Federation of Chiropractic Licensing Boards 901 54th Ave., #101, Greeley, CO   80634     (970) 356-3500    FAX (970) 356-3599 Protecting the public and serving our member boards by promoting excellence in chiropractic regulation.

Licensing: Does it have a future?

9th Annual Janse Lecture - by Louis Sportelli, D.C.

The Joseph Janse Lecture Series was created in 1991 by FCLB vice president Dr. D. Brent Owens, to commemorate the powerful oratory skills and visionary insight of the legendary Dr. Joe Janse.

The purpose of the honorary lecture series is to shatter the complacency of today with a sense of the urgency of tomorrow.

Speakers are selected for their ability to deliver an insightful and often controversial message while reaching deep into the hearts of the audience.

1999 marked the 9th Annual Joseph Janse Lecture. This was delivered by NCMIC and World Federation of Chiropractic president, Dr. Louis Sportelli, who spoke on "Licensing - Does it Have a Future?"

Speakers are presented with an engraved crystal clear flame, recognizing their contribution to the education of the chiropractic regulatory community and symbolizing Dr. Janse's burning commitment to the profession and the public.

Ladies and Gentlemen, fellow colleagues, I am indeed honored to have been selected to deliver the Joseph Janse Memorial Lecture. I know that if Dr. Janse is not busy lecturing in that great auditorium in the sky, he may just stop and listen to what I am about to say. For those of you who knew Dr. Janse, that is an intimidating thought. Many times when he would make a point that was controversial and not necessarily keeping with the current views of the audience to whom he was lecturing, he would (like Ronald Reagan) point his finger WEST.... and tell you that "Tarzanic Chest Thumping will not resolve issues."

I am humbled by the honor to deliver these remarks to this distinguished body. I am a bit apprehensive that my remarks MAY... no, strike that... WILL create a feeling of uneasiness in this audience. While this speech is my personal opinion and the need for an extensive bibliography to support my opinions is not necessary, I have nonetheless reviewed the position papers of a few organizations which have done extensive work in the areas of licensure, consumer protection, and public information.

In doing background review for this presentation, I read the PEW Task Force Report on the Accreditation of Health Care Professions. I read extensively from the Public Citizen Group headed by Ralph Nader, and some articles by the National Organization of Certifying Agencies (NOCA). Needless to say, it was an enlightening experience. It fortified some of the opinions I have held, dispelled others and created new concepts I had not dreamed of. One thing is for certain... RADICAL CHANGE IS IN THE WIND.

Here is a sobering thought. A few months ago, I attended a lecture by Tom Peters, the famous business guru. He was relating a story about his first day at college when he sat in class and his professor said: "Look to your left... look to your right... in four years, one of you will not be here." Peters went on to discuss a recent talk he had just delivered to an audience of national automobile dealers and said: "Look to your left... look to your right... in 5 years neither of you will be here."

I will go one step further and ask you to "look to your left... look to your right... in 20 years none of you will be here."

With that as an opener, I will quote the words of the enthusiastic preacher who said my job is to "comfort the distressed and stress the comfortable," so let's begin.

Licensing Boards are statutorily complex, legislatively archaic, intensely parochial, extremely political, often ineffective and... for the most part... VERY broke! Most have little control over their own finances, statutory authority, arbitrarily assigned board attorney(s), the interpretation of administrative regulations, or the composition of the board. One thing for certain... there is conflict and controversy on every board in the country.

I ask rhetorically and collectively, where are "we" going tomorrow as a profession? More specifically, what clear and shared vision will the licensing boards of the next century need to adopt and embrace in order to perform the responsibilities which have been delegated to regulatory bodies?

LISTEN TO THIS QUOTE
"A license to practice is a privilege. For too long state and federal government agencies chartered to protect us from those no longer fit to hold that privilege have fallen down on the job. Many state medical boards and other regulatory agencies have either entirely failed to catch doctors guilty of incompetence, drunkenness, or patient abuse, or have let them get away with slaps on the wrist such as fines or reprimands."

This hard-won privilege is a privilege to hear our innermost thoughts, to see us naked, to cut us open, and to provide us with potentially dangerous drugs. Yet for too long the state and federal government agencies chartered to protect us from those no longer fit to hold that privilege have fallen down on the job." Public Citizen Publication 1413 - 3/8/99

So in direct response to a "code of silence" and lack of adequately perceived responses from licensing boards, public citizen groups have formed and are becoming increasingly stronger, more viable, more visible, more credible and more demanding. Licensing boards of every discipline will need to alter a negative "perception" held by a majority of Americans and many elected officials who make and enforce laws, or eventually lose the privilege to self-regulate and self-police.

