In January 2002, President George W. Bush signed landmark legislation into law (Public Law 107-135) that ensured chiropractic would become a permanent benefit for recipients of veterans' health care services.
In addition, Section 204 of the law established the Department of Veterans Affairs Chiropractic Advisory Committee, whose mission was "to provide direct assistance and advice to the Secretary in the development and implementation of the chiropractic health program" within the Veterans Health Administration (VHA). In August 2002, I had the honor and privilege of being appointed by Secretary Anthony J. Principi to serve on the committee, along with five other doctor of chiropractic members and five members from the medical community. This report will give you a brief update on our progress thus far.
Veterans Health Administration (VHA)
The VHA is a comprehensive, integrated health care system encompassing:
- 163 hospitals;
- 850 ambulatory care and community-based outpatient clinics ("CBOCs");
- 137 nursing homes;
- 43 domiciliaries; and
- 73 comprehensive home health care programs.
The VHA endorses a primary care model of health care delivery in which each patient has an assigned primary care provider who is accountable for addressing a large majority of the patient's personal health care needs, with referrals to specialists when needed. The VHA health care system encourages an integrated, interdisciplinary, interdependent and collaborative team approach. The composition of health care teams in the VHA varies among sites, due to differences in the size and configuration of VHA facilities, staffing patterns and local business practices. This team approach to care serves veteran patients well, as many have multiple health care needs that overlap and influence one another. In this enormously complex health care system, it becomes immediately clear to any observer that incorporating chiropractic is no small undertaking.
Title 38 is a federal code that outlines how professionals will be contracted and employed within the VHA system. In its language, medical doctors, osteopaths, podiatrists and dentists are all mentioned and specified, but, because it is a new service, chiropractic is not included in the current "laundry list" of Title 38 contractees. Therefore, prior to doctors of chiropractic being contracted into the VHA system, Title 38 needs to be amended. In other words, once PL 107-135 became law, chiropractic became the proverbial "round peg," with Title 38 being the "square hole."
As a solution to this problem, the Honorable Jerry Moran (R-KS), member of the House Veteran's Affairs Committee, recently introduced HR 2414 to address this problem by amending Title 38 to include chiropractic. Later, HR 2414 was incorporated into HR 2357, a more comprehensive and broad-based VA bill, that eventually passed the full House on July 21, 2003, under a "suspension of rules" - a process reserved for only those bills that are widely supported. As of press time, this legislation is bound for the Senate for consideration, where it is not expected to meet resistance.
Another hurdle that must be overcome is that the chiropractic profession must undergo what is referred to as a "Major Occupational Study" (MOS) prior to any DCs being hired or contracted within VHA, because it is a "new" occupation. The committee identified this challenge following its first meeting in September 2002, and the recommendation to initiate an MOS was forwarded to Secretary Principi immediately thereafter. He concurred with the recommendation and the bidding process to conduct the task was initiated; the group that won the contract is called Caliber Associates. The entire process can take up to 18-24 months, but at least it is now officially underway.
In terms of the other "work in progress" recommendations the Advisory Committee has been deliberating on (scope of practice and privileging; direct access versus referral, and qualifications for hire), it is now possible to view the most up-to-date draft recommendation that includes these components on the VA website at www.va.gov/primary. Once there, look for "Chiropractic Advisory Committee," where you'll find the document available for viewing. In fact, the VA is currently accepting public comment on these draft recommendations, so anyone can"weigh in" on this important issue. (All public comments received will be appendixed to the final recommendation presented to the Secretary). If you wish to comment, the VA asks that you do so via e-mail at: .
The next meeting of the Chiropractic Advisory Committee is scheduled for Sept. 16-17, 2003, again in Washington, D.C. At that meeting, it is expected that the committee will put the finishing touches on this working draft recommendation and (if successfully completed), forward it to Secretary Principi for his consideration. After that, it is up to him to accept, reject, or amend the recommendations.
Once these recommendations are forwarded, the next major task the committee will undertake will be to develop and approve a training/teaching program on chiropractic for all VA staff -including medical physicians. While we recognize this will be a significant challenge, it is a critical one to ensure the overall success of eventual implementation.
Future meetings of the Chiropractic Advisory Committee are scheduled for early December and late March of 2004; I plan on providing further updates to the profession as events warrant.
Cynthia S. Vaughn, DC, FICC