The state of South Dakota has a peculiar law regarding chiropractic in that chiropractors are prohibited from being employed by corporations. In other words, a chiropractor can only work for himself or another chiropractor. They cannot work as an employee of a hospital, multidisciplinary clinic, or in an on-site clinic. After difficulty posting to the SDCA list-serve (since resolved), I wanted to publish this here as an alternate means of sharing my opinion.
As I am relatively new to South Dakota and practice (2016 UWS graduate), I’ve been quiet on the issue, but I would like to voice my support for legislation that provides patients the greatest access to chiropractic care. In my view, this includes allowing chiropractors the freedom of choosing to be employed by corporations including healthcare systems such as Sanford, Avera, and Regional Health.
I would like to thank Dr. Ivey for his tireless efforts to continue this important discussion.
I share the sentiment of Dr. Jason Evans that my opportunities to practice in the way I would like are being limited by the SDCA. Having worked alongside an MD in my clinical internship, and then completing my preceptorship in the Northern Las Vegas VA Hospital, I have seen first-hand the benefits offered to patients who have access to chiropractic through their chosen (or, often mandated) health system. I also enjoyed the opportunities to expand my knowledge and improve my practice by learning about other approaches to patient management. Practicing in collaboration with medical doctors, PAs, nurses, and other allied health providers appeals to me.
I have yet to read a compelling argument against the proposed bill. Some have shared concern over limiting payments for a small subset of their patient base. A significant number of people fear that allowing corporate hiring will somehow taint the profession or put us under the regulation of Big Pharma. Others think that chiropractors hired by a corporation will not be able to practice to the full scope of their license. None of these arguments have been accompanied by supporting data and have been addressed in previous responses. Indeed, experience shows that the result of integration is wholly positive for patients and chiropractors.
Dr. Richard Brown, Secretary-General of the World Federation of Chiropractic recently stated in an interview “Almost wherever you are in the world, chiropractic is advancing because they are collaborating with other members of the healthcare team.” Among his supporting examples, he cites the VA Healthcare System’s chiropractic program, as well as World Spine Care a multi-national non-profit founded and lead by Dr. Scott Haldeman. I have been fortunate to be involved with World Spine Care for the past few years and again have seen up close the need for chiropractors to be integrated within healthcare systems - especially in rural areas.
I may be naive, but I do not believe that these big corporations have malicious desires to take control of the chiropractic profession. Nevertheless, Dr. Van Hemert may be right that it has to do with money. In a 2015 systematic review by Dagenais and Haldeman, “cost comparison studies suggest that health care costs were generally lower among patients whose spine pain was managed with chiropractic care.” I’m sure many of you are aware of the studies comparing care from an MD vs DC, such as the Swiss study published in JMPT: “Spinal, hip, and shoulder pain patients had clinically similar pain relief, greater satisfaction levels, and lower overall cost if they initiated care with DCs, when compared with those who initiated care with MDs.” (J Manipulative Physiol Ther 2015;38:477-483) We provide great care at a lower cost, so of course these companies are interested in bringing us on board.
That said, it is unlikely that Avera and Stanford are trying to get rich off of our services. If organizations are familiar with the available research about incorporating chiropractic, they will recognize that the value of chiropractic lies in cost savings rather than profit generation. According to a multi-site qualitative case study cited below, “The cost savings seen after including chiropractic services presented a stronger business case for clinic expansion. One facility identified a 50% decrease in unnecessary hospital admissions for low back pain cases and an overall savings of over $600,000 per year after implementing spine care pathways and chiropractic care.”
More recently, two papers were published in JMPT and the Journal of Alternative and Complementary Medicine describing the process and qualitative results of integration of DCs into private sector healthcare facilities. As reported by Palmer College, "These D.C.s enjoyed the ease of referral, patient scheduling, and interprofessional communication supported by the information technology infrastructure of their facilities."
A few interesting data points from the second article:
"A survey by the National Board of Chiropractic Examiners Practice Analysis of Chiropractic reported that 9% of doctors of chiropractic (DCs) practice in settings other than chiropractic offices, including 7.8% who work in an 'integrated health care facility,' with 3.6% of those surveyed identifying that they hold hospital staff privileges."
Where integration is allowed, it remains a very small portion of practicing chiropractors.
Another promising result which addresses common concerns: “Virtually all DCs described their clinical practice as full scope diagnosis and management of musculoskeletal and neuromuscular conditions.”
As a final note, the schedule for NCLC happening this weekend highlights the value and importance of getting our state laws up to speed with the rest of the nation. While I am unable to attend this year, I’ve counted no fewer than 10 sessions discussing multidisciplinary care, two of which directly relate to this discussion of corporate hiring. I hope to hear more about these presentations from our delegates and others who are in DC this weekend.
In short, allowing chiropractors to be hired by corporate entities will not force all chiropractors to be employed only by corporations. Moving forward with this legislation will only expand the opportunities for chiropractors who wish to work in corporate settings, and - most importantly - expand access to chiropractic for patients in South Dakota.