The following opinion is presented on-line for informational use only and does not replace the official version. (Mich Dept of Attorney General Web Site - www.ag.state.mi.us) STATE OF MICHIGAN FRANK J. KELLEY, ATTORNEY GENERAL Opinion No. 5503 July 5, 1979 PUBLIC HEALTH CODE: Requirement that a health maintenance organization provide 'chiropractic services' CHIROPRACTORS: Requirement that a health maintenance organization provide 'chiropractic services' HEALTH MAINTENANCE ORGANIZATION: Requirement that a health maintenance organization provide 'chiropractic services' WORDS AND PHRASES: 'Chiropractic services' The Public Health Code requires that three years after initial licensure, a health maintenance organization shall provide chiropractic services to its subscribers. A health maintenance organization may not satisfy that requirement by having subscribers seek chiropractic services from a doctor of medicine or a doctor of osteopathic medicine and surgery. Maurice S. Reizen, M.D. Director Department of Public Health 3500 N. Logan Lansing, Michigan 48909 You have brought to my attention a statutory provision which requires health maintenance organizations to provide chiropractic services to their subscribers, and you have asked whether those chiropractic services may be performed by such health professionals as orthopedic surgeons, doctors of osteopathic medicine and surgery and physical therapists. Health maintenance organizations are created pursuant to the Health Maintenance Organization Act of 1973, 42 USC 300e et seq, and the Public Health Code, 1978 PA 368, as amended; MCLA 333.1101 et seq; MSA 14.15(1101) et seq and are licensed and regulated by the Department of Public Health and by the Insurance Bureau of the Department of Commerce pursuant to the latter act. The purpose of health maintenance organizations is to deliver health services to subscribers directly or through arrangements with affiliated providers; generally, health services are provided to subscribers in exchange for a fixed sum without regard to the frequency, extent or kind of health services furnished. All health maintenance organizations are required to provide primary health services to subscribers, including the services of physicians and certain related services. Pursuant to section 21034(d) of the Public Health Code, supra, three years after the initial license is issued, a health maintenance organization is also required to offer 'supplemental health services' unless a waiver has been granted: 'The department, with the concurrence of the insurance bureau, shall issue a license to a health maintenance organization upon being satisfied that: '(d) The proposed health maintenance contracts to be issued by the health maintenance organization include, as a minimum, the primary health maintenance services specified in section 21007(1) during the period for which the initial license will be issued, and the contracts issued or in effect after the date of the first renewal of the license shall include, as a minimum, the basic health services specified in section 21003. Three years after the initial license is issued, an organization shall offer the supplemental health services specified in section 21009 as separate or combined options to subscribers for such additional payment as the organization requires. . . .' (emphasis added) The term 'supplemental health services' as contained in section 21008(2) of the Public Health Code, supra, encompasses a variety of services, including chiropractic services: "Supplemental health services' means: ' (g) Chiropractic services.' The answer to your question turns on the meaning of the statutory language 'chiropractic services.' Chiropractors are licensed and regulated pursuant to the Public Health Code, supra. The Public Health Code, supra, Sec. 16401(1)(b), defines the 'practice of chiropractic' as follows: '(1) As used in this part: ' (b) 'Practice of chiropractic' means that discipline within the healing arts which deals with the nervous system and its relationship to the spinal column and its interrelationship with other body systems. Practice of chiropractic includes: '(i) Diagnosis, including spinal analysis, to determine the existence of spinal subluxations or misalignments that produce nerve interference, indicating the necessity for chiropractic care. '(ii) The adjustment of spinal subluxations or misalignments and related bones and tissues for the establishment of neural integrity utilizing the inherent recuperative powers of the body for restoration and maintenance of health. '(iii) The use of analytical instruments, nutritional advice, rehabilitative exercise and adjustment apparatus regulated by rules promulgated by the board pursuant to section 16423, and the use of x-ray machines in the examination of patients for the purpose of locating spinal subluxations or misaligned vertebrae of the human spine. The practice of chiropractic does not include the performance of incisive surgical procedures, the performance of an invasive procedure requiring instrumentation, or the dispensing or prescribing of drugs or medicine.' Thus, chiropractic is a discipline within the healing arts which is concerned with the treatment of patients who suffer spinal subluxations and misalignments. The authority of the chiropractor to diagnose is limited to an effort to locate such spinal subluxations and misalignments. Assuming that subluxations or misalignments are found, the chiropractor's authority to treat is limited to the adjustment of them, as well as to the adjustment of related bones and tissues. Chiropractors may also give nutritional advice and employ rehabilitative exercise. Doctors of medicine and doctors of osteopathic medicine and surgery are licensed to treat human ailments without restriction as to the nature of the ailment to be treated or the method of treatment to be employed. 