AN ANALYSIS OF THE INTEGRATION OF CHIROPRACTIC SERVICES WITHIN THE UNITED STATES MILITARY AND VETERANS' HEALTH CARE SYSTEMS
 
   

An Analysis of the Integration of Chiropractic Services
Within the United States Military and
Veterans' Health Care Systems

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:
   Frankp@chiro.org
 
   

FROM:   J Manipulative Physiol Ther. 2009 (Nov);   32 (9):   749–757 ~ FULL TEXT

Andrew S. Dunn, DC, MEd, MS, Bart N. Green, DC, MSEd, Scott Gilford, DC

VA Western New York Health Care System,
Buffalo, NY 14215, USA.
andrew.dunn@va.gov


OBJECTIVES:   The purpose of this article is to compare chiropractic integration within the health care systems of the Department of Defense and Department of Veterans Affairs and to identify practices and policies that may either support or challenge the extent of chiropractic integration within those systems.

METHODS:   As subject matter experts and providers within these systems, our team reviewed enacted legislation, policies, and the literature pertinent to chiropractic practice in Department of Defense and Department of Veterans Affairs medical facilities, and identified opportunities and threats pertinent to integration.

RESULTS:   We identified 9 areas wherein potential opportunities and threats to integration existed, including legislative history, programmatic growth, leadership structure, employment status of providers, clinical work duties, patient access, patient demographics, academic affiliations, and research.

CONCLUSION:   These findings provide a higher level of understanding regarding the current state and future direction of chiropractic service integration within these integrated health care systems.



The Full-Text Article:

Introduction

Chiropractic care is one component of health care available for active duty military personnel and veterans in the United States. Active duty military personnel are cared for through the Military Health System (MHS) under the Department of Defense (DoD), and veterans are cared for through the Veterans Health Administration (VHA) within the Department of Veterans Affairs (VA). The inclusion of chiropractic services in MHS and VHA medical facilities is the most systematic and widespread example of the integration of chiropractic care in the United States. Although both the MHS and VHA are federal health care systems, many differences can be seen with the integration of chiropractic. In this article, we analyze the 2 systems and identify practices and policies that may be opportunities or threats to the successful integration of chiropractic within these health care systems.



Methods

We used a simple 2-option analysis of several key factors related to the integration of chiropractic health care services within the MHS and VHA. Two of the essential components (opportunities and threats) of a strengths, weaknesses, opportunities, and threats (SWOT) analysis [1] were applied to 9 topic areas, including the following:

(1) legislative history
(2) programmatic growth
(3) leadership structure
(4) employment status of providers
(5) clinical work duties
(6) patient access
(7) patient demographics
(8) academic affiliations, and
(9) research.

These 9 areas were selected based upon the ability of the topic areas to contribute to objective comparisons between the respective organizational structures and general practice patterns. The primary sources of information were legislative reports, policy documents, and scholarly literature pertinent to chiropractic practice in MHS or VHA medical facilities. The analysis was performed by the authors, whose experiences in federal health care systems range from 5 to 14 years (25 years of combined experience), and includes representation from both MHS and VHA medical facilities.



Analysis

      Description of the Systems

The DoD was established in 1947 as the agency responsible for providing the military forces needed to deter war and protect our national security. [2] Today, the nation's armed forces are trained and equipped through 3 major departments within DoD: the Navy (including the Marine Corps), the Army, and the Air Force. The MHS provides a continuum of medical services across a range of military operations within this department. The MHS mission is to 3 “…provide optimal Health Services in support of our nation's military mission — anytime, anywhere.” These services for active duty members and their dependents who are entitled to DoD health care are managed by TRICARE Management Activity. [4] With 9.2 million TRICARE eligible beneficiaries, today's MHS employs 133,500 health care personnel, with a Unified Medical Program Budget of more than $42 billion. [3] The MHS direct care facilities include 63 hospitals and 413 medical clinics. [3] Originating as the “Chiropractic Health Care Demonstration Project” at 10 military treatment facilities (MTFs), [5, 6] chiropractic health care is currently available at 49 designated MTFs [7] (Table 1), with plans for further expansion [8] to include 11 new locations in the 2009-2010 fiscal year, including the first clinics overseas (Okinawa, Landstuh [1], Grafenwoehr). [9] The TRICARE chiropractic benefit is available to active duty service members, but not to dependents. When active duty personnel are discharged or retire from military service, they transition to veteran status and become eligible for health care services from VA.

