SIC 8041
OFFICES AND CLINICS OF CHIROPRACTORS



This category includes establishments of licensed practitioners having the degree of doctor of chiropractic and engaged in the practice of chiropractic medicine. Operations serving as clinics of chiropractors are also covered in this industry.

NAICS Code(s)

621310 (Offices of Chiropractors)

Industry Snapshot

The central element of chiropractic is the practitioner's belief that the nervous system holds the key to maintenance of a healthy balance in the body. Practitioners believe that their manipulations of the spine can prevent disease and promote well-being. Doctors of chiropractic (DCs) believe that a patient's susceptibility to disease increases when homeostasis, or a healthy balance, in the body is disrupted by the misalignment of vertebrae. Chiropractors use gentle manual pressure to correct such misalignments, or subluxations. Chiropractors also use muscle massage and ultrasound stimulation of deep tissue.

Although doctors of medicine, as represented by the American Medical Association (AMA), long have suggested that chiropractic is something that falls far short of medicine, in recent years, antichiropractic rhetoric from the AMA has diminished significantly. Indeed, some medical doctors today grudgingly acknowledge that there definitely is a place for chiropractic, particularly in the treatment of chronic back and neck pain and headaches. For their part, most chiropractors unhesitatingly refer certain patients to medical doctors if they feel the latter are best equipped to deal with those patients' ailments.

According to the U.S. Bureau of Labor Statistics' Occupational Outlook Handbook 2002-2003, there were approximately 50,000 active chiropractic licenses in the United States in 2000. Some of the DCs not currently in active practice on their own may teach, conduct research for chiropractic colleges, or work in hospitals. Chiropractors may be self-employed or salaried, with those self-employed usually earning more. According to the American Chiropractic Association (ACA), the average income in 2000 for all chiropractors, including self-employed, was about $81,500 after expenses. Median annual earnings of salaried chiropractors were $67,030 in 2000. A chiropractor's income may be influenced by a number of factors, including experience, characteristics, qualifications, and geographic location.

Based on a poll conducted by the Gallup organization in the early 1990s, the ACA estimates that about 10 percent of the adult American population visits a chiropractor every year. Assuming that this figure has remained relatively static, that would mean that 27 to 28 million Americans use chiropractic services each year.

Organization and Structure

Chiropractors must have a license to practice and can practice only in the states where they have licenses. According to the Occupational Outlook Handbook, all states recognize chiropractors trained by colleges accredited by the Council on Chiropractic Education. The majority of state licensing boards require at least two years of undergraduate college education, followed by the four-year training course at a chiropractic college, while others require a bachelor's degree.

Most states accept part or all of the National Board of Chiropractic Examiners' three-part test. Some states ask chiropractors to take an additional basic science proficiency exam. Those who complete a chiropractic education are awarded a doctor of chiropractic degree. Almost all states require chiropractors to complete a specific number of hours of continuing education every year to keep their licenses current. Some chiropractic associations provide courses to obtain specialty certification, called "diplomate" certification. Areas of specialty include: orthopedics, sports injuries, nutrition, radiology, thermography, neurology, internal disorders, and occupational and industrial health.

About 70 percent of licensed chiropractors open solo private practices. Some join established practices on a salary basis to earn enough money to open their own clinics. Although many chiropractors are self-employed, most work about a 40-hour work week and vary schedules to accommodate patients' needs. Chiropractors on average employ about three office staff, and their salaries constitute a practitioner's largest operating expense. The geographical location ratios of chiropractors are imbalanced, because many open their practices near chiropractic colleges.

Financial Structure. Average gross revenue for chiropractors totaled about $230,000 in 1999, down about 2 percent from 1990. Chiropractors had about 132 patient visits per week in 1999, up from 128 per week in 1990, and received 40 percent of their payments from private insurance; 29 percent from cash; 15 percent from worker's compensation (the lowest level since 1987); 8 percent from Medicare; 7 percent from personal injury, auto, no-fault insurance; and 1 percent from Medicaid.

Background and Development

The chiropractic method was first developed in America in 1895 by Daniel David Palmer, a teacher, spiritualist, and magnetic healer from Davenport, Iowa. Magnetic healing was based on a theory by Austrian physician Anton Mesmer. Mesmer believed that the body had magnetic poles that facilitated a natural flow of fluid. Any obstacle that interrupted this flow resulted in sickness. Healing could thus be obtained by massaging the body's poles to restore this natural flow.

In search of an alternative to traditional medicine, Palmer made his first discovery by manipulating the spine of Harvey Lillard, a deaf janitor who worked in his Davenport office building. Palmer had learned that Lil-lard had become deaf upon wrenching his back. An examination later demonstrated that Lillard's vertebra had moved. By "racking his spine into position" Palmer was able to eventually restore Lillard's hearing. It was from this "first adjustment" in 1895 that the field of chiropractic medicine was born.

Palmer, however, was soon dismissed as a heretic and a charlatan for his belief in healing through magnetism and spinal manipulation. According to J. Stuart Moore in Chiropractic in America, "Palmer was determined that his new brainchild, chiropractic, would acquire the scientific respectability that his earlier career in spiritualism and magnetic healing had lacked."

