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Economic and Resource Status of the Chiropractic Profession in Ontario, Canada: A Challenge or an Opportunity

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Economic and Resource Status of the Chiropractic Profession in Ontario, Canada: A Challenge or an Opportunity
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  I  NTERNATIONAL  C ONFERENCE ON  C HIROPRACTIC  R  ESEARCH  O RIGINAL  A RTICLE -S ECOND  P RIZE E CONOMIC AND  R  ESOURCE  S TATUS OF THE C HIROPRACTIC  P ROFESSION IN  O NTARIO , C ANADA  :A C HALLENGE OR AN  O PPORTUNITY  Silvano A. Mior, DC, a  and Audrey Laporte, PhD b A BSTRACT Objective:  Chiropractic is one of the most frequently sought nonphysician provider groups. Despite its apparent recognition, the profession faces numerous challenges, including the economic reality of an increasing supply within amarket of questionable demand. This paper evaluates the chiropractic manpower status in Ontario, Canada. Methods:  Data collected from administrative and education databases, insurance billing data, and population healthsurvey data between 1990 and 2004 were analyzed. Results:  Between 1990 and 2004, the total number of chiropractic registrants in Ontario doubled, with an averageannual rate of growth of about 5.4%; however, recent data suggest that the number of nonpracticing chiropractors isincreasing, whereas the number of new registrants is decreasing. The rate of applications to a chiropractic institution rosesharply and peaked in 1996-1997, thereafter declining but leveling off in 2002-2003. Despite the continued growth in thenumber of practicing chiropractors, the utilization of chiropractic services among the Ontario population has remainedrelatively stable, resulting in a decline in the average net annual incomes adjusted for inflation to 2002 dollars. Conclusions:  Our results support previous reports projecting an oversupply of chiropractors and suggest that thechiropractic profession in Ontario is in long-run oversupply. Competition from other providers, changing populationdemographics, and the recent loss of public funding for services may present significant future challenges to current  practitioners. Opportunities related to participation in multidisciplinary environments and accessing unmet populationhealth needs may contribute to influencing the demand for chiropractic services. A concerted effort by professional andeducational institutions is required. (J Manipulative Physiol Ther 2008;31:104-114) Key Indexing Terms:  Chiropractic; Manpower; Income; Health Resources; Supply and Distribution F rom its humble and unconventional beginning, thechiropractic profession continues to develop accord-ing to its interest to best service the needs of the population. This ongoing development occurs despite theexternal constraints imposed upon it by the state, specialinterest groups, and the specific health care system inCanada. 1 The profession has obtained self-regulatory statusin all Canadian provinces, maintains high patient satisfac-tion, and is the most frequently sought complementary andalternative health care group. 2 Yet despite this apparent acceptance, its future role within the health care systemremains controversial. 3 In addition, chiropractors are begin-ning to realize the potential economic threat of an increasingsupply within a market  of questionable demand. 4 Cooper and McKee 4 recently noted that the chiropractic profession in the United States has experienced little of therapid growth in market share it encountered in the early1980s. They questioned how much unmet demand there isfor chiropractic services, especially given the increasingnumbers of other health care professionals vying for thesame market share at a time when coverage for its services isdecreasing. Moreover, the practicing chiropractor, impacted by the increases in the number of new graduates, 5 the low barriers to entry for  other complementary and alternativehealth care providers, 6 a dampening of the strength of itsonce convincing evidence base, 4 and the ongoing divisive-ness within the profession, 3,6 is being forced to moreaggressively market his/her services and products 4 in amarket where the demand for chiropractic services hasdecreased from an estimated 10% of the US population in1997 to about 7.5% in 2002, despite an about 13% increase a  Professor, Division of Research, Canadian Memorial Chiro- practic College, Toronto, Canada. Graduate Student, Department of Health Policy Management and Evaluation, Faculty of Medicine,University of Toronto, Toronto, Canada.  b Assistant Professor, Department of Health Policy Management and Evaluation, Faculty of Medicine, University of Toronto,Canada.Submit requests for reprints to: Silvano A. Mior, DC, 6100Leslie St, Toronto, Ontario, Canada M2H 3J1(e-mail:  smior@cmcc.ca ).Paper submitted August 23, 2007; in revised form November 8,2007; accepted December 1, 2007.0161-4754/$34.00Copyright © 2008 by National University of Health Sciences.doi:10.1016/j.jmpt.2007.12.007 104  Table 1.  