By Randy Southerland
The GCC, GCA, Georgia Board of Examiners and Life University united together
to reform Georgia’s chiropractic law, only to have their efforts thwarted
by broken promises and old adversaries.
The last time Georgia’s state legislators successfully passed a scope
of practice law regulating chiropractic there were flappers on the dance floor,
Model Ts ruled the road, and Babe Ruth was just hitting his legendary stride.
That was 1921 and the bill that says what the state’s chiropractors can
and can’t legally do has seen little change since then. For today’s
chiropractors, it’s a bill that no longer reflects a modern profession
that is increasingly being called upon to deliver higher levels of care to patients.
The state’s two major chiropractic associations joined with Life University
and the Georgia Board of Chiropractic Examiners to craft legislation aimed at
modernizing and better defining the profession’s scope of practice. By
joining forces and crafting a bill that gave each side some of their primary
objectives, Georgia chiropractors have come closer than ever before to passing
the first major piece of chiropractic reform in 85 years.
While that process might sound simple and straightforward, drafting a piece
of legislation that could be supported by most doctors and then overcome the
traditional opposition of organized medicine has seemed like history in the
making. In past years chiropractic legislation had landed in committee never
to see the light of day, but the Georgia alliance was determined that this time
it would be different.
“We sat down for almost a year before we actually went down to the capital
(in Atlanta) and both associations got together and tried to come up with a
piece of legislation that both sides could agree on,” explains Dr. Brad
Pizza, president of the Georgia Council on Chiropractic (GCC).
These negotiations marked a sharp departure from past years when the associations
would often introduce competing reform bills that never came close to becoming
law.
“The battle between the different sides of the profession has been going
on for a long time and nobody was winning,” admits Dr. Greg Baker, who
accepted an invitation from the president of the Georgia Chiropractic Association
(GCA) to join in talks on organizing a scope reform campaign. “You can’t
eliminate those with perspectives other than our own. I think we’ve tried
this in the past and it isn’t a viable option.”
While the philosophical differences separating those who want to stick to finding
and correcting subluxations and the chiropractors who want a broader form of
practice hasn’t disappeared, there is clearly a new sense of purpose and
unanimity among Georgia’s DCs. In fact, don’t call them straights
and mixers anymore because as one doctor said, “We don’t like to
use those terms anymore. They point to our differences not our commonalities.”
While state laws regulating practice vary widely, Georgia has one of the most
antiquated in the country.
Changing the scope law took on additional urgency following a 2004 court ruling
that chiropractors could only perform those procedures listed specifically in
the practice act. In Colvard v. Mosley a chiropractor referred his patient to
Comprehensive Medical Group (CMG) for a series of tests. The results were interpreted
by CMG medical doctors for the chiropractor.
The Georgia Court of Appeals concluded “the tests leading to the CMG changes
were conducted outside the scope of [the chiropractor’s] chiropractic
practice, and were not otherwise shown to be performed under authority of any
medical provider competent to order the procedures…”
According to an opinion by the GCA’s legal counsel Aubrey T. Villines,
“If you cannot perform the procedure you cannot refer to another to perform
it when that person is also not authorized to perform or order the procedure.”
In addition, “the Court has clearly stated that when chiropractors refer
for procedures outside of their scope, the procedures must “be performed
under the authority of any medical provider competent to order the procedures.”
The fundamental problem with the Georgia scope law is that it is an exception
to the state’s medical practice act, according to Dr. Vincent Erario,
chair of the GCA’s Board of Directors, who helped lead the GCA’s
efforts to craft a scope reform bill that all segments of the profession could
support.
“Which means that if it isn’t written in our law we cannot do or
perform that particular activity,” he explains. “Whether it be a
particular therapy or a new type of adjustment or utilization of diagnostic
imaging. If it is not written, we can’t do it and therefore it is very
limited.”
The ruling also raised the specter of the medical profession becoming gatekeepers
for chiropractors. It also meant that insurance companies were unlikely to pay
for such procedures when ordered by a D.C.
“We are held to the same standards of care [as other healthcare providers],”
says Erario. “So we had to expand our abilities to utilize today’s
technology such as MRI, CT scans and other things that other professionals have
access to and chiropractors do not.”
Chiropractors contend that MRI and CT scans can detect physiological changes
in the body not normally seen on plain film radiography including early detection
of spinal tumors, infection or occult fracture. Other changes include recognizing
that chiropractors use and recommend massage, exercise protocols and rehabilitative
procedures to enhance and support the adjustment.
Within the scope of practice a Georgia chiropractor is limited to delivering
an adjustment by hand. Recommending exercise, nutritional supplements, requesting
an MRI or other diagnostic test or using an instrument to adjust the spine seemed
to be out of bounds.
Even as the case was making its way through court, the newly elected presidents
of the GCC and GCA were already discussing areas of common ground, according
to Baker. He and his GCA counterpart Dr. Robert Hayden met at the group’s
convention to hammer out a set of principles that the two could agree upon.