VA was established in 1930 to offer veterans benefits and burial services. [10] The VA hospital system was developed after World War II to address the specialized rehabilitative needs of returning troops. It later achieved Presidential Cabinet status in 1989, becoming the Department of Veterans Affairs, with the delivery of health services administered by VHA. In 1995, the hospital system was restructured into what are now 21 geographically defined Veterans Integrated Service Networks. With transformational strategies involving electronic health records, performance management, and a patient-centered focus, VHA has demonstrated measurable progress in the value domains of quality, access, satisfaction, function, community health, and cost-effectiveness. [11]

As stated on its Web site (http://www1.va.gov/health/AboutVHA.asp), the VHA mission is to “…serve the needs of America's veterans by providing primary care, specialized care, and related medical and social support services.” With 23.4 million living veterans, the responsibility of VHA to care for veterans, spouses, survivors, and dependents means that roughly a quarter of the nation's population is potentially eligible for VA benefits and services. [10] In 2008, VHA employed approximately 250,000 health care personnel serving the needs of 5.5 million patients. [10] VHA operates more than 1,400 sites of care, including 153 medical centers and 909 ambulatory care and community-based outpatient clinics. [10] In addition, VHA manages the largest medical and health professions training program in the United States. With the integration of chiropractic services within VHA in 2004, [12] care is currently available to veteran patients at 36 VHA medical facilities or community-based outpatient clinics nationally (Table 1) [13]; this number (36) excludes a few instances where VHA chiropractors provide care at more than one location within a given hospital system. Similar to the MHS policy, chiropractic services are not a benefit for dependents of veterans.



Legislative History

The integration of chiropractic services into the health care systems of DoD and VA was initiated through legislative action. Commencing with DoD, the National Defense Authorization Acts for Fiscal Years 1993, [14] 1995, [15] 1998, [16] 2000, [17] 2001, [18] 2004-2007, [19-22] and 2009 [23] drove chiropractic integration within MHS. The 10 pieces of legislation enacted over 17 years have contributed to the current landscape of chiropractic practice within the MHS of DoD and are summarized in Table 2.

With regard to VA, only 3 pieces of legislation enacted over a 9-year period have contributed to the delivery of chiropractic services within VHA medical facilities (Table 2). The signing into law of the Veterans Millennium Health Care and Benefits Act [24]; the Department of Veterans Affairs Health Care Programs Enhancement Acts of 2001 [25]; and the Veterans Health Care, Capital Asset, and Business Improvement Act of 2003 [26] eventually resulted in the establishment of the initial 26 chiropractic clinics within VHA medical facilities. The expansion of the VHA chiropractic program from 26 to 36 locations has occurred in the absence of legislative mandate.

Although the growth of chiropractic services within the MHS is significant, legislative directives have largely fueled this growth. Conversely, expansion of chiropractic services within VHA has been comparably slow but internally driven. We see this difference as an important one because the use of legislation, although it might be a necessary stimulator for integration, can result in resistance to chiropractic inclusion among individuals and systems having this change thrust upon them. This can potentially negatively affect how the integration of chiropractic is perceived and influence the maturation of the chiropractic discipline within those systems.



Programmatic Growth

It is interesting to note the amount of growth of the chiropractic benefit in both systems. The DoD started with a demonstration project, with fewer initial locations for chiropractic services than VA, before it was implemented across the continental United States to its current level of 49 commands (Table 3). These data actually underreport to some degree the actual number of active clinics because some commands offer several locations for chiropractic services. One example is the Marine Corps Base Camp Pendleton, where chiropractic care is located at 2 clinics aboard the 125,000-acre base. Another example is Naval Medical Center San Diego, where chiropractic care is offered by 3 chiropractors at 5 different locations in an effort to provide care to a broad geographic area and 2 special subpopulations (SEAL trainees and complex casualty patients). The authors are aware of other commands functioning in a similar manner. Regardless, DoD has demonstrated nearly a 5-fold increase in commands offering the benefit over a 14-year period.