Number of chiropractors registered with CCO from 1990 to 2004 Year  a  TotalRegistrants % Change Active  b % Change NewRegistrants % Change Nonactive c % Change Retired d Inactive e Suspended f  1990 1668 1610 82 97 9 49 391991 1716 2.9 1650 2.5 89 8.5 104 7.2 16 50 381992 1752 2.1 1696 2.8 96 7.9 91  − 15.4 22 34 351993 1830 4.4 1764 4.0 110 14.6 108 18.7 15 51 421994 1878 2.6 1846 4.6 105  − 4.6 78  − 27.8 15 17 461995 1999 6.4 1946 5.4 152 44.8 103 32.1 12 41 501996 2118 6.0 2042 4.9 156 2.6 136 32.0 16 60 601997 2243 5.9 2168 6.2 166 6.4 121  − 11.0 20 55 461998 2372 5.8 2293 5.8 159  − 4.2 101  − 16.5 25 54 221999 2516 6.1 2419 5.5 233 46.5 134 32.7 34 63 372000 2667 6.0 2576 6.5 177  − 24.0 124  − 7.5 31 60 332001 2939 10.2 2818 9.4 281 58.8 145 16.9 35 86 242002 3103 5.6 2953 4.8 243  − 13.5 191 31.7 33 117 412003 3302 6.4 3129 6.0 242  − 0.4 195 2.1 45 128 222004 3456 4.7 3213 2.7 207  − 14.5 259 32.8 66 177 16Average 5.4 5.1 9.2 9.1Source: College of Chiropractors of Ontario. March 2005. Used with permission. a  Year ending December 31.  b Those who have paid full registration and assume capable of practicing. c Assumes numbers not practicing and is the sum of retired, inactive, and suspended categories. d Those who are not actively practicing but wish to maintain membership in the CCO, hence included as registrant. e Those who are practicing in Ontario and have moved out of province. f  Those who are no longer registered with the CCO. Fig 1.  Number of new registrants compared with nonactive group. 105 Mior and LaporteJournal of Manipulative and Physiological TherapeuticsEconomic Status of Ontario ChiropractorsVolume 31, Number 2  in the number of practicing chiropractors and an almost 40%decline in the enrollment of US colleges in the late 1990s. 6 In one of the only published Canadian studies assessingmanpower needs, Grier and Lepnurm 7 used administrativedata collected over a 10-year period from the SaskatchewanMedical Care Branch to generate a provider-population ratiomodel to estimate the number of chiropractors needed toeffectively serve the people of Saskatchewan. They reportedthatduring the period understudy, both thenumber of licensedchiropractors and the percentage of the population usingchiropractic care grew. Their model predicted that theideal chiropractor to population ratio would be 1:2588, or 397 chiropractors, concluding that there was a shortage of chiropractors intheprovinceatthe time.GrierandLepnurm's 7 model assumed that all patients with a musculoskeletalcomplaint would seek chiropractic services; however, noconsideration of a change in demography, condition severity,or utilization of other provider groups was considered.In a 1996 unpublished internally produced report under-taken to assess the national manpower needs of the profession(personal communications with Paul Carey, 2005 March 15),the Canadian Chiropractic Association used a provider- population model to assess the chiropractic manpower needs projected into 2006. They combined known numbers of chiropractorsregisteredineachoftheprovinceswithestimatesof the number of Canadian students enrolled in chiropracticcollegesinCanadaand inthe UnitedStatesand a conservative projection of the number of chiropractors retiring or leaving practice, and population values from national census data.Assuming the utilization ratewould remainconstantat12.5%,they concluded that the uncontrolled growth of chiropracticmanpower would result in an oversupply by the early 2000s, Fig 2.  Graphical representation of total application numbers, applicants from Ontario, and tuition rates (in $10K, adjusted to 2003Canadian dollars) from 1990 to 2004. Table 2.  Reported student debt load at time of graduation 1990-1995 1995-1996 1996-1997 1997-1998 1998-1999 1999-2000 2000-2001 2001-2002 2002-2003 2003-2004 b $40K NA 16% 17% 20% 15% 14% 20% 25% 28% 10%$40K-$60K NA 44% 26% 31% 21% 18% 17% 16% 20% 10%$60K-$80K NA 28% 37% 27% 35% 33% 33% 9% 16% 28%$ N 80K NA 12% 20% 22% 30% 35% 30% 47% 36% 52%Source of data: the Canadian Memorial Chiropractic College Council on Chiropractic Education Annual Progress Reports. Used with permission. Student reported total debt load upon graduating from CMCC. This would include debt incurred during university education. K is equal to 000.  NA , Not available. 106  Journal of Manipulative and Physiological TherapeuticsMior and LaporteFebruary 2008Economic Status of Ontario Chiropractors  with some provinces being more affected. They proposed that incomes would decrease, feeswould rise, bankruptcies ofnewgraduates would increase, and unfavorable practice activitieswould impact on professional image.The growth in the competitive market for managingcommon musculoskeletal problems and the continued increaseinthenumbersofpracticingchiropractorsandotherhealthcare professionals raise serious questions about the relationship between the supply and demand for chiropractic services. Thedemand for health care services is a derived demand. The levelof this demand along with the existing stock of providersdetermines the wages, the number of providers employed, andtheirparticipationrate.Professional licensurerequirements andenrollment capacity determine the long-run supply or stock of manpower for the health care professions. The interaction between manpower and educational markets impacts upon thenumberofprovidersandtheirwages,andthepriceandquantityof their services, as well as being impor t ant in accuratelyforecasting health manpower requirements. 