Introduction
Health care in America is a big business with strengths and weaknesses. Primary care has demonstrated to be an essential part of health care, one that prevents illnesses and reduces more expensive medical and surgical interventions.1 The Affordable Care Act made health care more available for more than 40 million Americans.2 Community Health Centers have also made primary care more available to 32.5 million Americans.3 Yet there is one major problem with the delivery of primary care to Americans. Fewer medical graduates are choosing to become primary care providers/physicians.
DISCUSSION
Workforce Primary Care Provider Shortage
It has been predicted that a physician workforce shortage will occur in the United States by 2030. Outcomes of this study conclude that to meet the growing demand for health services, medical schools must produce more graduates, and the health care system should utilize mid-level providers.4
According to the AMA, workforce experts continue to predict that the U.S. will face a significant physician shortage for both primary care and specialty physicians over the next ten+ years if training positions are not expanded.5
Federally Qualified Health Centers
Flinter introduced resident training programs for primary care nurse practitioners in Federally Qualified Health Centers (FQHC) to meet the primary care needs of the medically underserved, special populations, and the uninsured throughout the United States.6 She revealed that the primary care workforce shortage is most apparent in the nation’s largest primary care system, the network of more than 1,100 FQHCs.7 Flinter and Hart revealed findings that resident training for APRN residents supported the transition from entry-level competency to a competent and confident primary care provider, one capable to function within very challenging primary care settings.8 Morgan claimed that Physician Assistants and Nurse Practitioners would reduce the workforce shortage if permitted to perform physician work.9
The most recent literature describes the use of chiropractic clinicians within FQHCs in America. According to Albertson, et al, there are 233 chiropractors providing clinical services within 146 FQHC primary care organizations with two thirds employing two or more chiropractic providers.10
The University of Bridgeport School of Chiropractic (UBSC)
The four-year curriculum for UBSC provides a comprehensive doctoral program including 4587 hours of Basic Sciences, Clinical Sciences, and Clinical Services. The breakdown demonstrates the extensive doctoral training offered to chiropractic doctoral students that serves as a reasonable platform for the future neuromusculoskeletal medicine specialist and advance practice primary care provider.
Basic Sciences 1152 hours
Anatomy (cellular and physiology, functional anatomy of the spine and extremities, general anatomy of the head, neck and visceral, and clinical embryology), Biochemistry, Physiology (organ systems and toxic pharmacology), Neurosciences, Pathology (fundamentals and systems pathology), Microbiology (clinical microbiology and infectious diseases), Public Health and Wellness.
Clinical Sciences 2277 hours
Principles, Practice, and Philosophy, Radiology, Diagnosis, (physical examination, orthopedics, neurology, laboratory and special populations), Differential Diagnosis (internal disorders, neuromusculoskeletal conditions, and psychological conditions), Physiological Therapeutics, Nutrition (nutritional pathology, and clinical nutrition), Emergency procedures, and Business procedures, Chiropractic skills and techniques.
Clinical Services 1158 hours
The 4 semesters include clinical rotations in the Health Science Center on campus, Federally Qualified Health Centers, Veterans Administration Hospital, and private chiropractic and medical clinics.