In comparison, the VA did not initiate chiropractic services with a demonstration project. Starting in September of 2004, the first of the initially identified 26 VHA medical facilities to offer chiropractic services began providing care to veteran patients. Over the following 1 to 2 years, all 26 sites implemented chiropractic clinics at varying capacities in fulfillment of the requirement set forth by then VA Secretary Anthony Principi. [25] Additional VHA chiropractic clinics have developed since then, some as academic affiliates, to the current total of 36 facilities; this represents 38% growth without legislative mandate. Despite the relatively limited number of medical facilities currently providing chiropractic services within each system, successful integration within any established system requires time. The growth to date as identified within both MHS and VHA serves as an indication of further growth to come, which is an excellent opportunity for more extensive integration within these environments.



Leadership Structure

Within the MHS, leadership for the chiropractic program initiates at the level of each command and is represented by a department head or similar figure. The department head usually reports to a leader one level higher in the chain of command, such as a director of a service, who will then, typically, report to the commanding officer of the military hospital. Hospitals in each branch of the military then are overseen by another level of administration, such as the Bureau of Medicine and Surgery for the US Navy. Each branch also has a Specialty Advisor who is responsible for addressing issues regarding chiropractic activities, in addition to other administrative functions. Finally, each branch of the military has its own Surgeon General at the top of the chain of command. For several years, DoD used an oversight committee until the demonstration project was complete, after which the oversight committee was disbanded. At this time, no chiropractors function within the described DoD leadership structure (Table 3).

In 2002, before the integration of chiropractic services into VHA, an Advisory Committee on Chiropractic Care Implementation was established. This committee was instrumental in the development of the program currently in place. In January 2006, VHA appointed a Chiropractic Field Advisory Committee (FAC) (Table 3) composed of VHA chiropractors, an administrative liaison, and a physician member to offer input from the field to VA Central Office, as requested. In 2007, chiropractic services were recognized as a national program aligned within Rehabilitation Services with an appointed field-based chiropractic program director (Table 3). The director provides administrative oversight of programmatic development, coordinating FAC input with the Office of Rehabilitation Services. This structure supports national coordination of communication between VHA chiropractors through regular FAC meetings, conference calls, and national or regional conference calls for all VHA chiropractors.

Although both the VHA and MHS have multilevel leadership and organizational structures, the central leadership post of VA's Chiropractic Program Director and chiropractic provider input through the FAC stand in stark contrast to the decentralized leadership structure present in MHS. It would appear that the chiropractic leadership configuration within VHA carries with it the potential to support provider development within the system and influence the learning curve of doctors of chiropractic within VHA. The decentralized structure of MHS and lack of a “go to” person could challenge integration of the service by contributing to providers working in relative isolation. The significance of having a doctor of chiropractic in a leadership position within the system cannot be overstated as an opportunity for integration with its inherent potential to influence communication, policy, and practice.



Employment Status of Providers

Doctors of chiropractic within the MHS currently serve in the role of contractor or as employees of contractors, as opposed to working as federal employees (Table 3); however, recent discussions have ensued pertaining to converting chiropractors to federal employee positions. The Navy contracts directly with individual chiropractors through Naval Medical Logistics Command (www-nmlc.med.navy.mil). The Army originally contracted with Aliron Internation Inc; and now, it contracts with Kuhana Associates (www.kuhana.com). The Air Force contracts with Cherokee Nations Industries (www.cnicnd.com). The contractual relationships with MHS are limited by the terms of the contract period. In situations where chiropractors are employees of contracting companies, employees of these contractors are potentially subject to dismissal if the contracting organization loses its next bid. However, these same chiropractic providers (employees) may be offered positions as new employees by the company awarded the contract for the subsequent contract period. If hired by a new contractor, the employee may lose employee benefits, which would otherwise be maintained by a sustained working relationship with the same employer. As a result, compared with their VHA colleagues, some MHS chiropractors may experience less job security and an inability to “grow” employment benefits. When a chiropractor is contracted directly, as is the situation with the Navy, that chiropractor could find him/herself out of work at the end of each fiscal year based upon the language of the individual contract. These contractors must provide their own major benefits, such as health and life insurance and a retirement fund. This type of work arrangement could potentially lead to greater turnover of providers, thus threatening the success of integration in the long term. However, given the obvious growth witnessed in the chiropractic program within the MHS, this may not turn out to be true.

