All chiropractors need to know about a recent paper published in Milbank Quarterly titled, "Chiropractic in the United States: Trends and Issues," by Richard A. Cooper and Heather J. McKee, from the Medical College of Wisconsin. Cooper, an MD engaged in health-services research, has been following "nonphysician" health professions for several years and has published several papers describing their impact on the health-care industry. In this particular paper, he tackles the future of chiropractic and finds it quite challenging. We may not like his conclusions, but we should surely pay attention. If he is right, chiropractic is facing a new set of economic, scientific and social challenges much different from those we are used to fighting.
Cooper admits that chiropractic now enjoys a legitimacy and prominence never before attained. He cites a broadening of laws and regulations regarding licensure, a wider scope of practice and reimbursement, and increasing acceptance by mainstream health plans, practitioners and payer systems. There is no doubt patient acceptance and satisfaction are extremely high, and that chiropractic enjoys strong political support. Moreover, chiropractic is seen as the "vanguard of complementary and alternative medicine." He notes, however, that chiropractic colleges continue to swell the ranks with new chiropractors at the same time managed care is restricting payments for chiropractic services. Cooper goes on to describe, in some detail, additional emerging challenges for chiropractic.
In the area of science, Cooper and McKee are not impressed with the last 25 years of randomized clinical trials of spinal manipulation. Their main point is that we do not yet have overwhelming evidence that chiropractic adjustments are the best thing even for low-back pain, neck pain or headache compared to other treatments. He is not totally wrong on this count - despite approximately 75 randomized clinical trials of spinal manipulation, there are still valid scientific arguments regarding its clinical value. I disagree with this pessimistic assessment, but I am forced to admit that controversy still exists; trial results are not consistent and huge problems remain in terms of design and execution. Cooper is correct that chiropractic has not validated its worth for viscerosomatic disorders. He points out the gaps in the evidence for managing pediatric disorder compared to what many chiropractors claim. He also is correct that chiropractors cannot continue to make blanket claims that chiropractic is always less costly than other forms of care, in the face of contrary evidence in a growing number of studies.
The authors go on to chronicle the many political and legal successes of chiropractic in the last 30 years, including Medicare; the anti-trust trial; expansions of practice rights in various states; and now the VA and DoD initiatives. These are indeed significant, but the authors also state that now, in the era of managed care and skyrocketing health-care expenses, additional limits on chiropractic care could be profound, regardless of political clout.
Perhaps the most interesting part of Cooper and McKee's essay deals with the new competitors of chiropractic. Even though the number of chiropractors is estimated to rise (according to Cooper) to 100,000 by 2015, equaling the number of primary-care medical physicians, acupuncture has experienced a sixfold increase in training capacity. Furthermore, massage therapists now number 250,000. Massage therapy is the fastest growing area of CAM, and massage therapists are beginning to take a significant share of the musculoskeletal-pain market. (See the recent paper by Wolsko in Spine). In addition, there is now growing interest in spinal manipulation and other manual methods by osteopathic physicians, physical therapists, primary care MDs and others.
While other CAM practitioners have enjoyed growth in market share in recent years, chiropractic has remained fairly stable - about 10 percent of the U.S. population per year. Cooper and McKee discuss the possibility of chiropractors becoming primary-care physicians, thus increasing market share by fulfilling needs in underserved areas. However, they also point out the significant controversy over scope and training that the position entails. Another way for chiropractors to branch out and maintain market share is to align themselves more thoroughly with the CAM field, and begin to act more like naturopaths; dispensing herbs; supplements; homeopathic remedies; and other "natural" treatments. Some chiropractors have always done this, but Cooper and McKee wonder whether this takes chiropractors too far from their "core of special knowledge." Regardless, the competition in this field also is becoming formidable.
In summary, the authors point out that chiropractic has major issues of supply, cost and competition with which to deal. Cooper and McKee discuss the options for chiropractic becoming a specialized form of physical therapy (without the advantages of medical alignment currently enjoyed by the profession of physical therapy), or a vague form of naturopathy. Concerns regarding science, philosophy, accountability and professional identity abound.
While I am generally an optimist, I read this paper with growing concern. None of these trends is new to most of us, but when described by an astute outside observer, they take on a new urgency. I do not think that things are as grim as Cooper and McKee suggest, but creative thinking and action are required to keep chiropractic on an even keel. Keeping abreast with how others see us is an important step in looking out for our future.
[Editor's note: For a related article, see "If Chiropractic Were a Business, Would You Invest in It? A View Beyond the AMA," in the May 19 issue: www.chiroweb.com/archives/21/11/20.html.]
References
William Meeker, DC, MPH, FICC
Principal Investigator,
Consortial Center for Chiropractic Research
Davenport, Iowa
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