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Texas Performance Review
Realigning Chiropractic Oversight


Background

It's a fact only now being turned around: Chiropractors sometimes lack respect-at least from the traditional medical community, which has historically questioned the chiropractic focus on treatment of the spine. As recently as 1966, for instance, the American Medical Association labeled chiropractic "an unscientific cult."[2] A court ruling subsequently directed the medical establishment to end its attacks on the chiropractic profession. But even today, chiropractors vie for respectability despite the fact that one in every 20 Americans consults a chiropractor each year and all 50 states and the District of Columbia officially recognize and regulate chiropractic as a health profession.[3]

Chiropractors were accused repeatedly in the early years of this century of practicing medicine without licenses. Yet Kansas issued the first chiropractic licenses in 1918, and 31 states followed suit by 1925.[4] In Texas, the Legislature considered its first proposal legalizing chiropractic in 1917, but action stalled for years.

The Legislature legalized chiropractic in 1949; 828 licenses were issued that year. Previously, Gov. Coke Stevenson had appointed a state board. But now the board had statutory authority. Its mission, as stated in the board's strategic goals, remains to "insure that only qualified individuals are licensed as Doctors of Chiropractic, and [that] they are abiding by the laws and rules governing chiropractic in Texas," and "to guarantee that the public is protected from incompetent services, fraud and misrepresentation."[5]

Today, the board consists of nine members appointed by the governor and serving staggered six-year terms. Six members must be practicing chiropractors. TBCE also has seven employees, including an executive director, director of human resources and personnel, director of licensure, director of enforcement and investigations, an accountant, and two part-time administrative staff members.

The number of chiropractors licensed by TBCE has risen steadily over the past decade. In fiscal 1986, Texas licensed 1,775 chiropractors; by fiscal 1996, the number of licensees had more than doubled, to about 3,560.[6]


Funding

TBCE's funding also has more than doubled over the past decade (Exhibit 1).

EXHIBIT 1: Legislative Appropriations
Texas Board of Chiropractic Examiners
1986-87 through 1996-97

Biennium Appropriations Percent Change
1986-1987 $218,480 13.6%
1988-1989 338,898 55.1
1990-1991 333,758 -1.5
1992-1993 324,558 -2.8
1994-1995 589,750 81.7
1996-1997 593,204 0.6

SOURCE: Texas Legislature, General Appropriations Act, (various years).

As Exhibit 1 indicates, TBCE received its first major funding increase in 1988-1989, to improve administration and increase contract investigations. Funding for contract investigations accounted for only $40,000 over the biennium, but at the time the agency was still operating with a staff of one full-time employee. Funding remained fairly constant until 1994-1995, when it increased 82 percent along with a legislative commitment to significant improvements in board operations, including full-time staffing for license administration and enforcement activities.

TBCE's funding is more than covered by its fees. Active licensees must pay an annual renewal fee of $325, including $125 for the chiropractic license and an additional $200 in professional fees imposed on chiropractors and several other professions by the 1991 Legislature.[7] The board charges separate fees for inactive and provisional licenses. In addition, the board collects examination fees from new chiropractors and re-examination fees from those returning to practice. TBCE follows a schedule of charges for providing specific pieces of information such as demographic profiles of licensees.[8] TBCE also registers chiropractic facilities, charging $40 per applicant. Each application may list several facilities such as multiple offices in a city.


Enforcement

TBCE's enforcement effort is driven by complaints received by the board. Complaints submitted to TBCE give a clear indication of the scope and breadth of the allegations against chiropractors. A cursory review of complaints submitted during fiscal 1996 revealed numerous alleged practices that could merit the suspension or revocation of a license.

Among the most serious alleged infractions:

  • One complainant alleged repeated contact of a sexual nature which her chiropractor claimed was part of her treatment. TBCE is seeking to revoke his license.
  • One chiropractor, failing to pay $9,000 in back child support, had his license revoked by court order.
  • One chiropractor was found to have repeatedly fondled a female patient. The chiropractor agreed to have his license suspended for three years, perform 120 hours of community service, undergo psychological evaluation and treatment, and serve no patients without another employee present or a door ajar.
Advertising complaints, often submitted anonymously, predominate.

