DCM

Doctor of Chiropractic Medicine The Future

By WNY Chiropractors

CHIROPRACTIC HISTORY

HOW DID WE GET INTO THE PREDICAMENT THAT WE HAVE

TODAY?

DD Palmer and the First Patient

Mr. Harvey Lillard, c. 1906

http://www.brianesty.com/bodywork/PDF/Chiropractic%20History.pdf

The Early Years of Chiropractic

• It was not long after DD Palmer founded chiropractic that he was then jailed.

• Why was he arrested? – For practicing Medicine without a license.

• Subsequently this was happening to chiropractors throughout the country.

Chiropractors Jailed For Practicing Medicine without a License

Patients protest outside the Ohio jail where their doctor, Herbert R. Reaver, D.C., was imprisoned.

Dr. Herb Reaver, Sr., was arrested repeatedly in Ohio for “practicing medicine without a license.”

http://www.brianesty.com/bodywork/PDF/Chiropractic%20History.pdf

BJ Palmer and Attorney Tom Morris Plan to save chiropractic

Senator Tom Morris Dr. BJ Palmer BJ, with the help of Attorney Morris, assists in court cases throughout the USA against chiropractors being accused of practicing medicine without a license. Chiropractic state licensing as supported by BJ was formulated in such a way as to generally not use the terms, “Diagnosis” and “Treatment of Disease”, often associated with the practice of medicine.

SPLIT IN THE ROAD BJ Palmer DC and Attorney Tom Morris Other Colleges States: Not licensed under the medical practice act. Scope of practice in most states does not include Diagnosis and Treatment of Disease

John Howard DC and Medical Doctors National College of Chiropractic - Chicago Illinois: Chiropractic licensed under the medical practice act. Illinois: Recognized full scope diagnosis but did not permit drug privilege.

http://moneymorning.com/

Dr. B.J. Palmer, c. 1920 Dr. John F.A. Howard

Expediency Without Foresight

https://razorleaf.com/2010/09/rule-efficiency-design-automation/

DIAGNOSIS & TREATMENT OF DISEASE

ANALYSIS & TREATMENT OF DIS-EASE

Similar benefit: but being under the Medical Practice Act Chiropractors in Illinois recognized as Physicians but without the right to prescribe medication.

Immediate benefit: Chiropractors no longer jailed but not recognized as physicians and have no prescriptive privilege.

Chester Wilk DC et al.

• In October 1974 Chester Wilk et al. filed suit against the AMA to essentially permit chiropractors access to diagnostic and other services where chiropractors had previously been denied such access. In 1987 Federal Judge Susan Getzendanner ruled in favor of the suit.

• Dr. Wilks suggests placing chiropractors in hospitals as gatekeepers. (*)

https://www.youtube.com/watch?v=wEUN46_gicc (*)

Manga Report

• Recommendation: Hospital privileges should be extended to all chiropractors for the purposes of treatment of their own patients who have been hospitalized for other reasons, and for access to diagnostic facilities relevant to their scope of practice and patients' needs. (1)

http://cdn2.perfectpatients.com/childsites/uploads/1744/files/2011-Chiropractic-Scientific-Literature-Review-ACA.pdf (1)

J Manipulative Physiol Ther. 2004 Jun;27(5):336-47. Clinical and cost outcomes of an integrative medicine IPA.

Sarnat RL1, Winterstein J.

Chiropractors acting as PCP’s demonstrate that they can act in such a capacity and make

referrals when necessary.

J Manipulative Physiol Ther. 2007 May;30(4):263-9. Clinical utilization and cost outcomes from an integrative medicine independent

physician association: an additional 3-year update. Sarnat RL1, Winterstein J, Cambron JA.

The initial report (2004) analyzed clinical and cost utilization data from the years 1999 to 2002 for an

integrative medicine independent physician association (IPA) whose primary care physicians (PCPs) were

exclusively doctors of chiropractic.

2007 report demonstrated chiropractors to be cost-effective primary care providers.

Importance of Full Diagnostic Scope

What allows chiropractors currently to practice as direct, first contact, primary care providers is

the unrestricted ability to diagnose.

