Journal of Manipulative and Physiological Therapeutics
Original articleBarriers to expanding primary care roles for chiropractors: The role of chiropractic as primary care gatekeeper☆
Introduction
Providing better access to primary care has been a longstanding priority all over the world since the first Alma Ata conference in 1977. Many Americans still do not have access to adequate primary care services. The Department of Health and Human Services estimates that more than 22 million U.S. citizens, nearly 10% of the population, have inadequate access to primary care, with mothers and children disproportionately represented in this disadvantaged group.1 Three related factors contribute to this problem, including a shortage of primary care providers (PCPs), limited geographic access to providers, and stringent licensing and credentialing regulations.
The shortage of trained PCPs is partly caused by rapid changes in technology that have made specialty fields more lucrative and attractive. Although the enthusiasm for primary care expressed by medical school graduates in the 1970s led to an increase in the number of primary care medical doctors (MDs) in the 1980s, that enthusiasm has waned more recently. Today's medical students seem to be interested in more predictable working hours and higher income levels. Consequently, the number of applicants for primary care residency programs is shrinking, despite state and federal support for programs to increase their numbers.2 Physician assistants (PAs) are also turning toward medical and surgical subspecialties rather than primary care.3
Residents of isolated and sparsely populated areas and impoverished inner city neighborhoods do not have accessible PCPs.4, 5, 6, 7, 8 The Department of Health and Human Services lists 865 counties, 1128 service areas (smaller geographic units defined by census tracts, minor civil divisions, and census county divisions), and many other entities as health-professional shortage areas (HPSAs).9, 10 These regions include both urban and rural settings.
A third factor contributing to the shortage of available, accessible primary care is the existence of licensing and credentialing regulations that prevent non-MD health care professionals from providing needed care.11, 12, 13, 14 Nurse practitioners and PAs, for example, are typically confined to practicing under the supervision of MDs, thereby restricting their ability to practice to areas where practicing MDs are nearby. These and other licensing or insurance restrictions prohibit performance of many routine office care activities that might be provided by these professionals with more modest training investments than MDs.
To provide greater access to primary care to all segments of the population, one option may be to
“allow primary care to be provided by those physicians currently in the fields and … let the remainder of care be provided by nurse practitioners, physician's assistants, homeopaths, naturopaths, chiropractors, and other non-allopathic physician providers.”15
This paper examines the feasibility of this idea by examining the barriers to expanded primary care provision by chiropractors. From the literature, we sought evidence pertaining to potential barriers, including legal, professional, financial, consumer preferences, accessibility, and self-imposed preference barriers. The most important barriers to expanded primary care roles are those imposed by managed care and insurance and those that are imposed by chiropractors themselves (practice preferences and location). In addition, the evidence on many issues is inadequate.
Section snippets
Defining primary care
The term primary care is complex and contentious. There are many definitions of primary care16, 17, 18, 19, 20 that include varying ideas about the services that constitute primary care21, 22, 23, 24, 25 and varying ideas about who is best-suited to provide primary care.2, 3, 11, 12, 15, 26, 27, 28 There is no single definition that is sufficient to enumerate the specific activities and competencies related to the provision of primary care; definitions and conceptualizations are general, and
Conclusion
Research on the barriers to a more expanded primary care role for chiropractors is incomplete. The available research helps little in ruling out plausible barriers that might make narrowing the scope of subsequent research on the feasibility of such roles in practice possible. The pattern of existing research and the limited, but available evidence suggests some support for each of the following as actual or perceived barriers to the use of chiropractors in primary care roles: self-perceptions
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