Offices and Clinics 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 anti-chiropractic rhetoric from the AMA has diminished significantly. Indeed, some medical doctors today 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 International Chiropractic Association, there were approximately 60,000 active chiropractic licenses in the United States in 2009. About two-thirds of chiropractors are in solo practice. The other third are either in practice with other chiropractors, teachers, or researchers, or work in an institutional setting such as a hospital. Chiropractors may be self-employed or salaried, with those self-employed usually earning more. According to the Bureau of Labor Statistics, the average income in 2008 for all chiropractors, including self-employed, was about $81,340. Over 80 percent of active chiropractors practice their profession full time.

According to a 2009 D&B Marketing Solutions report, there were an estimated 49,086 chiropractic offices scattered throughout the United States employing approximately 148,269 people. Chiropractors reported combined revenues of almost $7.6 billion in 2008. Chiropractors located in California earned $1.1 billion, for 14.6 percent of the market. Other dominant states included Florida with 3,017 offices; New York with 2,927; Texas with 2,715; and Pennsylvania with 2,642.

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 60 percent of licensed chiropractors open solo private practices. In fact, 86 percent of the industry are establishments employing fewer than four people, and nearly 98 percent of offices employ less than 10 people. Some chiropractors 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.

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 Lillard 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 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.
By the 1990s, a Gallup poll commissioned by the ACA found that roughly 10 percent of adult Americans visited chiropractors annually. The profession was gaining in popularity, and with just 30 percent of back care patients using chiropractic treatment, the potential for growth was enormous. Chiropractors in the 1990s were 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 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.

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 cited a study by National Medical Audit Inc., where a four-part chiropractic review program was used and helped to 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.

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%) 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.

Although nothing new in the chiropractic marketplace, some members of Congress introduced The Healthcare Truth and Transparency Act (H.R. 5688) in an effort to discredit chiropractors as non-medical physicians and suppress competition in the medical community once again. Other targeted health professionals included the American Association of Nurse Anesthetists, the American Podiatric Medical Association, and the American Optometric Association. Adding injury to insult, "the bill directs the Federal Trade Commission (FTC) to bring charges against individuals who falsely claim to be medical doctors, and calls on FTC to identify instances where any state public policy has permitted health care providers to 'misrepresent' oneself as a medical doctor, an action which could serve as a direct attack against states recognizing DCs as chiropractic physicians." Thus, the ACA joined a coalition of non-medical doctors to counterattack the opposition, namely medical doctors, in an effort to either "modify" or strike (H.R. 5288) all together. Meanwhile, the AMA established its own coalition. The Coalition for Healthcare Accountability, Responsibility, and Transparency (CHART) sought to ensure the bill became a law. The ACA anticipated the enactment of the new bill prior to the November 2006 elections.

Despite earlier legislation that called for chiropractic care for U.S. veterans, there were only 30 out of 154 facilities across the United States that had a chiropractor on staff as of 2006. Thus, newly introduced legislation (H.R. 5202) further directed the federal government to establish deadlines requiring chief VA medical facilities to have a chiropractor on staff at a minimum of 75 of the 154 facilities by 2008, and for the remaining chief facilities no later than 2010.

The outlook for the chiropractic field was positive heading into the late 2000s. Treatments have become more accepted in the United States, and more Americans continue to prefer alternative health care to avoid drugs and costly surgery.

Current Conditions

The place of chiropractic care in the American landscape continued to be debated even into the late 2000s. In May 2009, the industry received yet another round of bad press when the Office of the Inspector General released a report that accused the industry of billing for inappropriate Medicare payments for chiropractic services. In the midst of a national debate on health care reform, industry advocates were quick to defend the industry's business practices. Noting that the study was dated 2009 but used data from 2006, Steven Kraus wrote in Dynamic Chiropractic, "The profession became aware of documentation deficiencies in June 2005, and it took well over a year before information, in the form of classes, seminars, educational articles and direct communication, filtered across the profession's landscape....Thus, it took a few years to accomplish overall awareness, understanding and participation on the part of the profession." The key, according to Kraus, to proving the industry's new accountability will be a transformation away from paper records to electronic health records that can easily track patient activity.

The overall desirability of the chiropractic profession continued to be debated in the late 2000s. While such advocacy organizations as the American Chiropractic Association extolled the profession's many benefits and rewards, others questioned the potential payoff. An article appearing in U.S. News & World Report in December 2008 suggested that entering chiropractic practice was risky business, calling it an "overrated career." Chiropractors can leave school with well over $100,000 of debt; yet, according to data gathered by payscale.com, as of September 29, 2009 the average annual salary for a chiropractor with between 5 and 7 years of experience was just $63,839. Considering the education time frame is similar to a medical doctor, the salary pales in comparison with an MD with 5 to 7 years of experience who can expect to make $120,709 annually. Also at issue was how much time chiropractors spent marketing their business to keep clients walking through their doors. Unlike physical therapists, who perform many similar services and benefit from referrals from medical doctors, chiropractors have no such built-in referral structure, and although somewhat--and often begrudgingly--accepted by medical doctors, few referred their patients to chiropractors. Web sites such as www.chirotalk.com chropped up for disgruntled members or former members of the chiropractic industry.

Workforce

Despite misgivings of some outside the profession, the chiropractic industry was expected to grow at a faster than normal pace through 2016. Growth expectations were based primarily on an increasing awareness on illness prevention and health maintenance and an increase in the number of people seeking out alternative medicine. In addition, chiropractic services in the late 2000s were more commonly covered by insurance plans, making multiple visits more economically feasible for many people.