Let me be Blunt!!!

Radical changes in the way licensing boards operate is imperative. Some call it reorganizing, reengineering, revamping or reforming, but whatever you want to call it, consumers will no longer tolerate or accept anything less than full accountability. Licensing Boards exist essentially for ONE PURPOSE AND ONE PURPOSE ALONE--to protect the public.

Michael Cohen, in his wonderful book Complementary and Alternative Medicine, Legal Boundaries and Regulatory Perspectives (John Hopkins University Press) makes a compelling argument that licensure created specialization and professional monopoly and has allowed licensees to fend off nonlicensed competitors. In chiropractic, we have seen the effects of these kinds of lethal legalized licensure limitations. The book takes you from the beginning of the licensure of medicine to the regulation of all healing arts. Medical licensing has been criticized as protecting the licensed medical doctor, not the patient, by insulating physicians from the economic threat of other providers. Cohen takes you on a journey through the evolution of licensure and concludes with this statement: "The legal view of disease and wellness must embrace a broader understanding of healing than is reflected in the biomedical orthodoxy. Legal rules reflect essential social values and culturally accepted models of health care. As these values and models continue to unfold, legal rules, too, will evolve to embrace a more expansive and empowering vision of health care and the healing process."

What are some of the issues currently needing discussion which will impact the entire profession and ultimately challenge all licensing boards in the future?

1. Are there too many practitioners?
2. Are there too many colleges?
3. Will the market share support all licensed chiropractors?
4. Can we self-police with confidence before being overthrown by consumer groups?
5. Should there be individual state licensure vs a national license?

Let me address them one at a time.

1. Are there too many practitioners? -- Some would suggest that the state licensing boards have lost their mission and are taking on the role of accrediting agencies and not licensing bodies. If some of you are uncomfortable with that remark, could it be that there are some states that have interfered with the educational process, directly or de facto?

The U.S. educational system is structured differently from most countries for the expressed purpose of removing governmental influence from education. Such unwarranted influences and interference stifle academic freedom and expression. State boards in the U.S. have extended their influence in a retrograde fashion onto colleges , in a misguided attempt at pseudoaccreditation--a task for which they were not designed nor qualified. This very significant issue of interference (perceived or real) must be resolved before upcoming state board mandates create chaos in the educational system.

By the same token, and not to be taken lightly, how do the state boards resolve legitimate issues such as monitoring of quality and licensing doctors of chiropractic? Boards continue to express their concern that if they do not involve themselves in the "upgrading" of the educational process, more and more "bad" practitioners will enter their state.

Any attempt at limiting the number of doctors of chiropractic statewide or nationally must be achieved by a global consensus of the profession based upon needs assessments. The "demand driven" system of health care and accountability placed upon health professional practices will create difficult realities for many health professionals and great opportunities for others.

It is estimated by some authorities that the potential exists in health care for:

• Closure of as many as half of the nation's hospitals and perhaps 60% of the hospital beds
• Massive expansion of primary care in ambulatory and community settings
• Surpluses of medical physicians of 100,000-150,000 as the demand for specialty care shrinks; 200,000-300,000 fewer nurses will be needed; and, as hospitals downsize, 40,000 less pharmacists. HAVE WE DONE A NEEDS ASSESSMENT FOR DOCTORS OF CHIROPRACTIC? Can we afford not to?

I cannot speak to the Federation of Chiropractic Licensing Boards without making mention of the explicit review the educational arm of this profession must take in order to prepare doctors of chiropractic with whom the FCLB will ultimately and eventually deal. Here are some of the future educational challenges confronting our profession:

• Have our colleges truly analyzed how chiropractic health professionals are being prepared to practice 5, 10, 20 years from now?
• Has any group given consideration to how the education of our future doctors of chiropractic will be changed by technology?
• Have plans been made to accommodate the changes which will be required of continuing education for future doctors of chiropractic in this world of satellites, internet and extranet technologies?
• Has FCLB analyzed how the very "practice" of chiropractic will need to be regulated in a new and changing environment 10 or 15 years from now?

