Conflicts Over Scope

There has been a recent flurry of communications within the Minnesota Chiropractic Association’s members about some of the implications of this state’s scope of practice law. In particular, a specific weakness in chiropractic regulatory language appears to prohibit a DC from employing a physical therapist so that a PT can bill for physical therapy services. The language of the law appears to prevent a PT working for a DC to bill for physical therapy services, but forces them to only bill for chiropractic therapeutic services. There are at least two things wrong with this: one, PTs cannot perform chiropractic services, so billing for them misrepresents the services–and potentially conflicts with both PT and chiropractic scope; and two, PTs performing any services cannot be at the direction of the DC, as they are independently licensed professionals and must be free to exercise their own clinical judgement. In a circular reasoning world that makes Joseph Heller’s Catch 22 look rational, doctors of chiropractic are locked out of business arrangements that could potentially benefit all involved. It also picks at the scabbed-over wounds of scope battles going back a number of years. In the new world of health care, every provider group wants to broaden their scope, political medicine wants to keep a lid on things, and insurers wish the whole problem would go away. Chiropractic is headed for a two-tier professional scope structure. Where will this end up?

It’s hard to find a profession or discipline that has not sought to strengthen (expand) its scope of practice laws or to establish regulation where none exist. The ‘gold standard’ is that of medicine, which is capable as a profession of doing pretty much anything it wants to. Everything else is couched in various forms of terms that other professions are not practicing medicine, and an indication of the hierarchy of professions (and their lobbying power) can be read in what’s cited in rules and regulations. Chiropractic isn’t the practice of medicine; physical therapy isn’t the practice of chiropractic; and acupuncture or naturopathic medicine aren’t any of the above. Minnesota didn’t want to regulate the whole range of ‘complementary and alternative’ health care options, so it set up a catch-all oversight function that doesn’t really regulate them so much as to make providers accountable under a broad law if they do stupid stuff to the public.

Going up, anyone?
Scope expansion is an ongoing issue. A decade ago physical therapy set its sights on a doctorate-level credential as an entry-level degree in an effort to elevate the profession’s standing and clinical autonomy. The payer system has yet to reward that strategy, because the costs of DPT services aren’t easily justified over those of ‘regular’ PT services. Naturopathic medicine is seeking to position itself as the friendly (non-threatening) natural alternative to and ally of allopathic medicine, and has achieved the limited ability in California to prescribe drugs, to perform minor surgery and to deliver babies. Chiropractic is facing a raw and debilitating internal conflict over the enthusiasm one faction has for scope expansion with the goal of also having limited prescription privileges, and it’s difficult to see the profession avoiding a deep and permanent split over the issue.

With health care consumers having more autonomy, greater freedom of choice, and the Affordable Care Act buttressing this diversity with a specific anti-discrimination provision, where is this all likely to end up? If nothing changes, it’s likely that it will be fought over the qualifications and training to perform certain procedures, because that’s how competition is framed. But that’s a mistake, and it forces all involved to be either winners or losers. There’s another way, but it’s not an easy fix.

The distinctions of clinical paradigms
What really sets health care professions apart isn’t what they do, it’s why they do it. Western (allopathic) medicine sees its clinical world through the paradigm of health and disease, and sees its role based on that: to increase health by minimizing disease. Its therapeutic tools (drugs and surgery) are designed–and consistent–with this function in mind. Chiropractic sees its clinical world through the paradigm of optimal neurologic and resulting physical function, and in similar fashion its clinical tools (adjustments and preparatory or complementary procedures) are intended to permit and support the body’s normal expression of its innate healing abilities. Various factions split hairs on the specifics of that, but there’s a large territory of shared perspective in the middle. Naturopathic medicine has one foot in both clinical paradigms, focusing on supporting the wisdom of the body (vis medicatrix naturae) while employing drugs and surgery where they deem appropriate. Acupuncture and Traditional Asian Medicine sees their clinical world through a paradigm of energetic balance and use interventions that address imbalances, and on and on. Within each profession’s clinical paradigm, there must be a degree of coherence: its observations must be framed in the language (taxonomy) of its paradigm, and the application of any support, interventional or therapeutic role must be congruent with the philosophy its paradigm is based on. Judged by those requirements, the specific things each profession do aren’t necessarily something to fight over, as each profession should be free to develop and mature within the coherence of its own clinical paradigm. And there’s both the challenge and opportunity.

The challenge exists because it means each profession should be held accountable for defending the degree of coherence within its own practices, and not challenged on those practices outside of that context. It also follows that other professions don’t have standing to criticize the paradigm itself, but only to critique the degree of coherence within what each profession claims as its province. And the opportunity exists because this approach creates the space to have a different conversation about each profession’s ability to contribute to the health of humanity. This way the conversations–and the degree to which established health and payer systems embrace different professional approaches–must hinge on very different metrics (largely outcomes, costs, value, and engagement) than on whether or not someone down the street is doing something I view as an infringement on my law.

There are pointed challenges in approaching interdisciplinary relationships this way. Can physical therapy justify joint mobilization as a coherent element of its clinical paradigm? Can chiropractic justify specific adjustments within its own? Assuming both can, then the comparison must hinge on different considerations and be less about whether or not there’s enabling or prohibitive language in either’s scope of practice laws. And if they or others can’t defend the coherence of their consideration and approach, then it’s probably unlikely that they can point to outcomes that are consistent with the value proposition they associate with philosophy embedded in their discipline.

Bottom line: ‘splain yourself
With the US health care system exploring new models with a focus on ‘value-based purchasing,’ all professions that want to receive insurance-based compensation are ultimately going to need to prove they belong by demonstrating worth in the terms of the host economic and delivery paradigm. For those that want ‘to play the game,’ then in other words if the delivery paradigm creates alignment of patients and providers and the economic paradigm says, effectively, that ‘to be here you have to produce within this range of costs and outcomes,’ professions are either going to be able to justify their participation in those terms or not. Each profession, then, is going to have to demonstrate its own value, and worry less about whether other professions’ scope laws infringe on their own. Arguments over legislation will certainly continue, but are less likely to make much of a change in who’s able to do what. The advantage for many will be that mechanistic research explanations will matter less than whether or not professions can produce value, and that is where it’s likely a good many will enjoy some success.

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