We do not treat every condition but we must be able to diagnose any condition so as to make the

appropriate referral.

CHIROPRACTIC SCIENTIFIC REVIEW© Indiana State Chiropractic Association 2011

LEGISLATURE : Patient Protection and Affordable Care Act (PPACA)

• “If the government is serious about cost-effective care, chiropractic care must be a vital component of any health care reform act, allowing the population direct access to chiropractic services as a guaranteed, covered benefit.” (*)

http://cdn2.perfectpatients.com/childsites/uploads/1744/files/2011-Chiropractic-Scientific-Literature-Review-ACA.pdf (* page 215)

CCE Guidelines January 2013: “An accredited DCP prepares its graduates to practice as primary care chiropractic physicians…”

http://daddu.net/20-amazing-photos-of-roads-to-nowhere-get-inspired/

Society views a primary care practitioner as one that can prescribe medication.

THE DISCONNECT Without prescriptive medication privilege The chiropractor cannot be viewed by society as the primary care provider that CCE demands chiropractors be educated to be.

Doctor of Chiropractic Medicine

• Would be a new license for NYS • Would allow Chiropractors to perform primary

care with full drug privilege: – Such would require one additional year of

training.

INTRODUCTION:

DOCTOR OF CHIROPRACTIC MEDICINE PROGRAM • Is there a need to increase the number of

those that act as PCP’s both in NYS as well as Nationally? Yes. (See accompanying sheet)

• HANYS’ 2012 Physician Workforce Survey – calls for expansion of primary care for NYS.

• “Based on the Affordable Care Act’s effect on the uninsured/underinsured an additional 122,000 PCP’s would be needed.”*

*(The Council on Graduate Medical Education (COGME) 2010 report on Advancing Primary Care)

INTRODUCTION:

DOCTOR OF CHIROPRACTIC MEDICINE PROGRAM

• Additionally it is estimated that 214,524 American physicians will not be participating in any ACA exchange products.*

* A 2014 survey by the Medical Group Management Association, a trade group comprised of multi-physician medical practices

• Essentially 32% of these are primary providers.

• Estimating then there could actually be an effective deficit of 150,000-200,000 primary care practitioners in USA.

WNY Chiropractors - What have we done? • Presented to the Christian Medical Dental Association regarding the benefits and

challenges of the Affordable Care Act (March 19, 2009). • Wrote in Dynamic Chiropractic, February 12, 2009, to warn chiropractors of the

impending problem regarding “essential care” as well as encourage the profession to become Primary Health Care Providers. http://dcpracticeinsights.com/mpacms/dc/article.php?id=53635

• Published on primary care issues (references on request) • Work as UB Clinical Faculty, to educate UB medical students (2008 – present), and

FMD Residents. Work to create professional comradery. Lecture to students and FMD residents on primary care issues.

• Directed letters to the Dean of Medicine and Biomedical Science, University of Buffalo supporting chiropractors in primary care.

• Drs. Joseph Kowalski, MD; Joseph Serghany, MD; Joanna Garvey, DC; and Geoffrey Gerow, DC met with the Dean on 02/12/2015 on a program for chiropractors to be elevated to primary care status.

• The Dean was unable to accommodate the program at that time due to logistics.

• Created a website www.dcmnys.com to promote the Doctor of Chiropractic Medicine as the future of chiropractic.

• Creating Social media sites that link to the website to provide a live feed on the website.

Letters to Dean of Medical School Senator Tim Kennedy 63rd District

Assemblywoman Crystal Peoples-Stokes 141st District

Darius G. Pridgen Common Council President

Dr. Kevin Skowronek Wheatfield Family Chiropractic

John R. Garey Account executive Television

Dr. Christopher Acquisto Suburban Chiropractic Assoc.