Within VHA, most doctors of chiropractic are federal employees, more than half of whom are full-time, receiving salary and benefits determined by a centralized qualification standards board (Table 3). Some VHA chiropractors serve in contract positions in various capacities. Chiropractors can also be appointed as “without compensation” providers, where they are chiropractic college faculty members that provide academic and clinical services within VA medical facilities as part of academic affiliations.

The VHA employee benefits provide a sharp contrast to those of the contractor positions for chiropractors within the MHS, including retirement funds, health care, a structure for advancement in pay and rank, and a level of job security. The commitment made by a system or organization when it hires a chiropractor as an employee conveys a statement about how much that provider is an integral component of that system. It is more difficult to release an employee without cause than it is a contractor, as employee status carries with it certain protections. Contractors and employees of contractors do not have these benefits and may be released regardless of their performance, making the contractor position one that is less stable and less integrated into the system, serving as a potential threat to successful integration.



Clinical Work Duties

Chiropractors in both the MHS and VHA share similar work duties. Because they provide care at hospitals, they are allowed to practice within a set of parameters (privileges) established within their system and facility. The primary duty is to provide comprehensive chiropractic services as is commonly taught at accredited chiropractic colleges and in further specialty training. Chiropractors in both systems are allowed to use the manipulative techniques that they feel are appropriate for the needs of the patient, as well as other procedures, such as therapeutic modalities and rehabilitation. Typically, although chiropractors in these systems do not hire office staff, it is expected that they will provide direction to clinical support staff. One difference noted is that in some MHS clinics, military enlisted technicians provide ancillary clinical support rather than chiropractic assistants.

Chiropractors in both systems are often supervised by personnel who are not likely to be chiropractors and, in the MHS, are often officers. Both systems use peer review (referred to as chart review within VHA), which is an important quality assurance function that takes place either formally or informally. Formally, each chiropractor's peer reviews his or her electronic medical record and provides feedback on the quality of documentation and whether it meets the standards expected by the hospital and outside accrediting agencies, such as the Joint Commission of Accreditation. Informally, chiropractors in both systems interact with other providers (eg, chiropractors, physical therapists, medical doctors, osteopaths) in a highly transparent environment, often while treating patients, so that evaluation, even at the most subtle of levels, is ongoing.

Chiropractors in both systems are also expected to uphold guidelines, such as utilization reviews and risk management instructions, and may be required to perform administrative tasks. Chiropractors in both systems are expected to attend regular staff meetings, maintain a host of yearly live and online training competencies, and provide in-service training, as needed. Furthermore, both systems have documentation requirements within their electronic medical record systems. Within MHS, the system is Armed Forces Health Longitudinal Technology Application; and within VHA, it is the Computerized Patient Record System. Based upon communications between providers within both systems, the 2 electronic medical record systems differ considerably in their use and operation.

We feel that the similarities present in the work duties of doctors of chiropractic in MHS and VHA medical facilities represent opportunities for integration within and between systems. The resemblances within the systems allow for the mobility of doctors of chiropractic between locations within their respective systems as opportunities allow. Moreover, a chiropractor from within one of these systems should be able to transition fairly easily to a position in the other system, despite the differences in electronic medical record systems, providing a smooth transition for the hospital, patients, and providers.



Patient Access

Patient access to chiropractic services within either system entails obtaining a referral from a gatekeeper, timely scheduling of services based upon that referral, and patient proximity to a medical treatment facility where chiropractic services are provided. Within MHS, access to chiropractic services is largely based upon a gatekeeper referral; and within VHA, access is entirely referral or consultation dependent. Within VHA, patient access to any specialty provider requires a consultation request from the patient's gatekeeper, generally a primary care physician, who is responsible for the coordination of all clinical services received within the system. Upon completion of the consultation, the chiropractor's patient narrative is communicated electronically back to the gatekeeper. Professional relationships are quickly developed within this system of patient access, contributing to collaboration among provider types in a patient-centered environment.