It continues to be my opinion that chiropractic schools should develop academic programs that prepare future chiropractic physicians to serve as chiropractic specialists in both neuromusculoskeletal medicine and primary care medicine.11
Chiropractic Medicine Integration
Chiropractic medicine was first integrated with primary and specialty care within a health care system in 1991.12 It has been proposed that chiropractic medicine found Integrative Medicine Centers of Excellence as a strategy to build higher cultural authority.13 At this time, there is evidence that such centers of excellence exist within Federally Qualified Health Centers, which have integrated chiropractic services.14 Integration of chiropractic medicine has become a growing trend because chiropractic physicians are pursuing careers within both Veterans and University based hospitals and Federally Qualified Health Centers.15
Consortium of Advanced Practice Providers
One solution to the workforce shortage of primary care providers involved the training of nurse practitioners in primary care medicine. The first residency specifically designed for family nurse practitioners to provide primary care within Federally Qualified Health Centers (FQHC) began in 2007.16
In 2011, Flinter described the transition through the FQHC residency training for new nurse practitioners becoming primary care providers. She concluded that two innovations, community health center residency training and nurse practitioners trained to be primary care providers address the shortage of primary care services within the network of more than 1,100 FQHCs.17 Another study found that primary care residencies and fellowships offered within FQHCs produce advance practice nurse practitioners and they do address the shortage of primary care providers.18
According to HRSA, “Improving access to primary care services and increasing the number of practicing PCPs are key components to achieving national objectives in the Health Resources and Services Administration (HRSA) strategic plan.”19 The Consortium for Advanced Practice Providers is accrediting residencies and fellowships that prepare Advanced Practice Registered Nurses and Physician Assistants to become primary care providers within Federally Qualified Health Centers.20 Yet, the shortage of primary care providers persists with predictions that the shortage will continue to increase over the next 5-10 years. Is there another health care provider that may be trained as a primary care provider that might be part of a solution to the workforce shortage of primary care providers?
Is it possible that chiropractic physicians board certified in neuromusculoskeletal medicine with primary care fellowship training within Federally Qualified Health Centers and a full scope of practice including pharmaceuticals would provide high quality of evidence based medical care?
With respect to a set of primary care activities that occur daily in medical offices, chiropractors are able to make diagnoses in 92% of the activities and to make therapeutic contributions in more than 50% of the activities. Medical doctor involvement was perceived as required more frequently by the chiropractic panel than by the interdisciplinary panel.21
Americans embrace the integration of non-allopathic care into the primary care environments and their primary care providers welcome the additional services.22 Is it possible that chiropractic physicians with both specialty training and primary care medicine training could provide judicious prescription of pharmaceuticals, regenerative medicine, and non-pharmacological treatments?
Is there a credentialing body willing and capable of accrediting a Doctor of Chiropractic Primary Care Program(DCPCP)? Would the Consortium of Advanced Practice Providers accredit a non-APRN fellowship in primary care medicine? If yes, are there Federally Qualified Health Centers willing to prepare for and secure accreditation from the Consortium for chiropractic specialists to train in primary care within their primary care facilities? If Federally Qualified Health Centers are not willing to invest in provision of resources, leadership, and support of the DCPCP, it is not likely that chiropractic specialists could become primary care providers.
Integration of Chiropractic Medicine in New Mexico
Based upon one small study in New Mexico, patients perceive their chiropractic physicians to be primary care providers that should have prescriptive authority.23 Currently, there are approximately 70,000 practicing chiropractic physicians in America. I assume based upon discussions with chiropractic leaders in the profession that 10-20 per cent of the chiropractic physicians would pursue a position as a primary care provider if offered the opportunity within Federally Qualified Health Centers. If my assumption is correct, a minimum of 7,000 new primary care providers could enhance the availability of primary care services in America.
The integration of chiropractic medicine into traditional medicine (allopathic) facilities is not a new movement. In New Mexico, the Lovelace Health Care System credentialed chiropractic specialists into the orthopedic department of the hospital in 1991. Patient demand was the original reason for the addition of chiropractic services.24 Since Lovelace controlled non-MD/DO services with a gate-keeper process, it was unknown if the medical physicians would refer to chiropractic physicians. After a period of three years, it became obvious that medical physicians would refer patients for chiropractic services if the physicians trusted the chiropractic physician.25
Fifteen years after the integration of chiropractic medicine into the Lovelace Health Care System, 2 chiropractors integrated into community health centers in Ottawa, Canada. The outcomes were similar to the Lovelace experience. Twelve medical providers expressed increased willingness to trust the chiropractors in shared care.26 A 10-year study described the successful integration of chiropractic services into a large, private hospital system in Minnesota.27
Primary Care Medicine and Chiropractic Physicians in New Mexico
The Institute of Medicine (IOM) established a definition of Primary Care in 1996; “Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.”28 More than 15 years ago, chiropractic physicians in New Mexico completed post-doctoral training and became advanced practice providers with an expanded scope of practice, which included prescriptive authority. The Public Regulation Commission and Insurance Division defined chiropractic physicians as primary care physicians.
