CMS leads successful effort to roll back rule allowing chiropractic injections

Friday, March 01, 2013 12:14 PM

CMS staff report

The Colorado Medical Society marked another victory in its ongoing mission to improve patient safety when the state chiropractic board – facing intense pressure from CMS and its partners in organized medicine – backed down from an attempt to allow chiropractors to perform injections.

The decision came weeks after CMS and 14 component and specialty societies filed a lawsuit against the Colorado Board of Chiropractic Examiners, accusing the board of exceeding its authority and putting patients at risk. The attorney general’s office also issued an opinion stating the board didn’t have the authority to make the rule change, and a legislative committee, responding to concerns from the physician community, signaled it would oppose the rule.

CMS President Jan Kief, MD, said the chiropractic board’s emergency vote to not let the rule take effect averts what would have been bad public policy and a potential danger to patients. This unanimous decision was made less than a month after the lawsuit was filed.

“CMS has a long-standing commitment to making Colorado the safest state in the country for patients to receive medical care. Over the years we have demonstrated our willingness to work with our colleagues in health care to achieve that goal,” Kief said.
“But when that goal is threatened, it’s our responsibility as physicians to advocate vigorously on behalf of our patients. That’s what we’ve done in this case, and what we will continue to do.”

The fight over injections is just the latest skirmish to stem from the chiropractic board’s actions. CMS also has raised concerns about a board decision that would allow chiropractors to diagnose and treat the endocrine system.

CMS Chief Executive Officer Alfred Gilchrist said the moves have many health professionals concerned about the motivations of some members of the chiropractic board, which is responsible for certifying doctors of chiropractic.

“It appears some members are putting the interests of chiropractors ahead of patient safety,” Gilchrist said. “That’s obviously cause for alarm, and something we will be monitoring closely.”

Patient safety

Since CMS drafted its first strategic plan, the organization has been focused on improving and advocating for patient safety. In recent years, CMS has formed a Patient Safety and Professional Accountability Task Force and, along with component medical societies and other partners, has advocated for initiatives that improve peer review and provide more disclosure and transparency for patients.

As part of these efforts, CMS also has stressed appropriate scope of practice.

This has meant encouraging each medical professional to work at the height of his or her training, but also opposing attempts by professions to exceed their scope.

It was against this backdrop that CMS voiced concern beginning in 2011 about a chiropractic practice that was operating as a “Functional Endocrinology Center.” Reporters for ABC7 news said they received more than 100 calls and e-mails from patients who said they were misled about the chiropractor’s qualifications to treat diabetes and thyroid disorders.

The Colorado Medical Board’s licensing panel reviewed the case and found the chiropractor performed the “unlicensed practice of medicine.” The panel referred the case to the attorney general for legal review because it believed patients were at risk.

Last year, the attorney general’s office drafted a Notice of Charges detailing 25 counts against the chiropractor’s license. The charges included negligent chiropractic practice, false or misleading advertising and unethical advertising. But the decision of whether he should lose his license or be punished was left to the state chiropractic board.

CMS argued that the endocrine system is a complex set of organs and glands and that diseases such as diabetes are best treated by endocrinologists – physicians with more than 10 years of training who are specially trained to diagnose and treat this system.

But last fall, the chiropractic board opted not to take action against the chiropractor’s license, issuing only a letter of admonition for incomplete documentation of patient interactions.

The board also concluded that chiropractors could diagnose and treat the endocrine system, stating, “The scope of chiropractic practice includes diagnoses and treatment of human ailments, including those affecting the endocrine system.”

Legal battle

CMS was working with legislators to address that finding when the chiropractic board began considering a change to an existing rule.

The change authorized chiropractors to administer drugs topically, orally, and by inhalation and injection after completing just 24 hours of study and a certification exam. The rule did not restrict the medical conditions to be treated or where in the human body the injections could be administered. CMS objected to the change, arguing that the chiropractic board was exceeding its authority by essentially trying to change state law regarding which professions may practice medicine. CMS also noted that the General
Assembly did not approve 2010 legislation proposed that would have allowed chiropractors to perform injections.

Despite the objections, a majority of the chiropractic board voted in December to change the rule. It was to go into effect Jan. 14.

CMS filed suit in Denver District Court in late December. The following organizations joined in the lawsuit: Colorado Society of Osteopathic Medicine, Weld County Medical
Society, Clear Creek Valley Medical Society, Aurora-Adams County Medical Society, Denver Medical Society, Mesa County Medical Society, Colorado Radiological Society, Colorado Chapter of American College of Emergency Physicians, Colorado Orthopaedic
Society, Colorado Society of Anesthesiologists, Boulder County Medical Society and Larimer County Medical Society.

The groups also took their case to the General Assembly’s Legal Services Committee. This committee of state lawmakers reviews rule issues and can vote to not allow a rule to continue, though such a vote must also be affirmed by the full legislature and the governor.

Ken Spresser, DC, joined those opposing the rule change, and said that only a minority of Colorado chiropractors backed it.

Spresser, who has been a chiropractor for 30 years and has served in leadership for both the American Chiropractic Association and the Colorado Chiropractic Association for decades, said the 24 hours of study and instruction chiropractors receive in the administration of drugs by injection is “woefully inadequate.” He said the rule, as proposed, could allow for injection of drugs such as digitalis, morphine, cocaine and penicillin.

“Please protect the public from this small interest group and the Chiropractic
Board of Examiners that only wants to make more money by exceeding their statutory boundaries,” Spresser said.

Kief outlined several concerns about the rule, including the fact that anything of pharmaceutical grade that is to be injected must be done by prescription. Since chiropractors cannot prescribe, and would be injecting non-FDA approved compounds, Kief said.

“We urge the chiropractic board to take a step back, re-examine the issues and what their profession wants to treat,” she said. “As a physician, I do what I have been trained to do with excellence. Health professionals should each be proud of what we do; but first, do no harm and keep patient safety as a central tenant. Isn’t that what you would want of your health care provider?”

The Legal Services Committee voted unanimously against the rule. Weeks later, the chiropractic board voted to not let the rule take effect.

CMS leaders said they continue to stress collaboration and evolution in health care, as well as patient safety.
“We believe in health teams and would be happy to collaborate with the chiropractic community about these issues,” Kief said.