Dr. Scott Croce Erie County Chiropractic

Jed Dietrich, Esq. The Dietrich Law Firm, PC

Dr. Zair Fishkin, MD, Phd Pinnacle Orthopedics

Dr. Gary Smith, DC, DIBE General Diagnostic Associates

Mark Grisanti At that time NYS Senator

Harold L. Cohen MD Former Professor UB

Dr. John Syracuse, Niagara County Legislator, Dist 14

Dr. Joseph Kowalski, MD Director Spine Center ECMC

George Maziarz At that time NYS Senator

Frank J. Mascaro, MD WNY MRI

Ruben Noel, DDS Aspen Dental

Joseph Serghany, MD WNY MRI

Dr. Stephen Zajac Lancaster Depew Chiropractic

Suzanne Miller, PhD Professor Grad School Ed

Wayne Alt Green Peace

Holly Schoenborn, Esq. Dolce Panepinto Law Firm

John Cahill, Esq

Byron Brown Mayor City of Buffalo

Carl P. Paladino, Esq. Richard Nicotra, Esq NYSTLA Western Reg Affiliate

Dr. Charles Sperrazza, MD

Initial Letter – Dr. Joanna Garvey and Dr. Geoffrey Gerow

Scott Syracuse Syracuse chiropractic P.C.

Integrating with UB

• Our Group: (see attached)

– Provides rotational instruction in a course called “Diagnostic Imaging for the Primary Care Physician” for 3rd and 4th year medical students.

– We also provide rotational instruction for second year Family Medicine Residents also in Diagnostic Imaging.

• As chiropractors, we have found that our knowledge levels are similar in the basic areas but that we would need additional skills and privilege to perform in a primary care setting.

Diagnosis Our Team publishes on primary care conditions?

“OCD and Meniscal Tear” “Pseudotumor Cerebri and Papilledema.”

“HIZ Discogenic Pain Radiculopathy”

“Schwannoma”

“Lumbar Spinal Stenosis and Impairment Evaluation”

“Post-trauma: AVN/Impaction Fracture humeral head/Cervical Neuralgia.”

“Femoroacetabular Impingement – Pincer Type”.

“Rotator Cuff Tear and left C5 and C6 radiculopathy”.

“SLAP Tear and Clinical Cervical Radiculopathy”

“Myositis Ossificans Traumatica” “Post-Surgical Spinal Fusion: Comparative Study of Cervical vs. Lumbar Outcomes.”

“Multiple Crush Syndrome: Herniated Cervical Disc, Cubital Tunnel Syndrome and Carpal Tunnel Syndrome”

“Madelung Deformity, bilateral carpal tunnel syndrome, C6/C7 disc herniation, Possible double crush phenomena.”

“Simple vs. Complex Renal Cysts”

“Facet Joint (synovial) Cyst vs Other Dorsolateral Extradural Lesions of the spinal Canal”

“Clear Cell Renal Cell Carcinoma”

“Enchondroma” “Cervical Spinal stenosis, multiple level DJD & central discs ("washboard spine").”

“31 Year Old Woman Mature Cystic Teratoma.”

“Sickle Cell Disease, Avascular necrosis, Cervical disc herniation, Cervical radiculopathy, myelomalacia, COPD.”

“Pulmonary Thromboembolism Associated With Pregnancy, Small Lumbar Disc Herniation”

“L5-S1 disc herniation with S1 radiculopathy”

“Recurrent rotator cuff tears, suspicion for avascular necrosis of head of humerus”

“Cervical Spinal Stenosis Producing Myelopathy”

Diagnosis Our team publishes on primary care conditions?

“Post Stevens-Johnson syndrome, resembling fibromyalgia”

“Arnold–Chiari malformation I with Syrinx”

“Multilevel Disc Herniation with Left Lower Extremity Radiculopathy”

“Multiple Sclerosis Exacerbation vs. Trauma-Induced Symptomatology ”

“Thyroid Cysts” “Arthropathy Requiring Total Knee Arthroplasty”

“Scapholunate dissociation with DISI”

“Post-Traumatic Headache More Likely The Result Of Cerviogenic Origin From Resultant Disc Herniation Affect Than From A Post-Concussive Syndrome”

“Kienbock’s Disease” “Cervical radiculopathy with myelopathic changes”

“Persistent Central Canal/Post-traumatic Syringomyelia”

“Rotator Cuff Tendinopathy vs Cervical Radiculopathy”

“Internal disc disruption with secondary chemical radiculopathy.”