The healthcare focus will shift away from a "supply orientation" to a "demand-driven" system. This change will challenge all health care professions by:

• Redesigning ways in which health care professionals work in hospitals, clinics, private practices, and public health
• Re-regulating the ways in which health professionals are permitted to practice, allowing more flexibility, but ensuring that the public's health is genuinely protected
• Right-sizing the health professional workforce and the institutions that produce health professionals
• Restructuring education to make efficient use of the limited resources allocated to it

Perhaps if the regulatory boards would focus their energies on the regulatory aspects of licensing and dealt swiftly with those who violate the laws, the natural progression of the students entering colleges will cause them to gravitate toward those colleges which display the highest standards of excellence. Like the blindfolded group describing the elephant, every group sees the problem from a different perspective. In the final analysis however, the final regulator of all the issues will be... COMPETITION.

This very issue I am addressing has created a schism in the profession. It is a perception (and perception is reality) that FCLB and some state boards have taken on an air of combativeness with the educational community. There have been veiled threats of using the state regulatory clubs on the colleges to force the colleges to do things the way the regulatory boards want them to. A resolution must be found by cooperation rather than confrontation.

Ultimately each divergent group within the profession must know and define its unique area of expertise, recognize that it does not operate in a vacuum and be willing to discuss new models for each organization which may, and probably will, radically change the way each organization functions in the next century.

2. To the educational institutions and those who control the process, we must ask the tough question--are there too many colleges? -- This question must be answered as the various colleges begin to build consensus about the future. In this world of merger mania on wall street:

• Is it far fetched to consider many of the colleges merging not only with each other, but with state and private universities?
• Will the educational process require any "bricks and mortar" at all as we enter into the technological world of tomorrow? Is there a place for a Virtual Chiropractic College?
• Will U.S. colleges be competing with foreign colleges?
• Are U.S. colleges engaging in a process of honest institutional introspection with a clear and dedicated intention of providing only education of the highest caliber? If this process is done with integrity and honesty, the colleges may find they cannot continue to produce the numbers characteristic of the current enrollment. The process of each of the entities in this profession must approach each of their respective issues not from a self-serving or self-preservation perspective, but from a global perspective on survival of the profession despite individual hardships. Much like dealing with pollution on planet earth... what other planet to we have? Where will we go if we pollute our environment?
• Is it a concern at all that as of 1999, there are 16 colleges in the USA and 18 colleges in the rest of the world with no abatement to the enthusiasm and desire of the various underdeveloped countries to educate chiropractors?
• Will the educational standard to become a DC change with this global expansion?
• Will medical doctors, PTs, and other health professionals want to become doctors of chiropractic as the complementary and alternative movement gains momentum?
• What standards will apply? Who will set those standards?
• If a conclusion is reached that there are too many DCs in the USA, does that mean there will not be DCs needed for foreign lands? How will the colleges meet the licensing requirements?

3. Will the market share support all licensed chiropractors? -- Managed care has had a tremendous impact upon the delivery of health care. Recent studies have demonstrated that chiropractic, under the former "fee for service" model, treated approximately 10% of the population. Under the managed care model, that market share was reduced to less than 1%.

We could spend the next few days discussing the reasons why, but suffice it to say that a reduction in market share, coupled with an increase in practitioners, may be viewed as a prescription for disaster by some, while others may view a reduction as a potential benefit for the informed consumer. Regardless of how this is ultimately framed, we need to identify some of the issues. From the practitioner's point of view, I will call them barriers to survival:

1. Barriers to access -- medical gatekeeper, a professional barrier.
2. Barriers for payment -- co-pays, high deductibles, an economic barrier.
3. Barriers by exclusion -- one DC in 50 miles or 100,000 covered lives, an access barrier.

What then is the solution for market share? I will argue that the movement toward complementary and alternative care is unstoppable. I will also argue that the playing field has been leveled by new measures determining results--COST, EFFECTIVENESS, OUTCOMES and SATISFACTION.

All of which gives chiropractic a distinct advantage. What must be added to this mixture is "tincture of accountability" in a considerably larger dose than a homeopathic remedy. Additionally, a recognition that evidence-based protocols, science-based research, and human-based skills will be mandatory just to reach a baseline.

I will predict that market share can be expanded by appropriate cost studies which provide compelling evidence that chiropractic care saves money not only in the immediate treatment of the condition, but in long term preventive health.

I am convinced that people who use chiropractic care use less hospitalization, less medication, miss less work and are fundamentally happier and healthier individuals. Now the big question... WHERE IS THE PROOF? That discussion is for another time, but it must be answered before any positive, definitive and realistic advancements will be made.

4. Can we competently self-police before being overthrown or dismantled by consumer groups? -- Self-policing carries with it a higher responsibility than guidelines that are set by some other entity. Thus self-policing will entail greater information and easier access to information.