Palmer based chiropractic on the theory that a misaligned spine (subluxation) caused illness. By readjusting the spine and thus restoring full nervous system function, all illness could be prevented and or cured. By 1897, Palmer had founded the Palmer Infirmary and Chiropractic Institute (the Palmer School of Chiropractic) in Davenport. Palmer in 1910 became affiliated with the Pacific College of Chiropractic in Portland, Oregon. It was there that he wrote the textbook and primer for beginning chiropractors, The Chiropractor's Adjuster: A Textbook of the Science, Art, and Philosophy of Chiropractic for Students and Practitioners. His son, Bartlett Joshua (B.J.), became a practitioner. B.J. Palmer founded the first chiropractic association and helped establish chiropractic colleges nationwide. Early practitioners of chiropractic were defiant in the face of skepticism from the established medical community.

Theories of chiropractors often put them in direct conflict with medical doctors. The practice of chiropractic was often entwined in mysticism and unorthodox religious beliefs during the profession's early development. Some chiropractors were even jailed for practicing 'medicine' without a license.

Other practitioners would eventually refine spinal adjustments and use X-rays to make better diagnoses. But the development of the industry was often clouded. Chiropractors of the latter twentieth century come from a wide range of beliefs and theories, and many do not base their practices on a single chiropractic doctrine. For example, chiropractors who use chiropractic with other theories such as iridology, hair analysis, and colonic irrigation are termed "mixers" and are represented by the ACA. "Straights," represented by the International Chiropractic Association, base their practices solely on correcting subluxation in the tradition of Palmer. Then there are chiropractors who believe in manipulating a certain area of vertebrae (National Upper Cervical Chiropractic Association) instead of merely readjusting the spine at the site of pain.

By the mid-1990s, chiropractors followed a standard routine to diagnose and determine the treatment necessary. The data includes: the patient's medical history; results of physical, neurological, and orthopedic exams; posture and spine analysis; and sometimes X-rays and other laboratory tests. Chiropractic treatment had expanded so much that some practitioners specialized in select areas, such as sports injuries, neurology, orthopedics, nutrition, internal disorders, and diagnostic imaging.

Chiropractors of any kind, however, encountered fierce resistance to the profession in America throughout the mid-1990s. While chiropractic enjoyed increased recognition in many regions of the world at this time, the AMA was adamant in its opposition to the practice. Nonetheless, chiropractic care was included under Medicare coverage in 1973, and in 1974 Mississippi became the last state to establish a review board for licensing chiropractors.

Growth of Chiropractic. Current statistical surveys, including a Gallup poll commissioned by the ACA, indicate that roughly 10 percent of adult Americans visit chiropractors annually. The profession is gaining in popularity. With just 30 percent of back care patients using chiropractic treatment, the potential for growth is enormous. Chiropractors in the 1990s are the third largest medical profession behind dentists and medical doctors. Although chiropractors cannot administer or prescribe drugs or perform surgery, they may counsel patients about nutrition, exercise, and stress management.

One avenue that the chiropractic profession has pursued to secure acceptance in the medical community has been the legal system. In 1976 a lawsuit was filed by four chiropractors against the AMA for antitrust violations. The chiropractors in Wilk v AMA alleged that the AMA and other health providers conspired to put them out of business. The AMA said it was trying to protect patients from methods it saw as "unscientific and deleterious," reported the University of California Wellness Letter. In the 1960s, the AMA had told its members that it was unethical to associate with chiropractors.

The AMA dropped its ethical ban in 1980 after modifying it years earlier. In 1981, charges were dismissed against all defendants, but the federal appellate court ordered a new trial. In 1987 the Federal Court of Appeals ruled in favor of the chiropractors by issuing a permanent injunction against the AMA, the American College of Surgeons, and the American College of Radiology that prevented them from denying chiropractors entry to labs and hospitals and access to insurance reimbursement. The court dismissed charges against several other defendants.

Another lawsuit ensued in December of 1993, when three New York chiropractors again sued the AMA, along with state and county medical societies, four national insurance trade groups, and a dozen insurers and managed care plans. In this suit, the plaintiffs claimed that "physicians and insurers have conspired to keep them from taking part in New York managed care panels," and that many of the defendant plans do not cover chiropractic services, according to American Medical News. The AMA intended to file a request to have the case dismissed for lack of merit in 1994. According to a study in 1995, nearly half of all HMOs covered chiropractic treatments. In June of 1995, the AMA and two other medical societies were dismissed as defendants in the case, but the plaintiffs continued the suit against the remaining defendants.

In a report from The Back Letter in 1995, many hospitals began giving clinical privileges to chiropractors across the country. Hospitals recognized chiropractic treatment as more cost-effective than surgery in some cases, and the chiropractors would provide another source of revenue. The number of chiropractors reporting to chiropractic departments in hospitals doubled from 1993 to 1995, according to the ACA.