Anecdotal reports of high levels of clinic productivity by providers within both systems suggest that the requirement of a gatekeeper referral may not serve as a limiting factor to patient access. However, this productivity per provider could misrepresent the level of demand for services and patient access to chiropractic services, as there could simply be an insufficient supply of providers for the patients able to obtain referrals. The extent to which gatekeepers may refuse to refer patients to chiropractic clinics within either system is not known and could serve as a potential barrier to patient access. Furthermore, access to services has a temporal component, with most facilities requiring that patients are seen within 30 days of the referral. An accurate understanding of current wait times for access to chiropractic services is unclear, and high levels of demand for service coupled with limited provider capacity could negatively impact wait times and effectively limit timely patient access to chiropractic services.

The logistic issues of providing access to chiropractic services to a mobile military patient population vs a relatively immobile veteran patient population could also impact the integration of chiropractic services. Delivering chiropractic care for patients in the MHS can be a difficult task because patients often move or are away from their post on training exercises or deployments. The prevailing assumption is that chiropractic care will be provided, with the expected end result that the service member will recover and return to full duty status. Conversely, patients in VHA tend to need care for more chronic disorders. In addition, these patients are more permanent residents than their MHS counterparts; and they are more likely to have health care provided over longer periods of time in one location. In either case, as active duty military personnel and veterans move about the country, they will likely be stationed at or choose to live near an MHS or VHA facility that does not offer chiropractic services. Better patient access to chiropractic services could probably be achieved by integration of services on a national scale within both systems.

Patient access to chiropractic services within MHS and VHA through gatekeeper referral can enhance integration through collaborative case management between chiropractors and gatekeepers. However, if there are instances where access is not timely, referrals are not obtained, or services are not available, these will have a negative impact on chiropractic services and the integration of chiropractic within these systems. Timely and appropriate patient access to chiropractic services for all active duty military personnel and veterans cannot be fully realized, and the full integration of chiropractic within MHS and VHA cannot be achieved without service availability at all treatment facilities.



Patient Demographics

Those working in the DoD environment care for a mix of active duty patients and active duty veteran patients, as many have served in previous conflicts, having been deployed multiple times in support of Operation Iraqi Freedom (OIF) and/or Operation Enduring Freedom (OEF), or having been activated from reserve to active duty status. To date, there are no studies reporting on the demographics of any chiropractic clinic in the MHS. However, studies on OIF and OEF military members have noted a high rate of musculoskeletal disorders requiring care [27]; and a substantial number of these members experience clinically significant pain. [28]

Some published demographic data are available for one VHA medical center chiropractic clinic in 2 separate studies. One article reports the average of the 100 patients reviewed to be 55 years old, male (88%), and presenting with a chief complaint of low back pain (82%); and 55% had a service-connected disability, with the average percentage rating of 51%. [29] A later and more extensive (N = 292) study at the same facility found the average patient to be 55 years old, male (88%), with a chief complaint of low back pain (72%), and with an average body mass index of 30 kg/m2; and 54% had a service-connected disability, with the average percentage rating of 52%. This study also found that 36% of these veterans had a period of service during the Vietnam era and that 16% had been diagnosed with posttraumatic stress disorder. [30] Chiropractors providing service within VHA, anecdotally, have noted an increase in the number of OIF/OEF veterans receiving chiropractic care; but objective data have not been reported.

As a consequence, although it might be assumed that DoD patients are younger and healthier than VA patients, representing a bimodal distribution, it would seem that the 2 populations are potentially becoming more homogenous. Published accounts originally identified veteran chiropractic patients as likely older than those seen in MTFs, yet it has been anecdotally recognized that recent conflicts have contributed to less distinct differences in patient demographics between the 2 systems. Although the blending of these patient populations may encourage collaboration between MHS and VHA chiropractors, we do not know if the changing demographic makeup of the MHS and VHA patient populations will be an opportunity or threat to chiropractic integration within each system. We suspect that as more of these beneficiaries age and need care for chronic musculoskeletal disorders, the level of demand for services within VHA will likely continue to increase. The real opportunity or threat to chiropractic integration within these systems is the extent to which clinical effectiveness can be demonstrated in the maintenance of military readiness among active duty personnel [31] and in the management of more chronic musculoskeletal complaints among the veteran population.