In a typical example, a chiropractor advertised "no out of pocket expense" on a television commercial, in violation of statutory restrictions on waiving insurance copayments or deductibles. The offending chiropractor stopped running the TV ad after being notified by TBCE.

During fiscal 1995, half of TBCE's appropriation was devoted to enforcement activities, a typical ratio for professional licensing boards in Texas and other states.[9]

Since 1994, TBCE's board has employed a coordinator to administer enforcement activities. The current enforcement coordinator has held the job since August 1995.[10] A three-member enforcement committee-two chiropractors and one public appointee-hears disciplinary proceedings against chiropractors and oversees the board's handling of complaints. The committee's legal counsel is provided by the Office of the Attorney General.
The enforcement committee can carry out a minor sanction immediately; more serious actions, where the enforcement committee recommends revocation or suspension of a practitioner's license, must be approved by the full board.[11]


The enforcement process

Although complainants often contact TBCE over the phone or in person, the agency has a policy that individuals must file complaints in writing for the complaint to be acted upon.[12] The agency furnishes complaint forms, but will accept any written complaint. TBCE's tracking system assigns a case number to each complaint indicating the fiscal year and the order in which the complaint was received. For example, the first complaint received on the first day of fiscal 1996 would be tracked by the number 96-1. Complainants may name more than one licensee in a complaint. When they do, each cited licensee is treated as a separate case.

The enforcement coordinator logs each complaint into the tracking system and acknowledges its receipt by mail within 48 hours.[13] The coordinator then sends the licensee a copy of the complaint and a request for a response within 10 days.

After an initial review, the enforcement committee may close a complaint file by finding that the board has no jurisdiction in the matter or that no violation of state law has occurred. If the preliminary review convinces the committee to seek more information, it will arrange an informal hearing at which the licensee and the complainant may appear separately. After this hearing, the committee can close a complaint either by ruling that no violation occurred or by issuing a letter of warning, a letter of reprimand, or an agreed order.

A warning, the mildest sanction, states that TBCE has found evidence of an ongoing violation of the chiropractic statute, such as advertising professional superiority, and that the licensee should discontinue the practice. A reprimand constitutes a public statement of displeasure concerning a licensee's behavior and may require no further action from him or her. Agreed orders are employed when the board identifies a violation and reaches an agreement with the licensee for remedial action. In some instances, an agreed order essentially imposes probation on a licensee's practice for a specified period and may include requirements for additional training.[14]

If an informal hearing fails to resolve the complaint or if the licensee formally objects to the committee's findings, the case may be referred for a formal hearing to be conducted by the State Office of Administrative Hearings (SOAH). SOAH assigns an administrative law judge to hear the case. The results of this proceeding may serve as the basis for TBCE's suspension or revocation of a chiropractor's license.


Recent complaint trends

The number of complaints received by TBCE has fluctuated over the last four years, from 189 in fiscal 1993, to a high of 321 in fiscal 1995 to 242 complaints in fiscal 1996. The 1995 number, however, was due in part to a single complaint involving 69 chiropractors.[15] This complaint aside, the 1995 caseload more closely resembles the average annual caseload of from 200 to 250 cases a year.

Board staff group complaints into several categories corresponding to provisions of the chiropractic statute. These range from unprofessional conduct and improper solicitation of patients to sexual misconduct and improper exposure to radiation. TBCE also tracks the resolution of complaints.

During the past four years, TBCE received 960 complaints and took 86 disciplinary actions (Exhibit 2). About a third of the complaints concerned allegations of unprofessional conduct.

Letters of warning, the mildest sanction, were by far the most common board sanction. Letters of warning accounted for more than 80 percent of all disciplinary actions between 1993 and 1996.

EXHIBIT 2

TBCE Complaints and Disciplinary Actions
1993-96

Complaints Disciplinary Actions
Type Number Total Excluding Warnings
Unprofessional Conduct 345 36 10
Fee Dispute 196 12 1
Advertising 162 31 2
Radiation 87 2 1
Sexual Misconduct 41 3 3
Practice w/o License 31 0 0
Other 98 2 0
Total 960 86 17
Percentage  9.0% 1.8%

SOURCE: Texas Board of Chiropractic Examiners.


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