A paper by Foreman and Stahl in the journal Chiropractic & Osteopathy reports that the attrition rate for licensed California chiropractors in the first 10 years of practice has risen in the past several decades.1 Reasons given for this increased attrition include fundamental adverse changes in health care reimbursement for chiropractic services, tuition increases, and a decrease in the population-to-chiropractor ratio.
The data presented are startling. Consider chiropractic college tuition. In an example cited by the authors, quarterly tuition at one institution (and typical at most others), rose from $255 in 1970 to $4,530 in 1998, a total increase of 1,676 percent! What about inflation? "The $255 quarterly tuition adjusted for inflation to 1998 dollars would have risen to $1,092. Thus, the $4,530 per-quarter tuition in 1998 outpaced inflation by 414%."
I graduated from Palmer in 1973. In checking the 1972-1973 catalog, tuition was $320 per quarter.2 Like many of my classmates, I graduated broke, but with no debt. In stark comparison, many of today's grads are saddled with crippling debts.
Foreman and Stahl also note: "Unrestricted group health (employer provided/private payer) coverage that paid 80% of submitted chiropractic charges, and a 20% (80/20) patient co-payment was common in California in 1970 but was soon to change. Passage of the Health Maintenance Organization Act of 1973 allowed for the creation of alternative reimbursement systems such as Preferred Provider Organizations (PPOs) and Health Maintenance Organizations (HMOs) that are collectively referred to as 'Managed Care.' The PPOs and HMOs frequently restricted access to the chiropractic profession and used fee schedules that paid a smaller percentage of the usual and customary fees."
Many DCs like to reminisce about the "Mercedes 80s," which are arguably gone for good. The reality is that third-party reimbursement continues to worsen. Chiropractic's role under the Patient Protection and Affordable Care Act (nicknamed Obamacare) is unknown at this time.
An Oversupply of DCs?
Some have suggested that there are simply too many chiropractors. Mior and Laporte3 state that the results of their study "suggest that the chiropractic profession in Ontario is in long-run oversupply." After 30 years of consulting for chiropractic offices, Stanley4 concluded that there is an "appalling oversupply of new chiropractors into the marketplace" and suggests as a possible solution, "Greatly limit the number of new DCs being licensed. Control the supply."
Esteb5 hit the nail on the head when he wrote, "There may be too many DCs. But there are far too few chiropractors." Few appreciate the distinction between a DC degree holder who attempts to practice a limited branch of medicine and a chiropractor who acknowledges chiropractic as a separate and distinct profession offering a unique contribution to human health. As Esteb observed, "The solution will come from more DCs becoming chiropractors. Because while there may be too many DCs, there's a shortage of chiropractors. And with more chiropractors, not only is chiropractic sustainable, it would be unstoppable."
Barriers to Broader Utilization of Chiropractic Services
1. Lack of a clear identity: The public does not have a clear concept of what chiropractic is. Fortunately, the chiropractic profession, at least in North America, has a strong consensus on at least three key issues. A study6 by the Institute for Social Research at Ohio Northern University found, "For all practical purposes, there is no debate on the vertebral subluxation complex. Nearly 90% want to retain the VSC as a term. Similarly, almost 90% do not want the adjustment limited to musculoskeletal conditions. The profession - as a whole - presents a united front regarding the subluxation and the adjustment."
Furthermore, 93.6 percent of the chiropractors responding to the survey said they recommend maintenance/wellness care. Unfortunately, there is a disconnect between the field and our political organizations. The latter should not be surprised that only a minority of chiropractors are members. Our national and international organizations need to support and promote the concepts of vertebral subluxation and wellness.
2. Erosion of our lexicon: Hudson wrote, "If one wished to kill a profession, to remove its cohesion and strength, the most effective way would be to forbid the use of its characteristic language."7 Attempts to do so have had precisely that result. Vertebral subluxation needs to become a household term. Colleges, authors of scientific papers, professional associations, and spokespersons for the profession must be strongly encouraged to use our unique terminology, such as vertebral subluxation and chiropractic adjustment. This does not create confusion. Rather, when properly defined, use of such terms provides clarity and differentiates us from the plethora of purveyors of manipulative therapy.
3. Barriers to access: Attempts to pigeonhole chiropractors as practitioners limited to the treatment of musculoskeletal pain syndromes has severely stifled our potential. Limiting access to chiropractic care for the episodic treatment of a short list of covered conditions has produced an economic barrier for potential patients. For example, Medicare and most third-party payers require that a patient have a qualifying musculoskeletal condition to qualify for coverage. This is unfortunate, given the evidence that supports spectacular cost savings when a broader application of chiropractic services is implemented.8
4. Perpetuating acquired ignorance: Evidence for many clinical procedures used by chiropractors is lacking. For example, orthopedic tests are taught in our colleges, tested on licensing examinations, and considered an essential part of proper documentation by many. Yet the reliability and validity of these tests is, with few exceptions, either lacking or unfavorable. Worse, there is resistance to the adoption of modern technologies which provide reliable and valid measurements of manifestations of vertebral subluxation.9
5. A paucity of relevant research: The chiropractic profession needs to direct our limited resources toward research that investigates the clinical meaningfulness of vertebral subluxation. Specifically, instead of characterizing the adjustment as a treatment for a narrow range of medical conditions, we need to investigate how correction of vertebral subluxations affects health-related quality of life, function, and cost-effectiveness.
Turning Things Around
This is a tall order, yet it can and must be done. Once the public realizes the potential contribution of chiropractic care to improved function and quality of life, the problem will shift to how to cope with consumer demand given the relative short supply of chiropractors.
- Foreman SM, Stahl MJ. The attrition rate of licensed chiropractors in California: an exploratory ecological investigation of time-trend data. Chiropractic & Osteopathy, 2010;18:24.
- Bulletin 1972-1973. Palmer College of Chiropractic.
- Mior SA, Laporte A. Economic and resource status of the chiropractic profession in Ontario, Canada: a challenge or an opportunity. J Manipulative Physiol Ther, 2008;31(2):104-14.
- Stanley G. "The Sustainability of Chiropractic." Dynamic Chiropractic, Sept. 10, 2007;25(19).
- Esteb B. "Where Did All the Chiropractors Go?" www.chiroviewpresents.org/article_files/Article-2380.pdf
- McDonald W, Durkin K, Iseman S, et al. How Chiropractors Think and Practice. Institute for Social Research, Ohio Northern University; Ada, Ohio, 2003.
- Hudson K. The Jargon of the Professions. Billing and Sons, Ltd., U.K., 1978.
- Kent C. "A Strategy for Health Care Reform." Dynamic Chiropractic, Sept. 9, 2008;26(19).
- Kent C. "Examining Exams. Are They Reliable?" Dynamic Chiropractic, Aug. 12, 2008;26(17).
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