Interview

Advocating for Chiropractic on Capitol Hill: Interview with John Falardeau

Daniel Redwood, DC

 

author email   

Topics in Integrative Health Care 2013, Vol. 4(2)   ID: 4.2003



Published on
June 28, 2013
Text Size:   (-) Decrease the text size for the main body of this article    (+) Increase the text size for the main body of this article
Share:  Add to TwitterAdd to DiggAdd to del.icio.usAdd to FacebookAdd to GoogleAdd to LinkedInAdd to MixxAdd to MySpaceAdd to NewsvineAdd to RedditAdd to StumbleUponAdd to Yahoo

John Falardeau is the Senior Vice President for Government Relations for the American Chiropractic Association (ACA) located in Arlington, Virginia and is responsible for monitoring legislation, formulating policy, and carrying out the overall political strategy for the organization.

Before coming to ACA, Falardeau was the Director of Government Affairs for the Rubber Manufacturers Association. Prior to that, he spent ten years as a senior assistant to two members of the House of Representatives. During his tenure on Capitol Hill, he was involved in drafting and monitoring legislation regarding transportation, taxes, and health care. He was also active in several congressional campaigns. 

A U.S. Navy veteran, he holds a BS degree from the State University of New York, College at Brockport, and an MA degree from George Mason University. 

From your perspective as a non-chiropractor who works tirelessly to help chiropractors and their patients to advance their cause in Washington, what would you say have been the major positive achievements in recent years?


I can tell you this. Even in my relatively short time with this group, eight years, without question what I’ve seen is a more universal acceptance on Capitol Hill of the services provided by doctors of chiropractic. Especially during health care reform, in 2009 and 2010, we visited probably over 200 offices [of senators and members of Congress], and in not one of those offices was there any pushback or any indication that what we did was not important. Many of them, in fact, if they weren’t chiropractic patients themselves, they had a family member or a friend who was. And they had nothing but glowing things to say about what you folks do. That, to me, is what I have seen. I have seen the acceptance grow and it is continuing to grow.
 
An Ever-changing Landscape

What are the largest immediate and long-term challenges the profession faces in the political and policy realms?


One of the challenges that we’re going to be facing in a couple of years is the loss of one of our biggest advocates on Capitol Hill, Senator Tom Harkin of Iowa. He is not going to run for re-election in 2014. That challenge of political turnover is always on our minds. Last year at this time, it was uncertain if Senator Orrin Hatch from Utah, another of our biggest advocates, was going to win re-election. He was in a very tough primary fight, which he ultimately won. But that type of turnover is something we’re always concerned with.

It takes time for a Congressional ally of chiropractors to rise through the ranks to achieve the positions of power, which in Senator Harkin’s case is the chairmanship of the Senate Health, Education, Labor and Pensions Committee. When someone like that retires, it’s a major loss. I’m also aware that when you mention Senators Hatch and Harkin, one is a Republican and the other a Democrat. So chiropractors have, over time, cultivated support on both sides of the aisle. It’s not a partisan issue.


You’re right; it’s not partisan by any means. When health reform was being legislated, both houses were controlled by Democrats, so we had to work a little more closely with Democrats than Republicans, just based on the numbers. It’s also very important to remember that our biggest advocates are patients, who understand first-hand what chiropractors have to offer and can convey this to their representatives.

The Importance of Participation


Would you say it’s important for chiropractors and their patients to send letters and emails to Washington, that this really matters?


Oh, yes. It really matters, especially when bills are before the Congress because dealing with issues there is in many ways a numbers game. The number of calls, letters and email messages are counted by Congressional offices. When one of our bills is being considered, we need to build up the numbers. Because when a legislative assistant goes in to the Member of Congress and says, “Congressman, I received 75 emails on this chiropractic bill yesterday,” that really makes a difference. Numbers make a difference, because all of those people are voters.

Let’s use health care reform as an example. At this point, it’s in the implementation stage where the executive branch is developing rules and regulations which will be used in implementing the law. When proposed rules are put out, we generally don’t call the rank and file to comment on them. In this case, at this stage with the Administration, our input needs to reflect quality rather than quantity. The people in administrative roles are not up for re-election so it’s not so much a numbers game as it is when we’re trying to get a law passed.