An initial draft of this document, which has since been adopted and presented
at COCSA as a model for other organizations, was provided by Dr. Guy Riekeman,
president of Life University in Marietta, Ga.
“I thought that was something that would need to happen before we could
really move forward legislatively, but the legislative issue raised its head,”
says Baker.
After a number of meetings between representatives of the state’s chiropractic
organizations as well as sympathetic legislators, a reform bill began to take
shape. Both sides admit that it represents a compromise from the hard line positions
taken in past years.
“There were things in there that we weren’t really happy with and
there were things that they weren’t real happy about,” says Pizza.
“We felt it was a good bill. In addition, we felt that the person it [served]
the most were the people of Georgia.”
The GCA wanted a broader scope of practice that included the right to refer
for diagnostic testing. The GCC’s primary goal was inclusion of language
on the vertebral subluxation and its correction as the central defining purpose
of the chiropractic profession. The original law contained no mention of this
central tenet of chiropractic philosophy. Over the years, few attempts have
been made to include it.
Pizza admits that “Ten years ago when I was down there [at the state legislature]
crafting this legislation we literally defined what a chiropractor does and
what a chiropractor takes care of but we never put the word in there.”
“My concern is that there was a small segment of the profession that was
trying to move the profession toward a primary care physician kind of model,”
says Baker of the scope reform process. “So I was hoping to get some language
in the current law that would help to protect the fundamental principle of chiropractic—
get the definition of subluxation into the law and help protect the right of
doctors to make that the focus of their practice.”
Yet, each side realized that in order to achieve at least some of the goals
they were seeking through the scope law reform they needed to work together.
In past years bills had been placed in the legislative hopper and never even
made it out of committee.
“The legislature always used as an excuse that if you guys can’t
agree we’re not going to talk to you,” explains Baker. “So
it became imperative that if we were going to make a change at all of any kind
we were going to have to work together to do it.”
After being introduced in the 2005 legislative session the bill was passed out
of committee but died before getting a vote. During the 2006 session, the bill
[now labeled SB 422] was revived in the Senate Health and Human Services (HHS)
committee chaired by a medical doctor.
“We went to see the president pro tem [of the Senate] and said we’re
out here helping support candidates all over the place and we’ve given
to the [Georgia Republican] Foundation,” recalls Dr. Jeff Slocum, chair
of the GCA’s Political Action Committee. “We’re right in the
middle of this thing we told him. He took a look at us and said, ‘Well,
I didn’t know that. I guess you guys are participating. What do you want?’
We said we just wanted a fair hearing. We want a vote. So he promised us a vote.”
Under the sponsorship of Republican State Sen. Renee Unterman and other legislators,
the bill gained enough supporters to pass successfully out of the committee.
Yet, even as it was gathering steam, it was already being assailed by an old
adversary—the Medical Association of Georgia (MAG). Along with other medical
groups such as the Georgia Orthopedic Society, a stream of attacks and misinformation
including wild claims about inflated spending on diagnostic testing and comparing
chiropractic education to two-year technical school training was channeled to
wavering legislators.
MAG has a long history of opposing any efforts by rival health care providers
to expand their scopes of practice. Along with attacking the chiropractic bill,
the medical association also worked to defeat other bills affecting groups ranging
from audiologists, to physical therapists to physician assistants.
The state’s chamber of commerce came out against the bill, believing that
it would place a heavier financial burden on employers, even though studies
document the opposite effect.
As the 40-day legislative session wore on, medical lobbyists succeeded in stalling
the bill in committee and postponing hearings. Chiropractic representatives
led by the GCA’s teams of lobbyists buttonholed legislators, including
the senate majority leader who had promised they would get a vote. Thanks to
this pressure, the HHS committee passed the bill after being amended to prohibit
chiropractors from ordering diagnostic testing from facilities in which they
have a financial interest.
After passing the Senate 30-15 and surviving a call for reconsideration by the
HHS committee chair, the scope bill made its way across to the Georgia House.
When it arrived at the Health and Human Services Committee, the DCs expected
a fair hearing. After all, the committee chair had promised to support the bill.
Instead, the chair assigned the legislation to a sub-committee composed largely
of pro-MAG members.
“They chose not to act on it thereby defeating it and likely thwarting
the will of the House, which we believe would have passed it out [of committee]
had they had the opportunity to vote,” declares Slocum.
The state’s chiropractors learned some hard lessons about the power of
money and influence. They found some lawmakers to be staunch allies, while others
revealed their true allegiances only when compelled to do so.
While chiropractors have yet to taste the fruits of victory, they have come
further than ever before even in the face of fierce opposition. The bill made
its way successfully through one chamber and now seems poised to achieve equal
success in the House during the next legislative session. In doing so, they
have achieved a newfound respect from those who make the state’s laws.
The issue motivated many Georgia chiropractors to contribute to efforts to push
the legislation. The GCA’s PAC is on course to raise an unprecedented
$300,000 for the cause. By raising money and bringing large numbers of chiropractors
to the state capitol in Atlanta to persuade lawmakers, politicians are seeing
that the profession is both serious and, to an unprecedented degree, united.