Advisory panel nixes VA patient self-referral to chiropractors

Chiropractic care at the Dept. of Veterans Affairs could expand dramatically, if the final recommendations of the VA chiropractic advisory committee are followed.

"Any provider of care in the VA would be able to refer a patient for chiropractic services," said Warren Jones, MD, a member of the advisory committee and immediate past president of the American Academy of Family Physicians.

This would mean that nurse practitioners and rehabilitation therapists could be making referrals as well as orthopedic surgeons and primary care physicians.

A federal law enacted in December 2001 requires at least one facility in each of the VA's 21 regional health care networks to provide chiropractic care.

The advisory committee gave VA Secretary Anthony J. Principi its final report in November 2003. Expectations were high among those involved in the project that the secretary would take the recommendations seriously and act on them quickly.

"All indications are that the secretary is very tuned in with the committee and is waiting to hear what we have to say," said Reed Phillips, DC, PhD, committee chair.

Wake-up call

Dr. Jones said the committee's decisions focused on patient safety and access to care.

"The public law was a good wake- up call for us [physicians]," he said of the growing desire for chiropractic care. The law says there will be chiropractic care [in the Veterans Health Administration] and we had to figure out how to integrate it in a patient-centered and effective way."

The 11-member committee with six chiropractors, three physicians, a physical therapist and a member of a veterans service group found it a challenge to reach a consensus on all recommendations. Patient access was the most hotly contested issue.

Previous drafts of the recommendations showed the committee almost evenly divided initially over the issue of direct access vs. physician referral. In the final report, however, only two members favored direct access.

Dr. Phillips said the way the recommendations were worded, gaining permission to see a chiropractor could be as simple as a phone consultation with a VA health care professional, and each of the VA's 21 regional health systems would have some latitude in how they structured the referral process.

Those in favor of direct access said physicians in the VHA had made few referrals to chiropractors in the past and were skeptical that patients would get better access to chiropractic care without having the power to contact chiropractors themselves. There also was concern that those wanting an appointment for a referral would create further delays in an already backlogged appointment system.

As it stands now, the VA requires almost all specialty care, including chiropractic, to be done with approval from the patient's primary care physician. Chiropractors work outside the VA system. Patient visits require additional administrative paperwork, and payment is on a fee-for-service basis.

The VA must hire at least one chiropractor for each of its 21 services areas but has yet to determined how many chiropractors will be hired beyond that, according to Dr. Phillips. He predicted that once chiropractors become part of the VA system they would be swamped with patients.

"We've been assured we'll have more patients than the time to see them," Dr. Phillips said.

Karen Fedele, a VA spokeswoman, said the agency's records documenting the volume of chiropractic therapy for VA patients were incomplete. Chiropractic services have been funded since at least 1997.

The VA paid $364,500 in fiscal year 2001 and a similar amount again in 2002 under one CPT code for chiropractic services.

Dr. Jones said the committee's next step was to look at teaching chiropractors how to work in an inpatient setting and teaching VA clinicians how to work with chiropractors.