The New Mexico Board of Chiropractic Examiners expanded the scope of practice for chiropractic physicians with advanced practice training, which became effective March 31, 2009.29
STATUTORY AUTHORITY: This part is promulgated pursuant to the Chiropractic Examiners Practice Act Sections 61-4-2, 61-4-4, 61-4-6, 61-4-12 and 61-4-13 NMSA 1978. [16.4.15.3 NMAC - N, 3/31/2009]
“Certified advanced practice chiropractic physician” means advanced practice chiropractor who shall have prescriptive authority for therapeutic and diagnostic purposes as authorized by statute and stated by the board in 16.4.15.11 NMAC.
A chiropractic physician shall have the prescriptive authority to administer through injections and prescribe the compounding of substances that are authorized in the advanced practice formulary. Those with active registration are allowed prescription authority that is limited to the current formulary as agreed on by the New Mexico board of chiropractic examiners and as by statute, by the New Mexico board of pharmacy and the New Mexico medical board. The New Mexico board of chiropractic examiners shall maintain a registry of all chiropractic physicians who are registered in advanced practice and shall notify the New Mexico board of pharmacy of all such current registered licensees no later than September 1st of each licensing period.
The Public Regulation Commission, Insurance Division issued rule 13.10.21.1 NMAC which became effective 09/01/2009 with a permanent duration that applies to all health care insurers that provide, offer, or administer health care coverage pursuant to the health maintenance organization (HMO) laws of the state of New Mexico:
“Health care professional” means physicians, dentists, registered nurses, licensed practical nurses, podiatrists, optometrists, chiropractic physicians, physician assistants, nurse anesthetists, certified nurse practitioners, certified nurse-midwives, registered lay midwives, clinical psychologists, social workers, pharmacists, nutritionists, occupational therapists, physical therapists, doctors of oriental medicine, and other professionals engaged in the delivery of health care services who are licensed to practice in New Mexico, are certified, and are practicing under the authority of an HMO.
“Primary care practitioner” means physicians, other health care professionals such as doctors of oriental medicine, chiropractic physicians, nurse practitioners, physician assistants, or certified nurse midwives who may provide primary care, provided that the health care practitioner: 1) is acting within his or her scope of practice as defined under the relevant state licensing law; 2) meets the HMO eligibility criteria for health care practitioners who provide primary care; and 3) agrees to participate and to comply with the health care insurers or HMO care coordination and referral policies.30
The New Mexico Board of Chiropractic Examiners expanded the scope of practice for chiropractic physicians with advanced practice training, which became effective March 31, 2009.31
STATUTORY AUTHORITY: This part is promulgated pursuant to the Chiropractic Examiners Practice Act Sections 61-4-2, 61-4-4, 61-4-6, 61-4-12 and 61-4-13 NMSA 1978. [16.4.15.3 NMAC - N, 3/31/2009]
“Certified advanced practice chiropractic physician” means advanced practice chiropractor who shall have prescriptive authority for therapeutic and diagnostic purposes as authorized by statute and stated by the board in 16.4.15.11 NMAC.
A chiropractic physician shall have the prescriptive authority to administer through injections and prescribe the compounding of substances that are authorized in the advanced practice formulary. Those with active registration are allowed prescription authority that is limited to the current formulary as agreed on by the New Mexico board of chiropractic examiners and as by statute, by the New Mexico board of pharmacy and the New Mexico medical board. The New Mexico board of chiropractic examiners shall maintain a registry of all chiropractic physicians who are registered in advanced practice and shall notify the New Mexico board of pharmacy of all such current registered licensees no later than September 1st of each licensing period.
