Imposed Barriers to Growth
A long history of professional discrimination can no longer excuse today's lack of chiropractic leadership and progress. Rather than blame oppressive outside agents, chiropractic leaders must wake up and create (and actually use) a strategic plan for updating education and research to meet the challenges of 21st century health care.
Since the mid-1990s, chiropractic research has failed to impress health policy decision-makers, politicians or payers, or address the health concerns of the general public. Meanwhile, chiropractic colleges still follow the rule of maximizing enrollment, irrespective of population health needs and the negative repercussions of too many chiropractors chasing too few patients.
The diminishing relevance of chiropractic research and the "same old" chiropractic education are failing to equip chiropractors for 21st century health care in the U.S., as is obvious by the lack of opportunities for graduates. Policy failures from either institutional inertia or benign neglect continue to degrade chiropractic practices, devalue professional services, and inevitably lead to unethical behaviors to stay in business - ultimately rendering chiropractic less competitive with other health care professions.
Instead of taking a strong stance in the historic 2010 U.S. health care reform, the chiropractic profession essentially took a weak position of "please include chiropractic because patients like us" - bitter fruit to show for over 25 years and millions of dollars of investment in research.
Chiropractic colleges ignore the plight of the chiropractic field doctor at their own peril. Conversely, producing successful graduates and offering postgraduate programs to update the clinical skills would cultivate loyal and generous alumni. Dynamic, accountable, monitored, achieved, and unified chiropractic research goals convey accomplishment, invite interest (and donations!) and may improve morale among practitioners.
In short, while the health care world has changed dramatically in the past few years, chiropractic education and research have not. Without immediate and clear shifts in education and research, chiropractic is not a promising career choice as so many chiropractors fight over a tiny and fixed number of patients. To that end, the chiropractic profession needs to look ahead and work together in a coordinated fashion. Here are our recommended solutions:
Straightforward Solutions
In summary, now that health care reform is underway, new opportunities will emerge and many will disappear. It is entirely the choice of chiropractic leaders to stay with a status quo non-strategy of reacting to bad news, choose to innovate, lead and equip the profession to work alongside or inside pharmacies and in Wal-Mart types of retail clinics (one viable future), or "stay the course" and hope for the best.
We submit that the chiropractic profession has gone as far as it can under the "no particular direction" direction, and that the education and research elements of the profession must align firmly with the needs of chiropractors who invested in their education in good faith, and who should assume that their colleges and research departments are working on their behalf.
References
When I graduated from chiropractic college in 1981 and started practice, I heard it all, and very little was positive. “You are a quack; you do not know what a subluxation is; you couldn’t get into a real health care program, so you chose the one that is slightly above a mail-order degree; you have no proof that chiropractic works; Are you really licensed?”, and so much more.
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