Chiropractic in FQHCs

By Michel Tetrault, DC Email

Chiropractic has begun to find similar recognition in Community Clinics that Dentistry experienced in the last decade. Medicaid covers chiropractic services in 35 states with some variations of benefits. In California MediCal covers 24 visits per year, limited to two visits per month. There are presently in the USA an estimated 30 clinics that offer equal access to chiropractic within their clinic programs, representing 1% of our nation’s safety-net clinics. Why is this percentage so small and what can be done to correct this inequity?

Chiropractic services have been included in the scope of services available to beneficiaries of Medicaid and Medicare since 1972 TITLE 42 – PUBLIC HEALTH – Sections 410.20 – 410.22 and 440. FQHCs are covered under Federal laws which states that optional services, including Dental, Chiropractic, Podiatry, etc. are a covered service when delivered by an FQHC, and must be paid. This ruling is reaffirmed on September 23, 2013 by the Ninth Circuit Court of Appeals.

The gradual integration of chiropractic into government-funded programs began as Community Clinics began to add chiropractic to their scope of services in the late 80’s and early 90’s; the Department of Defense has added chiropractic as a permanent on-site service for the healthcare of our men and women in arms throughout the world; and recently, the Department of Veterans Administration has implemented by a law in congress to fully integrate chiropractic within the VA health care services over the next several years.

Community Clinics in rural and urban areas have been undergoing their own growth and transition over the past decades. Over the last 10-15 years in particular we have seen CHCs change their focus from delivering purely primary and emergency outpatient care to the gradual expansion into various medical specialties, mental health, dentistry, podiatry and now chiropractic. The historical evolution of the CHCs can be reflected today by the commentary made by Herrmann Spetzler, past president of both the California Primary Care and the California State Rural Health Associations at a fall 2001 awards dinner in Sacramento: “Community Clinics have come to understand that our mission is to provide quality healthcare and not just medical care.”

An earlier telephone survey summarizes conversations of over 100 CEOs of FQHC, RHC and IHS facilities revealing some interesting facts about chiropractic and safety net clinics today. Three questions are reported here from these conversations:

  1. Has your organization discussed starting a chiropractic program? — Yes-10% No-90%
  2. Were you aware that chiropractic was a covered service in CHCs? — Yes-15% No-85%
  3. If funding and space were available, would you be interested in seeing a chiropractic program established in your clinics? — Yes-80% No-20%

But simply creating the awareness that CHCs are able to add chiropractic services does not mean we are seeing a proportionate response in addressing this unmet need in these communities? If 15% are aware and 10% of the clinics have discussed the topic, why do we only see 1% of the CHCs delivering chiropractic services? Extensive conversations with CEOs and Medical Directors reveals how much of a gap in understanding of the true needs for chiropractic in their communities, coupled with an understandable lack of familiarity with the “know-how” required to successfully implement a chiropractic program in their clinics is a big part of the answer.

In an article published in the March 2002 issue of The Rural Advocate, by the California State Rural Health Association, this author discusses solutions in two primary subjects: Perceptions and Logistics. False perceptions in needs assessments, start-up costs, delivery and implementation are at the root of these misunderstandings. Once these areas are understood, one finds there are really no barriers to the implementation of chiropractic services in the FQHCs in California.

Public Health, Title 42, Section 440, f) and g) specify “freedom of choice” and “equal access to care” provisions that exist to enforce the rights of Americans to decide the best course of action in making their healthcare decisions. It is nice to know that there is help available to conduct “feasibility evaluations” of Community Clinics and that the technical and professional knowledge is available to successfully implement chiropractic services.

Chiropractic Feasibility Evaluations are currently being conducted by the Chiropractic Community Health Alliance, a chiropractic management service organization. Based on a clinic’s patient population, volume of visits and mix of benefits the actual chiropractic need of a given clinic can be estimated. Physical space of the clinic can be performed to identify the specific requirements to bring a DC into the clinic. Cost projections and logistical proposals are then recommended as a part of the Feasibility Evaluation. Email Dr. Michel Tetrault at to request this professional service.

There are really no barriers to the implementation of Chiropractic services throughout the Community Clinics in California. All that is required is a desire on the part of the organization to make it happen. What influences this desire, or the lack thereof? Admittedly there are residual effects of the historical separation of the chiropractic profession from traditional medicine that have ingrained certain attitudes. Mostly, the desire to engage another program is stifled by sheer “overwhelm” of the demands of the day, current plans and often temporary space limitations. What good would it be to discuss an opportunity without offering a viable solution? The surprise is that today, chiropractic can be implemented without the need for capital investment seen with other programs and under the management of a professional service familiar with the development and maintaining of a chiropractic program in FQHCs.