The University of New Mexico/School of Medicine offers integrative medicine services through the Center for Life, which has included rotations for fourth year medical students. The School of Medicine has offered medical training including a rotation with a chiropractic physician since 2002.32 Arti Prasad MD, Center for Life’s founding Executive Director, was also the founding Section Chief of Integrative Medicine at the University of New Mexico’s Health Science Center (UNM HSC). This section was created to develop a comprehensive primary health care system based on an integrative approach that combines allopathic medical care with Complementary and Alternative medicine (CAM) using the best current evidence. Under her able leadership, UNM SOM is now a member of the national Consortium of the Academic Health Centers for Integrative Medicine (CAHCIM).
Pilot Study: Community Health Center Inc.
A detailed analysis of patient data revealed that in 2012 there were more than 12,000 patients cared for at CHCI with chronic painful conditions. These patients accounted for nearly 40 percent of all adult patient visits during that year. Opioids were commonly used in primary care to treat chronic pain. More than 1,200 patients were managed with opioids for more than 90 days. Very few patients with chronic pain were referred to providers of complementary and alternative medicine and none to chiropractic providers.
To test the potential of providing a pathway for integrated chiropractic care for patients with pain, CHCI and University of Bridgeport conducted a single-site pilot study in which a chiropractic attending provider and 3 chiropractic students from the University of Bridgeport offered chiropractic services for patients suffering with painful musculoskeletal conditions. The chiropractic providers practiced within 1 of the CHCI primary care facilities using the health center’s electronic health records (EHRs). The internal referrals for chiropractic services were received via the primary care providers (e.g., MD, DO, APRN). Chiropractic and primary care providers collaborated closely and used the principles of stepped care treatment. Chiropractic physicians utilized custom templates created in CHCI’s integrated EHR, eClinicalWorks (eCW), to document all care.
Working in an examination room in the primary care clinic with appropriate equipment, the DCs provided chiropractic treatment to health center patients for two days a week from January 2012 to August 2012. Seventy-six unique patients, referred by 10 PCPs, underwent treatment during this period and completed a satisfaction-with-chiropractic-services survey. Results demonstrated extremely high degrees of satisfaction (i.e., 98.7 percent of patients were completely satisfied). Ninety percent of all patients who completed chiropractic treatment stated that their conditions improved. Based on these results, CHCI expanded this project and added on-site chiropractic treatment to nine sites across Connecticut.33
Currently, the credentialed, chiropractic specialists are fully integrated and serve at all Connecticut CHCI sites. They provide evaluation and management services within a patient-centered model of care, along with UB faculty, residents and students participating in our intercollaborative professional practice and education model of care.
Chiropractors have been shown to be suited to participate on funded primary care teams in Canada. Chiropractors were integrated into medical teams because of a high demand for their services by both patients and providers. The chiropractors provided musculoskeletal care as members of the primary care team. The teams employed unique approaches to integrating chiropractors and indicated high demand for their services by patients and providers. Provision of MSK care without economic barrier is desirable and highly valued by the teams. The study demonstrated that chiropractors are well suited to participate on funded primary care teams in Canada.34
Conclusion
There is a potential pathway for chiropractic physicians to become trained and credentialed as primary care providers within credentialed Federally Qualified Health Centers. One of the pragmatic solutions to the primary care provider workforce shortage is the training and credentialing of chiropractic physicians to provide primary care services within Federally Qualified Health Centers. In addition to the completion of the Doctor of Chiropractic program and the resident training program in Neuromusculoskeletal Medicine, it would be necessary to complete a primary care fellowship within a Federally Qualified Health Center. This training and regulatory changes would be required to enable a chiropractic specialist to become credentialed as an advanced practice primary care provider. The Primary Care Fellowship would require accreditation by the Consortium of Advanced Practice Providers and regulatory changes that enable expansion of scope of practice to include prescriptive authority.
As a chiropractic specialist that taught APRN residents orthopedic and neurological examination procedures for a period of three years, I feel confident that professionally trained and credentialed chiropractic specialists could become competent and capable primary care providers within FQHCs.