So what we have been doing with the proposed rules is that we’ve sent templates to state associations, through the Chiropractic Summit, so that they can weigh in. That’s more of the “grass tops” lobbying rather than grassroots lobbying. You just have to find that balance.

The Critical Role of Research


When you’re talking to federal regulators, what tools are most helpful to you? For example, how important is it for you to have strong research supporting the effectiveness or cost-effectiveness of chiropractic care?


That’s huge, very huge. The holy trinity, if you will, of healthcare reform is cost, access and quality. These days, cost is a big segment of that. When I can exhibit cost-effectiveness through research, that resonates. Eyebrows rise for that more than for the other two. It’s very important. The research that’s being done is tremendous and it helps us. We have good patient satisfaction, which is part of quality, and we have good access with most insurance plans, including direct access through Medicare. But cost-effectiveness is a key driver in policy here in Washington.

There are articles every day about health care costs, and you very rarely see the cost of anything go down. So it’s very important that we be able to talk cost-effectiveness.

There was a cost-effectiveness research review performed by non-chiropractors, that was published in the European Spine Journal in 2011.
1 Among their conclusions was that for chronic low back pain (which is tremendously costly to society), spinal manipulation is cost-effective. On the other hand, for medications, the researchers said they could not find any evidence of cost-effectiveness. The studies have apparently never been done. Which means that for chronic low back pain, there is stronger evidence of cost-effectiveness for the main method used by chiropractors than for the main method used by MDs. And yet insurance companies will often just wave claims through the gate if they involve prescriptions for painkillers. Do you feel that the bias behind that approach is gradually being worn away by evidence of chiropractic cost-effectiveness?

It’s like trying to turn an aircraft carrier on a dime. I spent four years on an aircraft carrier and I know it’s hard to do. You’re absolutely right and it’s essential that we get this message out there more and more. F4CP [the Foundation for Chiropractic Progress] does a wonderful job at that. During the week of this year’s National Chiropractic Legislative Conference, they ran ads in major Hill publications and in the Wall Street Journal. That helps tremendously.

But I wish they could have done it, I wish we could have done it, for weeks afterwards. This is a campaign to change minds. It needs to be sustained, so that people hear the message over and over again. Think of the “Just Say No” campaign about drugs, which some of us older guys can remember, or Michelle Obama’s “Get Up and Move” campaign. It’s not a one-week campaign; she’s been doing it since the Obama Administration came into office. I wish we had the resources within this profession to mount a campaign that would last for a long time.

Back in the Clinton healthcare reform of 1993-1994, I’ve seen some of what the ACA office did, and it was really good. They were able to run commercials on The Larry King Show on CNN. At that time, cable advertising was relatively cheap. But now it’s gotten to the point where it’s almost as much, or even more, than network advertising. I wish the profession could fund that kind of sustained campaign, but those kinds of resources are just not in our coffers right now. I would like someday to see the research talked about repeatedly, because that’s what it’s going to take.

Another key challenge we face is that virtually anything that’s done legislatively on Capitol Hill has to go through the Congressional Budget Office (CBO), which has many flaws. They’re not set up to investigate or determine savings. For example, in the VA [Veterans Administration], for the past several Congresses we’ve had a bill to further integrate chiropractors in the VA system. And there have been Congressional Budget Office estimates of what it would take to do that.

Congressional Budget Office Considers Only Costs, Not Savings


CBO is looking at what would be paid for those services rather than including in their calculations the services that would be displaced, such as medication costs and MD visits.


Exactly. So if the bill calls for having doctors of chiropractic in 120 more facilities in the VA, the only thing they do is take what the average doctor of chiropractic makes in the VA, and multiply it by 120. That’s all they do. So when Congress asks CBO, “What is this going to cost?” that’s the only thing they have to go on.

During healthcare reform, there were several instances not related to chiropractic, where Speaker Nancy Pelosi came down hard on CBO, saying how can you claim it’s going to cost this amount, this is awful, your numbers are wrong. But then there were other points where she was praising CBO.