FCLB has taken a giant step with CIN-BAD and NCMIC is proud to have helped in this process, but now what do we do with the information? Some will want it judiciously guarded. Some will cry foul that only egregious offenses should make the practitioners' data bank. Still others blissfully don't get it. They simply do not understand that the consumer controls and calls the shots. Not only should (and might I say... WILL) CIN-BAD be on the internet to list those doctors who have been involved in board action against them, but I would predict that soon CCE will be forced to publish information regarding the characteristics of all chiropractic colleges.

When self-studies are completed and institutional inspections are reviewed, the consumer and USDE will one day demand that these reports be public information. I would predict that all boards will be required to do self studies to determine effectiveness and efficiency of their boards. Quality management will dictate that these reports will also be made part of the public record of each and every board. Are you doing anything like that now? Should chiropractic boards take the lead in this area?

The public is no longer barred from information. FOIA, the wonderful Freedoms of Information Act, has literally turned the world topsy-turvy. With adequate information, no longer will there be an opportunity to cloak incompetence in a veil of secrecy. Will CIN-BAD bring with it greater beneficial USE, the potential of MISUSE, calculated and targeted ABUSE, or will all this data be considered REFUSE?

I believe the potential for information availability has yet to scratch the surface not only of how this information will be obtained and disseminated, but how consumers and other groups will access this data. The changing world of telecommunications, telemedicine, and telediagnosis, tele-case histories, and tele-consultation has created an entirely new area of potential statutory investigation and oversight.

The impact on the careers, lives, futures, and livelihood may truly depend on the reporting of issues to the National Practitioners Data Bank or CIN-BAD. The impact on claims settlements and malpractice outcomes is hanging on the very issue of how the data is reported. There must be ways to "balance the needs of the consumer to know" and the "needs of the practitioner to have some latitude in reporting." This will be one of the big issues facing FCLB in the future. The data bank must deal with the provider with "fairness" and the determination of significance of the allegation must be considered.

It is imperative that a disgruntled patient, because of a dispute with a bill versus an outright breach of the standard of care, be given proper "weighted" recognition of the relevance. Perhaps alternative dispute resolutions must become part of every board regulation and thereby impose a system of fair and equitable determination of the reportability of the offense. Too much depends on this to not become proactive and find a suitable resolution.

5. Should there be individual state licensure vs a national license? -- There needs to be an assessment and discussion of WHY individual state boards exist. Have they outlived their usefulness? Is graduation from a CCE accredited college and successful passage of a national board examination proof enough of competence? Why does a modern-day graduate need to be burdened following his/her successful graduation from a CCE approved college with the minimal and often archaic standards imposed by a state licensing board whose statute has not changed in 30 years? When has there been mandatory sunset reviews on boards that were supported by the professions? Fix the fixable, throw out the unmanageable, and design the new with a vision to prepare for the unknown of tomorrow.

What about the state that permits doctors to become licensed practitioners, but then does not permit them to obtain continuing education credits outside the borders of the state? Then there are states that mandates a BS before entering chiropractic college. And what about the state.....oh you know what I am talking about.

Will managed care increase pressure on governmental agencies to encourage the mobility of practitioners to move and relocate to areas of the country now undeserved by health care providers? Will the managed care mania cause an exodus of providers from those heavily controlled urban areas to rural America where the ability to negotiate and participate carries with it greater weight because of fewer providers?

All of these issues are going to be significant in the next few years. Should the FCLB form a task force NOW to consider the very issue of "relevance" of state boards as we now know them? Should the licensing boards refocus and redefine their mission, perhaps to extricate themselves from their current role and concentrate on a disciplinary role to manage the errant practitioners?

Should this task force be charged with looking into new and innovative ways to regulate, license, report, monitor, re-license, educate, and proactively share data with national consumer groups?

Much of what I have said today is not new, what is new however is the fact that we are talking about this in 1999--the last year of this century.

Nothing will magically transform this body to a new and revolutionary organization. BUT A VISION FOR TOMORROW, COUPLED WITH A LOOK AT YESTERDAY, and a RECOGNITION OF WHERE WE ARE AT THE MOMENT, should provide significant thought to the comment I made at the beginning of this talk.

Look to your left, look to your right, in 20 years will any of you be there? Will chiropractic be here? And, I might ask... where is "there?" Is it mainstream, or on the fringes, or perhaps lost in the vague memory of those who spent most of their lives in the "old" 20th century?

In order to guarantee a place in the regulatory advances of the 21st century, revolutionary changes and radical thinking must take place NOW.

In this room collectively there is an awesome power. A power to change, a power to transform, a power to revitalize, and a power to advance this very profession we all love.

Y2K is here! Are we ready?