“Lumbar Radiculopathy in the Presence of Spondylolisthesis”

“Lumbosacral Compressive and Chemical Radiculopathy”

“Chondromalacia patella in the presence of meniscal tear.”

“Medial Meniscal Tear and Comminuted Fibula Fracture”

“Lumbar Herniated Disc” “Pseudoarthrosis After Anterior Cervical Discectomy And Fusion (ACDF).”

“Full-Thickness Rotator Cuff Tear.”

“Cervical Disc Herniation with Radiculopathy”

“Lumbosacral Disc Herniations with Radiculopathy”

“Partial Rotator Cuff Tear” "Tarlov Cyst”

“Acoustic (Vestibular) Schwannoma”.

Institutions of Higher Learning(IHL)

• Chiropractors have been disparaged in the past for not having medical training.

• This is the opportunity for IHL to bring chiropractic into the medical fold.

• The DCM would care for conditions typically seen in a PCP practice and yet have a strong background in neuromusculoskeletal conditions.

• NY State would lead the nation addressing current and future health care needs. It is in every way a win-win situation.

Our Concerns: • Govenor George Pataki in 1997, signed into Law

Senate Bill 5594 that mandated chiropractic coverage in NYS.

• The Affordable Care Act allows, as a cost cutting measure, for States to drop health care mandates beginning in 2016.(1,2)

• If a State continues to offer such health care past 2016 any cost associated with such will be at the expense of the State and not supported by Federal monies.(1,2)

1.http://www.sciencebasedmedicine.org/obamacare-and-cam/ 2.http://www.sciencebasedmedicine.org/obamacare-and-cam-iii-great-expectations/

MANDATES

• A bill that only seeks to prevent state mandates not be discarded will not help: – Insurance carriers have already found the way

around the mandate by making co-payments greater than the cost of service. That way they can appear to have chiropractic coverage but in reality do not.

Additionally:

• Although the Affordable Care Act covers essential services (1), the state for monetary reasons could decide that some services are not as essential as others (2). This rationale has been previously implemented in Ontario (3) negating coverage for chiropractic service. 1. http://www.barackobama.com/issues/healthcare

2. http://www.sciencebasedmedicine.org/obamacare-and-cam/ 3. http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=46

289

PCMH 2014 Content and Scoring (6 standards/27 elements)

1: Enhance Access and Continuity A. *Patient-Centered Appointment Access B. 24/7 Access to Clinical Advice C. Electronic Access

Pts 4.5 3.5 2

10

2: Team-Based Care A. Continuity B. Medical Home Responsibilities C. Culturally and Linguistically Appropriate

Services (CLAS) D. *The Practice Team

Pts 3 2.5

2.5 4

12

3: Population Health Management A. Patient Information B. Clinical Data C. Comprehensive Health Assessment D. *Use Data for Population Management E. Implement Evidence-Based Decision-

Support

Pts 3 4 4 5

4

20

4: Plan and Manage Care A. Identify Patients for Care Management B. *Care Planning and Self-Care Support C. Medication Management D. Use Electronic Prescribing E. Support Self-Care and Shared Decision-Making

Pts 4 4 4 3 5 20

5: Track and Coordinate Care A. Test Tracking and Follow-Up B. *Referral Tracking and Follow-Up C. Coordinate Care Transitions

Pts 6 6 6 18

6: Measure and Improve Performance A. Measure Clinical Quality Performance B. Measure Resource Use and Care Coordination C. Measure Patient/Family Experience D. *Implement Continuous Quality Improvement E. Demonstrate Continuous Quality Improvement F. Report Performance G. Use Certified EHR Technology

Pts 3 3 4 4 3 3 0 20

*Must Pass Elements

Scoring Levels Level 1: 35-59 points Level 2: 60-84 points Level 3: 85-100 points

28

http://www.ncqa.org/Portals/0/Programs/Recognition/RPtraining/PCMH%202014%20Intro.%20Training%20Slides%20Part%201%20-%20Standards%201-3%20-%2011.26.pdf