Academic Affiliations and Research

The first training rotation for chiropractic clinical education within the DoD began in July of 2001 with a single New York Chiropractic College student at the National Naval Medical Center (NNMC). [32] The rotation at the NNMC has allowed for supervised clinical training within the chiropractic clinic along with rotations with other trainees through various hospital departments, thereby providing opportunities for chiropractic integration within the medical center. The NNMC program has continued to evolve, to include students from multiple chiropractic institutions, and has served as a model for other similar programs. A postgraduate chiropractic fellowship in integrative medicine developed at NNMC was completed in June of 2004. This represented a first of its kind structured postgraduate chiropractic training program within the MHS. Two other training programs for students, similar in design to that at NNMC, have also functioned at Marine Corps Base Camp Lejeune and Marine Corps Base Camp Pendelton; but these are currently not operating (Table 3).

Since 1946, VHA has collaborated with many of the country's medical and allied health professional schools to create the most comprehensive academic health system partnership in history. For more than 60 years, VHA has trained new health care professionals to meet both the patient care needs within VHA and those of the nation (http://www.va.gov/oaa/OAA_Mission.asp). Chiropractic academic affiliations within VHA began in September 2004 at the VA of Western New York Health Care System. [33] Since that time, academic affiliations have developed at 14 VA medical facilities involving 11 different chiropractic institutions (Table 3). Although most chiropractic academic affiliations were established with doctors of chiropractic already appointed within VA medical facilities, chiropractic programs have been implemented as academically affiliated programs in at least 3 VHA medical facilities that were not initially mandated by VHA. [34] Methods to enhance chiropractic student education as well as new opportunities for training are under development.

With the overwhelming majority of the duties of DoD chiropractors focused on providing care, little research activity has been realized from this environment. We are unaware of any contract that indicates that the chiropractor has time allocated for research activity. To the best of our knowledge, 4 articles (Table 3) that represent education research efforts, [32] 2 clinical case reports, [35, 36] and 1 editorial on how chiropractic services are used within DoD and VA [37] have been published. A few doctors have mentioned efforts pertaining to conducting studies or endeavors to author articles, but we do not know the full extent of this activity. It is unknown if any chiropractors in the DoD participate on research committees or institutional review boards. In addition to there being no time allocated for research in this environment, many commands have a requirement that principal investigators are government employees or officers. Because there are no chiropractors in such positions, it effectively hampers the viability of research efforts. Although it is possible for a contractor to participate as a principal investigator associate, if his or her idea is tasked to an officer who does not share the same zeal for the project or who is also likely to move to another post within a short period, it is difficult to complete the research effectively.

With research being one mission of VHA, doctors of chiropractic within VHA have had the opportunity to serve as investigators in local and multisite studies, both funded and nonfunded, including survey methods, retrospective analysis, and randomized controlled trials. The number of peer-reviewed publications [29, 30, 33, 34, 38, 39, 40] stemming from this work continues to grow (Table 3). As practitioners, researchers, and academics, both within and outside of the VA system, become more aware of the work of the chiropractic profession within this arena, it will hopefully contribute to further interprofessional understanding, relationships, and collaboration. The FAC has played a role in supporting the effort for VHA chiropractors to take part in the research process through mentoring and encouraging attendance and participation at the Association of Chiropractic Colleges Annual Meeting/Research Agenda Conference. In addition to serving as investigators in VA-sponsored research, a number of VHA doctors of chiropractic serve on local research committees (research and development committees and institutional review boards), contributing to a broader range of research involvement outside of chiropractic.

The emphasis placed on and resources provided for the purpose of training and research within VA have provided the VHA chiropractic program with an opportunity to develop providers within the system, interact with a generation of trainees from other health care disciplines, and work to advance the scientific understanding of our work through supported research efforts. This undoubtedly has been an opportunity for the integration of chiropractic within VHA. Within MHS, the high turnover of patients and local leadership, no resource allocation for research, and the role of contractor as opposed to employee or officer have likely limited academic and research pursuits.