8 The decrease inthe utilization rate for chiropractic services and the drop inenrollment seen in chiropractic colleges in the United Statesmay be providing warning signals of an oversupply of  providers and changing market forces. 9 This paper evaluates the chiropractic manpower status inOntario, Canada, and makes a unique contribution byincorporating various data sources to triangulate the findingsto enhance accuracy and serve as a template for other  jurisdictions and future studies. M ETHODS Data were collected from administrative, insurance, andeducation sources between 1990 and 2004 and descriptivelyanalyzed.Dataobtainedfromthelicensingbody — Collegeof Chiropractors of Ontario (CCO) — were used to assess thetotalnumberofregistrants andthenumbersretiring,entering,and leaving the profession. Enrollment and tuition data fromthe Canadian Memorial Chiropractic College (CMCC) wereused to assess trends in applications and debt loads.Administrative insurance billing data from the publiclyfunded Ontario Health Insurance Plan (OHIP) were used toassess the changes in the income levels of practicingchiropractors and their practice location. Only administrativeOHIP data obtained for complete years before the delisting of chiropractic services in Ontario in the fall of 2004 were used.Forthepurposeofthispaper,theannualincomeofchiropractorswasestimatedfromOHIPbillingdata.TheOHIPbillingswereused as the base value from which overhead expenses (ie,estimated to be about 40% of gross income) and other incomesources (ie, co-payments and other income revenue estimatedto be about 60% of total income) were added as previouslydetermined from a sample of Ontario chiropractors. 10 Toensure this estimate was consistent with the actual annualincome, a comparison was made with the annual income datafor chiropractors from Ontario as reported in the 1995 and2000CanadianCensus. 11 Allnetincomefigureswereadjustedfor inflation using the all goods and services Consumer PriceIndex 12 and compared with the base year 2002.Ontario population health data from national surveys wereused to provide demographic data on those seekingchiropractic services. The National Population HealthSurvey 13 was used to provide 1996-1997 demogra phic data,and the Canadian Community Health Survey 14  provided2000-2001 data. Although these are 2 different populationhealth surveys, the sampling strategies were similar; and carewastakentoensurethatthesamequestionsfrombothsurveyswere used in the analysis. The appr opriate sample weightswere used to adjust the reported data. 15 Permission to use all nonpublic accessible databases wasobtained from the source agency. Anonymity was ensured by producing aggregate data and numerically coding regionallyderived administrative billing and utilization data. R  ESULTS The CCO is the profession's regulatory and licensing body. Every chiropractor must be registered with the CCO to practice chiropractic in Ontario. Recently obtained informa-tion from the CCO revealed that, between 1990 and 2004,the number of registrants doubled, with an average annualrate of growth of about 5.4%. The rate of growth increasedin 1995 from an average of about 3% per year to about 6%, except in 2001 when there was an increase of 10.2%.This spike in growth was followed by smaller increasesuntil 2004 when there was a 4.7% increase, the lowest since1995 (Table 1).The number of active registrants (ie, those paying ageneral registration fee and presumed to be engaged in thedelivery of chiropractic services) appears to mirror theincreases seen in the number of total registrants (Table 1).The actual annual numbers of new registrants continuesto vary from year to year but since 2001 appears to bedecreasing. The difference between total and activeregistrants appears to be due to the increase in the groupof   “ nonactive registrants ”  who are assumed not to bedelivering patient services (Fig 1). The nonactive group iscomposed of retirees, inactive registrants (ie, those main-taining their registration but having confirmed that they arenot engaged in the practice of chiropractic in Ontario), andthose with suspended licenses due to nonpayment of dues.According to the CCO, the inactive registrants are assumedto be exiting the profession in Ontario, moving out of  province, or going to the United States to practice (M Simas, personal communication).The increasing growth in the number of registrants inOntario appears to reflect the number of applications to theeducational institution. The CMCC is the only English-speaking chiropractic training institutionin Canada. Students107 Mior and LaporteJournal of Manipulative and Physiological TherapeuticsEconomic Status of Ontario ChiropractorsVolume 31, Number 2  enter the program after a minimum of 3 years of universitystudy,withmostenteringwitha4-yearuniversitydegree.Thechiropractic program involves 4 years of intensive study. TheCMCC's annual enrollment is capped but has varied from155 from the 1980s to 1994, to 160 from 1994 to 2004. Onaverage, about 7.3% do not graduate; however, the rate of noncompletion has been decreasing over the last severalyears. The rate of applications rose sharply and peaked in1996-1997, after