1978 PA 368, supra Secs. 17001(1)(c), 17501(1)(c). (1) Accordingly, such physicians are authorized by law to treat the same conditions and employ the same methods of treatment as are chiropractors. However, the health maintenance organization is not thereby excused from its requirement to make 'chiropractic services' available to subscribers. Chiropractors perform their activities in accordance with a theory of healing which is different from that which underlies the practice of medicine or the practice of osteopathic medicine and surgery. That difference was recently noted by the Michigan Court of Appeals in Kelley v Raguckas, 84 Mich App 618, 624-625; ---- NW2d ----, ---- (1978); app den ---- Mich ---- (1979): "Medical doctors, though under no compulsion to do so, rely chiefly upon drugs and surgery in ministering to the sick. Though there are notable exceptions, they tend for the most part to be either apathetic and skeptical or frankly antagonistic to the use of manipulation as a curative agent. "Doctors of osteophathy, on the other hand, while they too are trained and licensed to prescribe drugs and to perform surgical operations, also make use of manipulative procedures. "In contrast to both of these kinds of doctors, the doctor of chiropractic gives no medicine and practices no surgery. This is not because he feels that he has the answer to every health problem and believes that drugs and surgery are never necessary. It is because he is convinced that the chiropractic way offers safest, sanest, and most promising approach to the great majority of human ailments. . . .' Opportunities in a Chiropractic Career (New York 1967), p 8.' In their treatment of patients, chiropractors are required to adhere to the tenets of their separate healing systems. In Janssen v Mulder, 232 Mich 183, 190; 205 NW 159, 161 (1925), the court so ruled in a case wherein a chiropractor was charged with malpractice for failing to properly treat a child suffering from diphtheria: '. . . To maintain such an action, the plaintiff must show that the result complained of was due to negligence or unskillful treatment. While not registered, the defendant was a graduate of a chiropractic school. He but assumed to treat human ailments in accordance with the system taught in such school. This fact was well known to plaintiff. The burden was therefore cast upon her to show by competent evidence, not only that his treatment was injurious or not effective, but that the requisite care and skill was not exercised by him in administering it. It necessarily follows that such proof must be made by one engaged in treatment by similar methods to those employed by defendant. . . .' (2) Doctors of medicine are required to treat patients in accordance with accepted standards of medical practice. Doctors of osteopathic medicine and surgery are required to treat patients in accordance with accepted standards of osteopathic practice. Bryant v Biggs, 331 Mich 64; 49 NW2d 63 (1951). A person who seeks chiropractic services expects the practitioners to adhere to that system. Thus, as neither a doctor of medicine nor a doctor of osteopathy renders chiropractic services, only a practitioner of the chiropractic system of healing renders 'chiropractic services' within the meaning of section 21008(2)(g), supra, of the Public Health Code. However, a doctor of medicine or a doctor of osteopathic medicine and surgery may lawfully treat the same ailments in accordance with the standards of their profession. It should be noted that although the requirement to provide chiropractic services must be satisfied by a practitioner of chiropractic, doctors of medicine and doctors of osteopathic medicine and surgery, as well as other health care professionals, may play a role in the provision of chiropractic services. Pursuant to section 21031(j) of the Public Health Code, supra, an applicant for licensure as a health maintenance organization is required to describe the procedures to be utilized in monitoring the quality of health care provided to subscribers. Further, section 21021 of the Public Health Code, supra, provides: 'The department, in conjunction with the insurance bureau, shall establish a system of licensing and regulating health maintenance organizations in this state to protect and promote the public health through the assurance that the organizations provide: '(a) A high quality of health care by qualified personnel. '(b) Health care facilities, equipment, and personnel which may reasonably be required to economically provide health maintenance services without causing unnecessary duplication of health care facilities in the area to be served. '(c) Operational arrangements which integrate the delivery of various services. '(d) A financially sound prepayment plan for meeting health care costs.' In addition to any internal policies of a health maintenance organization, the Department of Public Health, in conjunction with the Insurance Bureau, may require that the delivery of health services be monitored on an interdisciplinary basis to assure both high quality and to integrate the delivery of services. My conclusion that chiropractic services must be delivered by a practitioner of chiropractic is limited to the actual delivery of services, and does not require a health maintenance organization to be a collection of autonomous units of practitioners of the various healing arts. It is therefore my opinion that the Public Health Code, supra, requires that three years after initial licensure a health maintenance organization provide chiropractic services to its subscribers. A health maintenance organization may not satisfy that requirement by having subscribers seek chiropractic services from a doctor of medicine or a doctor of osteopathic medicine and surgery. Frank J. Kelley Attorney General (1)
(2)
The court went on to hold that the plaintiff would be entitled to show that diphtheria is an ailment for which a recognized treatment is available through the medical sciences, and that the defendant chiropractor was negligent in failing to refer the patient to a physician trained to treat such conditions.