We’ve seen the same thing under Speaker Boehner, just on different issues. CBO is non-partisan, not the servant of the party in the majority.


Yes. The current cost-estimation arm of the U.S. Congress is flawed. The back surgeries that are saved if more veterans go to doctors of chiropractic are not considered in CBO computations.

Provider Nondiscrimination Policy: A Historic Breakthrough


What’s your sense at this point of the provider nondiscrimination policy in the Affordable Care Act? I know it doesn’t go into effect until January 2014. What is in that policy and is it a step forward?


It’s a huge step forward. That’s not just something I’m saying. It was said by the National Association of Chiropractic Attorneys, which is comprised of the counsels for all the chiropractic associations. They called it “historic.” Not only will this apply to plans that are in the newly formed exchanges in the small group market [which open in January 2014], but it will also apply to ERISA, which at this point still regulates the plans that the majority of Americans get their health insurance from. It’s the first time that we’ve been able to pierce that ERISA shield. That took a lot of effort, specifically from our folks in Iowa and Connecticut, who had developed relationships over the years with Senator Harkin and Senator Chris Dodd, who was the chair of the Senate HELP committee following the death of Senator Ted Kennedy, before Senator Harkin became the chair. It took a great deal of work with our doctors in those states. They helped the senators see the problem that has been around almost as long as chiropractic has — that insurance companies have discriminated against doctors of chiropractic. So it was a huge win!

There will most likely be a rule for this …

Rulemaking: Public Comments Do Matter


For people who may not be familiar with this, we should probably explain what a rule is. When you say there will be a rule, are you basically talking about an interpretation by the Department of Health and Human Services to guide insurance companies, state governments and others as to how to interpret the legislative language in the nondiscrimination section of the Affordable Care Act?


Exactly. Prior to that proposed rule being drafted, it will be published as a proposed rule and the public will have 30-60 days to comment on it before they come up with a final rule.

In your experience, do the comments that people submit to the government during these comment periods sometimes actually influence the content of the final rule?


I can give you a great example of that. Back in 2011 (and so much happens so quickly these days that when I talk about 2011, it feels like I’m talking about 1963), there was a proposed rule for the Medicare Accountable Care Organizations section of the Affordable Care Act. There was nothing in there about doctors of chiropractic. And when doctors of chiropractic are not mentioned, they’re pretty much out. We said, “Look, if the goal of these ACOs is to achieve cost savings, based on our evidence of cost-effectiveness, you have to ensure that doctors of chiropractic are included in this program.” That was in our comments and that template was also sent to all chiropractic state associations so they could weigh in as well. So in the final rule, HHS basically said, you’re right, based on the quality and cost-effectiveness of the services that doctors of chiropractic provide, they can become part of ACOs and take part in any cost reduction incentives that the ACO attains. Basically, they told ACOs that they could hire doctors of chiropractic. That was huge.

I’m also hearing in this language a critical difference between “may” and “shall.” ACOs may include DCs, but are not required to do so.


In that rule, they never did that for any kind of practitioner. The ACOs are independent and the rule writers did not think it wise to dictate who and how many people they should employ. But even putting those words, “cost-effectiveness” and “quality” in a federal regulation when referring to doctors of chiropractic, was huge.

The Road Forward


I don’t know if you feel it’s helpful to make long-term predictions, but at least in terms of what you hope will happen, what kind of chiropractic legislation would you like to see Congress pass in the next ten years?


First, we’re going to work to have the bills that we now have in play enacted sooner rather than later. There’s a bill to commission doctors of chiropractic in the Public Health Service Commissioned Corps. I believe this has a good chance of passing in the current Congress and I would certainly like to see that happen. There’s support. Right now, we’re one of the only provider groups that is not included. Even the veterinarians have representation. If you’re going to have veterinarians in a corps like this, you should certainly include doctors of chiropractic. We have a House bill for that and we’ll soon to have a Senate bill.

Another key goal is to further integrate doctors of chiropractic in the VA, as I spoke about earlier. We have both a House and a Senate version for that. We think that given the evidence provided by the VA itself, that the majority of vets coming back from Afghanistan and Iraq have musculoskeletal problems. Who better to address those than doctors of chiropractic?