Thoughts on the Future

Although the inclusion of chiropractic services in both VHA and MHA has met with warm reception at many locations and it seems that the service is now firmly part of 2 of America's largest health benefit plans, issues for further integration remain. Health care delivery within MHA and VHA is guided by a theme of service to those who wear or have worn the cloth of the nation. These are systems dedicated to extensive patient populations that require utilization management and the efficient allocation of limited resources driven by measures of patient access, effectiveness of care, and patient satisfaction. It is not the individual provider who determines the value of their service, but the system that ultimately assigns a value consistent with the mission of that system and the varying needs of its stakeholders. For chiropractic to more fully integrate within these federal programs, chiropractors operating within these systems need to strive to ever more effectively provide health care services in a manner dictated by the needs of the patient base served, all the while being sensitive to other disciplines and providers and the fiscal, physical, and political constraints of those systems. The success of any discipline within these systems hinges on the quality of clinical services delivered along with a high level of communication and consistency among providers. This is further enhanced through individual and group contributions to administration, policy development, academic pursuits, and an organized research agenda that must be collaborative, coordinated, and in concert with the metrics of the individual systems. Although legislative drivers have introduced chiropractic to these federal health care systems, the level of acceptance and integration of chiropractic will ultimately depend on the ability of established and future chiropractors within both MHA and VHA to add measurable value to service delivery within those systems.


Limitations

There are several limitations to this analysis. First, this is a partial SWOT analysis; and SWOT analyses have received scrutiny for being overly simplistic. [41] Nonetheless, we used an even simpler version. This poses certain limitations in that we analyzed the opportunities and threats to the integration of chiropractic services in both the MHS and VHA, but not necessarily the strengths and weaknesses inherent to these 2 systems. We acknowledge this shortcoming; however, our analysis at least provides a starting point for future endeavors in this area.

Another limitation is that it did not include a systematic review. To overcome this limitation, we relied upon data from another study that investigated this topic [42]; and consequently, we feel that we had adequate access to the available literature on this topic. Third, we recognize that some variations within each system and between facilities and providers likely exist beyond the generalizations made within this analysis. We did not attempt to analyze nuances within each system, but opted to look at larger indicators of opportunities or threats to integration. A final limitation of this research is that the authors working as providers within these systems may be subject to biases that would not be present if this analysis was performed by authors external to each system. However, it would be difficult, if not impossible, for external researchers to identify some of the opportunities and threats easily observed by providers within the systems analyzed. Perhaps future work could include a team of authors that are both internal and external to the systems reviewed.



Conclusion

The integration of chiropractic services within both MHS and VHA has continued to advance based upon the level of demand for patient services, the collaborative nature inherent to patient care in these facilities, and legislative drivers. The development of a chiropractic program director position in VHA and the largely employee status of providers within VHA appear to have positively influenced integration. Further research is necessary to determine if the largely contractor-based chiropractic workforce within MHS is an opportunity or threat to integration.

Chiropractic service utilization within both MHS and VHA may be limited in instances where patient access is denied or is not timely, or if chiropractic services are not available; however, collaborative working relationships between chiropractors and gatekeepers are opportunities for integration in both settings. Although differences in patient demographics within MHS and VHA may be decreasing, the impact of demographic variables, both shared and unique to each system, on chiropractic integration will actually stem from the level to which clinical effectiveness can be demonstrated in meeting the health care needs of patients in both systems.

More efforts at conducting such research have occurred in a VHA environment supportive of research activity creating more opportunities for integration. The evolution of training programs and academic affiliations have contributed to integration, particularly in the VHA where there has been substantial growth; further development of training programs in the MHS may further strengthen the integration of chiropractic within this system.



Practical Applications

  • Integration of chiropractic services within MHS and VHA has advanced.

  • Development of a chiropractic program director position in VHA and
    employee status of providers within VHA appear to have
    positively influenced integration.

  • Collaborative working relationships between chiropractors and
    gatekeepers are opportunities for integration in both settings.

  • Evolution of training programs and academic affiliations have
    contributed to integration.

  • Further development of training programs may further strengthen
    the integration of chiropractic within these health care systems.



Funding Sources and Potential Conflicts of Interest

No funding sources or conflicts of interest were reported for this study.


Acknowledgment

The authors thank Anthony J Lisi, DC, the Director of VA Chiropractic Services, for his input to this manuscript.



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  30. Dunn, AS and Passmore, SR.
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  33. Dunn, AS.
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  36. Green, BN, Sims, J, and Allen, R.
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