The National Committee for Quality Assurance (NCQA) formed the PCMH Recognition Program

• To head a PCMH (primary care medical home) under the Affordable Care Act and essentially act as the PCP/Gate Keeper requires: Six must pass standards *, 3 of which are: – Plan and Manage Care – Implement Evidence-Based Guidelines – Manage medications and have the capacity for

electronic prescribing

*http://www.sciencebasedmedicine.org/obamacare-and-cam-iii-great-expectations/

Obviously

The present DC cannot act as a primary care provider/gate keeper

within the ACA under the NCQA guidelines because chiropractors are

not able to prescribe.

Nurse Practioner’s

Training and Privilege

Nurse Practioner’s

• After the Bachelor in Nursing, a 4 year program, the nurse can then take the NP program. – TOTAL REQUIRED FOR NP(M.S.): 40-42 credit hours.* – New York State has enacted a new law called the

“Nurse Practitioner Modernization Act” (the “NPMA”), that went into effect on January 1, 2015

• (Can act as a primary care provider without MD supervision)**

*DYC Graduate Catalog page 64 ** Ellen F. Kessler, Esq., http://rmfpc.com/new-change-in-new-york-nurse-practitioner-law/

Many applicants to chiropractic school already have a BS – For those that do not you can see that such requirements are

greater than what is needed for Medical School.*

*http://www.yourmedicaldetective.com/drgrisanti/mddc.htm

Chiropractor

• After the BS or prerequisites, the chiropractic program:

• In this DC program are cross listed courses:

– CHR 613 Pharmacology I – CHR 614 Pharmacology 2

Total Credits Required for the DC *

Credits

Project Option 182-185

Thesis Option 186-189

*DYC Chiropractic Curriculum

Comparison NP and DC

• NP - BS + up to 42 credit hours = Primary Care • DC – BS + up to 189 credit hours including

pharmacology and no prescription of drugs. This really is discriminatory and needs to be

corrected.

DCM Bill

• 1. The practice of the profession of chiropractic medicine is defined as the diagnosis and treatment of human disease without the use of operative surgery.

• 2. Such designation allows for the use of full drug privileges.

How does the DCM differ from the DO or MD degrees

• DO and MD degrees permit the prescription of drugs and performance of operative surgery. – The DCM would only permit drug prescription but not operative

surgery.

• DO or MD degrees permit any specialty thereafter and where 32% of those go on to PCP status. – Virtually all DCM providers would go on to PCP status as the other

opportunities would not be available to them.

DCM and Chiropractic Programs • The DCM requires prescriptive level pharmacology

for those who have not had it within 5 years: – Students likely will desire DC programs that already have

the Pharmacology requirement. These same students entering the DCM program can be afforded advanced standing by acceptance of these previously taken pharmacology courses.

Support: This is not just a state movement it is a national movement of over 4,000 chiropractors and growing!

The FCPAA is Fighting to Integrate chiropractic physicians into the healthcare system as specialists and primary care providers with full prescriptive rights.

Summary • The DCM will enable chiropractors to implement in

practice what they have been taught in school. – The DCM will, as a separate license, correct an antiquated

State Law in NYS that has severe limitations.

• The DCM will eliminate duplicative office visits/procedures reducing health care costs.

• The DCM will answer the need for more PCP access and more readily permit incorporation into the PCMH.

• The DCM will meet the needs of NYS and as it spreads, nationwide, service the needs of America.

Fellow Professional

• As you can see, the health care market has changed around us as chiropractors and we are not necessarily asking to change the health care market at this time.

Rather: Simply we are asking to the afforded the tools to participate in the Health Care of Today

and the Future.

We humbly ask your support of this bill to allow us to have a future in health care.

As WNY Chiropractors: We encourage you to support efforts to create another license, The DCM, available to chiropractors that wish to pursue additional training. If you are in another state we encourage you to set up your own DCM website. Feel free to adapt bill language from that available here to your state. Together, as a group, we can make a difference for chiropractic and ensure it’s longevity into the future.

Thank you.