We’re also working to gain further inclusion in Tricare [the insurance plan for active duty military, retirees and their dependents]. General Halstead is a perfect example, in that when she was in uniform she had a chiropractic benefit and the day she walked out, she lost it. This may take a little longer, because Tricare is always under the microscope. As I mentioned, the Congressional Budget Office does not consider savings that would come from including chiropractic services, only costs.

Also, we’re in the midst of a multi-year clinical demonstration project within the Department of Defense, which we hope will further show that chiropractic is effective and cost-effective. It’s likely that any further progress on integrating chiropractic into military healthcare services will have to wait until this project is done.

That clinical trial is the one funded by a $7.5 million Congressionally-directed research grant, which involves three different studies, each of which is a randomized trial. We did
an interview with the lead investigator, Dr. Christine Goertz, in a recent issue of Health Insights Today where she described this project. Hopefully it will show a benefit from chiropractic care. But it will take a number of years to be completed and published.

When this first was first announced, we were a little upset, because our feeling was, “How many more studies do you guys need?” But in talking to the staff of the House Armed Services Committee, this is something that they’ve done in many other instances [not related to chiropractic], such as with PTSD [posttraumatic stress disorder]. I also think this clinical trial is going to have effects beyond DOD because it will be the biggest clinical trial in the history of chiropractic.

So afterwards, I felt better about it. It is part of the grant, and part of the law, that it include Special Forces units, who I understand are our biggest fans — SEAL teams, those folks who really go through a physical beating as a normal part of their work. We’ll be embedded with those folks as well. I expect these trials to go very well, and if they do I expect the effects to bleed over into Medicare and even private insurance.

Step by step. What can chiropractors and chiropractic students do to enhance a positive profile for the profession?


We’ve seen greater acceptance of chiropractic among policy makers. I believe there are other things that can further the evidence that we are in the big leagues. Two things come to mind. One is the Physician Quality Reporting System, which is a Medicare program. It basically says that if you can report quality [through filling out certain forms], and for us it’s only two measures, you get a bonus. It’s not much, a few hundred bucks here and there. But it shows that we do report quality, that we are equal with our brethren among the MDs and DOs that we do participate. Currently, the participation level of doctors of chiropractic in this program is small.  A lot of it has to do with the bonuses being very minimal. But this is how we exhibit our place in the system.

So by participating in this, the individual chiropractor, beyond any small amount of money that they receive, is helping the profession as a whole and helping you to make our case in a stronger fashion.


That’s a great way to put it. It’s how we show that we have matured, that we have ripened. And that we can play on a level playing field. Related to that is the whole electronic health records incentive program, which is another Medicare program. We’re doing better in the levels of participation by doctors of chiropractic. We worked hard to be sure that doctors of chiropractic were included in the legislation and DCs can now earn up to $44,000 over a few years by going electronic. All the information about this is available on the ACA website.

When these types of programs come out, and we publicize them in ACA News and Week in Review, we want doctors to take part. I know that some people think, “This is another opportunity for the federal government to audit me,” which I can understand. But it’s much more than that; it’s an opportunity for chiropractors to really exhibit their place in the healthcare delivery system.

Thank you.




Daniel Redwood, DC, the interviewer, is a Professor at Cleveland Chiropractic College–Kansas City. He is the Editor-in-Chief of Health Insights Today, Associate Editor of Topics in Integrative Healthcare and serves on the editorial board of the Journal of the American Chiropractic Association. Dr. Redwood’s website and health policy blog are at www.redwoodhealthspeak.com.

A previous version of this article was published in Health Insights Today, a publication of Cleveland Chiropractic College -- Kansas City, and is reprinted with permission.
Share:  Add to TwitterAdd to DiggAdd to del.icio.usAdd to FacebookAdd to GoogleAdd to LinkedInAdd to MixxAdd to MySpaceAdd to NewsvineAdd to RedditAdd to StumbleUponAdd to Yahoo

References

1.   

Lin CW, Haas M, Maher CG, Machado LAC, Tulder MW. Cost-effectiveness of guideline-endorsed treatments for low back pain: a systematic review. European Spine J 2011;20(7):1012-23.