which it began an equally sharp decline that subsequentlyleveledoffin2002-2003(Fig1).Ifoneassumes(derived from comparison of CMCC graduates and number of new registrants with CCO) that only Ontario students whograduate from CMCC stay in the province to establish a practice, then the proportion of new CCO registrants enteringthe profession from CMCC has declined from a high of 75%in early 1990s to about 55% in the 2000s, suggesting that asubstantial number of the new Ontario registrants aregraduating from other chiropractic schools or migrating toOntario. More detailed demographic information regardingnew registrants for the period under study was unavailable.Figure 2 illustrates the comparison between the rates of tuition and applications to CMCC. An increase of about 150% in applications occurred between 1990 and 1996, after which they steadily declined until 2003. Tuition steadily rose by an average of about 6.5% per year, after adjusting for inflation in 2003 Canadian dollars. In addition, graduatingstudents are entering practice with larger debt loads asevidenced by a 200% increase in the number of studentsreporting total debt loads of greater than $80 000 (Table 2).Data providing mean debt load of graduating studentswere unavailable.As the number of chiropractors entering practice wasincreasing, the utilization of chiropractic services amongOntarians remained relatively stable and the average number of services per patient stayed about the same or slightlydecreased (Table 3). Not surprisingly, the average annual net income adjusted for inflation in 2002 dollars was declining at a rapid rate, a decrease of about 50% between 1992 and2002, whereas the number of chiropractors increased byalmost 70% (Fig 3). Our calculation for the estimated annualreal net incomes was $68 718 for the fiscal year ending 1994-1995 and $58 686 for 1999-2000, compared with that fromthe census data of $68 257 and $57 663, respectively. Thedifferences in part can be accounted for by the different year-ends; that is, OHIP's year-end is the end of March and thecensus data's year-end is the end of December. If the2 estimated annual incomes from OHIP-based billingsstraddling the census year are averaged, the difference between the estimated annual incomes for years 1996 and2000 amounted to only $21 and $1, respectively. Therefore,the estimated annual income appears to be reflective of theactual average annual net income of chiropractors.As income was decreasing, so were the key practice-related variables, except for the number of chiropractors(Table 3). In an effort to determine an ideal ratio of thenumber of chiropractors to population, we made thefollowing key assumptions: the utilization rate of chiroprac-tic services in Ontario is 10% 10 ; the average chiropractor works (direct patient contact time) about 37 hours per week, 16 takes 4 weeks vacation per year (this includesstatutory and holiday days, sick days, etc), and spends onaverage about 15 minutes per service (64% of patients spend between 6 and 20 minutes per visit with a chiropractor) 17 ;and each patient receives on average of about 10 services per year. 10,18 Under these assumed conditions, the averagechiropractor would see about 710 discrete patients per year.Because theutilization inOntariowas10%fortheyear2002-2003, the number of chiropractors needed to efficiently provide the calculated maximum number of services would beabout1700,oraratioofchiropractortogeneralpopulationof 1:7099. However, the actual number of chiropractorsmaking an OHIP claim was 2773, or a ratio of 1:4352.During this same time, the decrease in annual income wasmirrored in each of the 49 Ontario counties. Although the Table 3.  Chiropractic income and utilization statistics for years 1992-1993 to 2002-2003 1992-1993 1993-1994 1994-1995 1995-1996 1996-1997 Population a  10 570 475 10 690 447 10 827 501 10 964 925 11 100 876 No. of patients  883 601 907 751 919 556 925 094 964 369 No. of chiropractors  1638 1698 1743 1834 1933 Ratio chiropractor-population  6453 6296 6212 5979 5743 Utilization chiropractor service  8.36% 8.49% 8.49% 8.44% 8.69% No. of services per patient  10.25 10.24 10.04 9.99 9.97 Annual net income  b $97 892 $89 873 c $80 171 d $77 468 e $77 7571997-1998 1998-1999 1999-2000 2000-2001 2001-2002 2002-2003   Source: Ontario Health Insurance Plan Statistical Reporting System. a  Ontario population derived from Statistics Canada. Annual Demographic Statistics 2002.  b Estimated annual net income adjusted to 2002 dollars-derived from assumption that OHIP payments comprise about 40% of total gross income andoverhead expenses account for 40%. c Payment figures include social contract reductions of 10% and 12.5% for the periods October 1 to December 31,1993, and January 1 to March 31,1994, respectively. d Payment figures include the social contract reduction of 12.5% for the period April 1, 1994, to March 31, 1995. e Payment figures include the social contract reduction of 12.5% for the period April 1 to September 30, 1995, and a 5% reduction from October 1, 1995,to March 31, 1996. 108  Journal of Manipulative and Physiological TherapeuticsMior and LaporteFebruary 2008Economic Status of Ontario Chiropractors
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