Recent studies have suggested that chiropractic care may even be more effective for back and neck pain than regular medical care. Treating back pain is estimated to cost from $8 billion to $24 billion annually in the United States. A report by the RAND Corporation found that chiropractic care is "effective in treating acute back pain when no serious neurological symptoms are present," and that patients with low-back pain did better with chiropractic treatment, often at less cost than medical treatment. The British Medical Journal found that "spinal manipulation was more effective for relieving low-back aches for up to three years after diagnosis." However, those with nerve disorders, sciatica, and chronic low back pain did not benefit as much from chiropractic treatment.

Industry Reform and Renewal. According to Robin Kamen in Crain's New York Business, chiropractors are increasingly turning to modern marketing techniques to maintain their businesses, using advertising and sales promotional literature to educate the public about the benefits of chiropractic.

A renewed interest in alternative medicine has contributed to an increasing public interest in chiropractic theory. Slowly, medical doctors are discovering they can benefit from referring their patients to chiropractors because they request "natural treatment" and noninvasive techniques. Chiropractors, in turn, refer patients who need medical treatment they cannot provide.

However, chiropractors nationwide are finding that they are losing patients because their insurance or worker's compensation either restricts visits to chiropractors or does not cover chiropractic at all. Medicare does cover some services but is limited. Trade and state chiropractic associations in Oregon, New York, and Colorado have conducted extensive lobbying efforts to garner more extensive insurance benefits for chiropractic patients, although without much success. For example, New York lawmakers in 1993 approved a bill requiring unlimited insurance coverage for chiropractic clients but withdrew the legislation after Governor Mario Cuomo threatened to veto it.

Efforts also are underway to provide cost-containment strategies to reduce chiropractic costs, as reported in Risk Management. Excessive treatment, at times because of criminal motives, has been cited as a key factor in the price of chiropractic care. Risk Management magazine cited a study by National Medical Audit, Inc., where a four-part chiropractic review program was used and helped reduce chiropractic costs by 25 percent. The ACA in 1992 issued guidelines to set parameters on the frequency and duration of care and "more appropriate and realistic reimbursement systems," reported National Underwriter Life & Health.

Chiropractors won an important victory in November 1999 when President Bill Clinton signed into law legislation that makes chiropractic care more accessible to U.S. veterans. The Veterans Millennium Health Care Act (H.R. 2116) requires the Veterans Administration to develop a policy covering the use of chiropractic treatment within the Veteran Administration's (VA) health care system. Successfully lobbying for the chiropractic provision were the ACA and the Association of Chiropractic Colleges. The legislation gave the VA 120 days to develop a chiropractic care policy.

Current Conditions

The complementary and alternative medicine market grew 12 percent in 2001, reaching $30 billion. Chiropractic medicine accounted for half of that total, or $15 billion. According to the National Market Measures for Landmark Health, two-thirds of HMOs (67 percent) offered at least one type of alternative care to their members by 2000. Chiropractic care was the most common type of alternative care. More and more HMOs were also allowing members to choose a chiropractic doctor as their primary care physician.

In 2000, the ACA, along with other national and state chiropractic groups, doctors, and patients filed a lawsuit against Blue Cross/Blue Shield Association and Trigon Healthcare Inc. The suits alleged that Trigon, the Blue Cross/Blue Shield insurer in Virginia, put unreasonable caps on spinal manipulation and paid chiropractors less than physicians for the same services. They alleged discriminatory practices were aimed at steering patients away from chiropractors to medical physicians.

The chiropractic field is expected to grow faster than the average for all occupations through 2010. The field has become more accepted in the United States, and more Americans are turning to alternative health care to avoid drugs or costly surgery.

Workforce

The job outlook appeared very favorable for chiropractors in the late 1990s. The number of chiropractic graduates increased "fourfold since the early 1970s," according to U.S. Occupational Outlook Handbook. In 2000, there were approximately 50,000 chiropractors practicing in the United States, according to the ACA. Employment growth will depend on the need to replace retired chiropractors, the continued popularity of the practice, and the ability of patients to pay for services under health insurance plans. In addition, as the population of elderly people increases, so will the need for treatment of mechanical and structural difficulties. The growth of chiropractors is expected to accelerate faster than the average for all occupations through 2010.

Further Reading

"Alternative Becomes Mainstream at HMOs." Research Alert, 3 March 2000.

American Chiropractic Association. "Frequently Asked Questions." 2003. Available from http://www.amerchiro.org .

——. "What Is Chiropractic?" 2003. Available from http://www.amerchiro.org .

Blackwell, John Reid. "National Chiropractic Groups Allowed to Continue Lawsuit Against HMOs." Richmond Times-Dis-patch, 3 August 2001.

"CAM Spending Rose 12 Percent in 2001." Research Alert, 5 April 2002.

"Realigning Chiropractors." Chicago Tribune, 22 October 1999.

U.S. Bureau of Labor Statistics. Occupational Outlook Handbook 2002-2003. Washington, DC: GPO, 1996. Available from http://stats.bls.gov .



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