Chiropractors face uphill battle for acceptance
By Christie Wilson
Advertiser Staff Writer
Last month's veto by Gov. Ben Cayetano of a bill that would have expanded the scope of chiropractic treatment is an example, say Hawai'i chiropractors, of their uphill battle for acceptance by the medical community and insurance industry.
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In his veto message, Cayetano said Senate Bill 233 could lead to increases in medical malpractice insurance and health care costs, as well as automobile insurance rates.
Dr. Steven Rawson checks the pelvis of 5-year-old Christian Horcajo of Salt Lake on a visit with the mother, Joy.
Chiropractic doctor Lisa Baptista, president of the Hawai'i State Chiropractic Association, said the bill would not have increased costs. She said it was meant to update a decades-old law and make it consistent with other state rules governing chiropractic care and with national chiropractic educational standards.
"The powers that be think we are incapable of practicing our trade as we are taught. They just don't like us," Baptista said.
"The powers that be," she said, are the medical profession and insurance companies and regulators who perceive a threat from the growing popularity of chiropractic care and other complementary and alternative health care methods.
The bill would have changed the definition of chiropractic care from "the science of palpating and adjusting the articulations of the human spinal column by hand ...," to "the science of palpating and adjusting the articulations of the human body by hand ..." It also would have allowed chiropractors to make referrals for blood, urine and other laboratory tests.
Baptista said the change would have made it clear that chiropractors are capable of treating the extremities for such problems as carpal tunnel syndrome, sprains and other joint-related injuries.
Many chiropractors here already do so and order lab tests as well, based on a finding from the state Board of Chiropractic Examiners that chiropractors are qualified to treat the extremities and order diagnostic procedures.
Chiropractors said they want that finding codified in Hawai'i law to eliminate any doubt about what types of cases they can treat.
"It's not about treating something in a way we haven't treated them before, or doing something we haven't been trained to do," said Hilo chiropractor Rex Weigel, who closely followed SB 233.
But the Hawai'i Medical Association, representing medical doctors, said the bill would have given chiropractors leeway to treat any body part.
"Chiropractors do spinal manipulation. They are not trained to go beyond that," said Dr. Philip Hellreich, the association's legislative chairman and immediate past president. "They want to treat the extremities, the joints of the extremities, even the abdomen and the chest. You're talking about serious infections, malignancies and vascular diseases like lupus, and if the diagnosis is missed or delayed, there can be dire consequences."
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Many chiropractors effectively use spinal manipulation to treat pain and inflammation from injuries and other disabilities, he said, and Hellreich has referred patients for this type of therapy.
Dr. Steven Rawson manipulates the neck of Corina Bruckner of Aliamanu military housing in his Salt Lake office.
"But there's a second group that believes you can cure anything with spinal manipulation," he said.
"Acting as a primary-care physician is totally beyond their scope of expertise. It's a quality-of-care issue. It has nothing to do with turf."
Opponents also said expanding chiropractic care would confuse consumers, who would not distinguish between physicians and chiropractors.
Baptista responded, "They're not giving the general public much credit."
Chiropractors have the skills and experience to examine and diagnose patients who may or may not be suffering from a problem related to the neuromuscular or skeletal systems, Baptista said. If it is determined that the illness or injury is beyond the scope of chiropractic care, patients are routinely referred to medical doctors, she said.
"We're a point-of-entry doctor and can provide the same care as a general practitioner," she said.
Another fear cited by the Hawai'i Medical Association in its legislative testimony against SB 233 was that physicians treating chiropractic referrals would bear the brunt of any malpractice claims as a result of delayed or improper treatment. The effect, it said, would be a rise in malpractice insurance rates.
The medical association also expressed concern that if chiropractors are allowed to order lab tests at the same time their scope of practice is broadened to treat other parts of the body, they would order unnecessary tests and X-rays "because they lack the education to determine what tests are appropriate or how to adequately interpret their results."
The unnecessary tests would increase health care costs, the group said.
Baptista said performing and reading lab test results are part of a chiropractor's clinical training and required to be licensed in Hawai'i.
"There is a stigma out there that says our profession is a bunch of quacks. They don't realize our educational standards and our chiropractic curriculum are almost the same as medical school," she said.
A minimum of two years of undergraduate college work with an emphasis in science is necessary for admission to an accredited chiropractic college, where students undergo four years of study. Half of that training involves practical or clinical experience.
Hellreich said there is no comparison.
Medical doctors have a four-year pre-med degree, four years of medical school and an additional three to four years of clinical training, plus a year or two for specialities.
"Our education and experience is totally different from chiropractors. To argue that we receive the same training and same clinical expertise is wrong," he said.
Along with concerns for patient care, the prospect of higher insurance rates and increased costs to business is what led the Chamber of Commerce and the Hawai'i Insurers Council to join the medical association in its opposition to SB 233.
The issue is one of cost containment, said Alison Powers, executive director of the Hawai'i Insurers Council, a trade organization for the property and casualty insurance industry.
It is the nature of chiropractic care to treat patients over the course of multiple visits — an average of three times as many visits as to a medical doctor for the same problem, Powers said.
Even if an amended bill contained exclusions for no-fault and workers' compensation cases — the bulk of the chiropractic trade — the effects would be felt by other segments of the insurance industry, she said.
Weigel pointed to a recent news report on a study that showed a type of knee surgery performed on more than 300,000 Americans each year to ease arthritis pain is worthless. Some of those patients most likely could have avoided costly and potentially harmful surgery if they had sought chiropractic care first, he said.
"We could be saving system money by doing manipulation rather than a surgery that might cost $8,000," he said.
The National Council on Compensation Insurance, a nonprofit organization that provides statistical analysis of issues affecting workers' compensation, did not take a position on SB 233 or provide legislative testimony, said NCCI State Relations Executive Carolyn Pearl in Honolulu.
However, she said, the group did advise state officials that expanding the scope of chiropractic treatment could result in an increase in utilization of services, possibly leading to higher workers' comp rates.
Nationally, chiropractors have been making gains against traditional opposition.
At least 12 states require health coverage for chiropractic care, and use of complementary and alternative health care methods is being adopted by a number of medical schools and clinics, including the Honolulu Medical Group.
Baptista said chiropractors in Hawai'i have yet to accumulate the kind of political clout needed to do battle with more influential special-interest groups here.
There are about 500 chiropractors licensed in Hawai'i, compared with approximately 6,000 medical doctors. Baptista's organization has about 50 members, she said.
The fact that SB 233 passed the Legislature is an indication that chiropractors have gained a measure of credibility among lawmakers, and Baptista said the association will continue its public education efforts and try again.
