Oh Canada! Similarities and Differences Between Canadian and American DCs
PERSPECTIVE
Anthony J. Lombardi, DC
For over 150 years, the United States and Canada have been friendly neighbors. In fact, the father of our profession, D.D. Palmer, was bom in Pickering, Ontario, Canada.
The United States has a population of 310 million while Canada has a population of 35 million people, which is about the same population of California. Canada has approximately 10,000 licensed chiropractors and the US has seven times that number. However, the utilization rate of our services by the general population is reported at 12 to 15%, although South Dakota and Iowa had once reported a 24%(1) utilization rate and Alberta, Canada a 27% rate (2). For this article, I interviewed many DCs who practice in both Canada and the US. All of them preferred that their input stay anonymous.
Tuition and Training
There are 15 chiropractic colleges in the US and only two in Canada, and one of those is exclusively French-speaking. Tuition fees for chiropractic education are considerably less expensive in Canada compared to the US. In this comparison, I used the present day exchange rate of $1 US = $1.35 CDN.
• My last year at NYCC was 2002 and I paid $5,700 per trimester. Today, the cost is $12,000 per trimester ($36,000 US/$46,800 CDN per year).
• Logan Chiropractic College went horn $6,500 in 2003 to $10,600 today ($31,800 US/$42,300 CDN per year). • University of Bridgeport went horn $8,500 in 2003 to
$13,200 today ($39,600 US/$51,880 CDN per year).
• CMCC, Canada’s only English-speaking chiropractic school had a tuition change horn $15,000 per year ($12,000 US) in 2003 to $24,000 ($19,000 US) today. The first two years are equal to two trimesters each, and the last two years are equal to three trimesters per year.
I interviewed chiropractors who worked in both countries as litigation experts and they said the US supersedes Canada “tenfold” in postgraduate training. They contend that American chiropractors are much more equipped to defend themselves in court during cross-examination versus their Canadian counterparts. For instance, in Canada there is just one DC who is an accident reconstructionist, but in the US, each city has a DC who is an accident reconstructionist dealing with court testimony in auto injury cases.
Saturation Factors
Ontario has the highest population of chiropractors of any Canadian province, and the College of Chiropractors of Ontario (CCO) reported that the number of chiropractors in the province rose dramatically by 23% from 2009 to 2015. The utilization rate and population of Ontario did not increase at all during this same period, which is a contributing factor to the oversaturation of chiropractors in the province.
California, the state with the largest population of chiropractors and people, experienced the same thing as reported in Chiropractic & Osteopathy in 2010. In that study, of the California chiropractors who started practicing in the early 1990s, almost 30% left the profession due to over saturation.
Salaries
Oversaturation may be reflected in the salaries of DCs from both nations:
US:
• 1989 - $101,000 (Source: American Chiropractic Association)
• 1997$86,500 (Source: American Chiropractic Association)
• 2016 - $81,000 (U.S. Bureau of Labor Statistics)
Canada:
• 2001 - $144,254.50 ($108,000 US) (Source: JCCA, 2005, salary data for Ontario)
• 2010 - $70,000 ($53,000 US) (Source: PayScale, salary data for Toronto)
• 2015 - $66,531 ($50,000) (Source: PayScale, salary data for Canada)
These statistics make sense since the number of chiropractors has been steadily increasing while utilization rate has generally stayed the same. This means more chiropractors are fishing from the same unchanging patient pool.
Business Restrictions
I interviewed three American DCs and they told me that chiropractors in the US can have multidisciplinary practices and hire other healthcare professionals as independent contractors (IC). In the US, DC/PT (physical therapist) practices and MD/DC/PT integrated offices are permitted on a stateby-state basis. Some states, such as Texas or North Carolina, may consider a DC-owned corporation that employs an MD as “practicing medicine without a license.”
It gets complicated when the topic of “fee splitting” arises, or when a DC owner and an IC split incoming revenue by percentage. It is illegal in some states, but the consensus is that most practitioners still do some kind of fee split.
In Canada, chiropractors can become professional corporations and employ any healthcare professional they wish. Independent contractor arrangements and fee splitting is permitted in Canada.
Billing, Insurance, and Practice
• Extended Health Insurance
With regards to how chiropractors are paid in the US, it varies from state to state. In South Carolina, I spoke to a chiropractor whose practice was about 60% insurance-based coming from seven to 10 different insurance companies. Each insurance company pays different amounts per service based on their individual fee schedule, and each company also has different procedure codes that they may or may not approve depending on the type of plan the patient has. For example, some insurances will pay for acupuncture, massage therapy, and soft tissue work, while others will only pay for an adjustment.
Each insurance plan also varies as to whether or not the patient has a deductible, as well as if the patient has a copay or coinsurance. Some plans pay at 100% and some plans have high deductibles.
In Canada, patients usually have health insurance through their employer and chiropractic benefit carries a monetary limit of coverage, which is typically $500 per year. In most cases, the patient pays the chiropractor up front for the visit and then submits the receipt to the insurance company to be reimbursed. Additionally, HMO networks do not exist in Canada.
• Medicare/Medicaid
In the US, Medicare is health services for those who are 65 years old and older. Medicare sets fixed fees for spinal adjusting. They do not pay for extremity, exams, X-ray, or anything else, and you cannot opt out of Medicare. Medicaid is usually for disability or low-income patients and is different on a state-by-state basis. Some states, such as Illinois, only pay $2 per adjustment, while some states, such as Kentucky, will pay for exam, X-ray, and adjustment, and it’s lucrative.
In Canada, Medicare and Medicaid do not exist. Even people on a disability pension do not have insurance for chiropractic care. At one time, the Ontario Health Insurance Plan contributed a $9.65 CDN copay on behalf of the patient, but that was eliminated in 2004. There are still certain cases where other provincial government health plans provide a copay, but it is very limited.
• Workers Compensation
Basically, when a patient in the US is injured at work, the DC bills the patient’s insurance company or deals with the state to be reimbursed.
In Canada, the Workers Safety and Insurance Board has set fees and treatment is preapproved prior to beginning therapy. Payment is made when treatment is complete.
• Auto Insurance
In the US, when dealing with auto insurance, it depends on the state whether you have to deal with an attorney or if you bill a patient’s MEDPAY thru their auto insurance carrier.
In Canada, auto injuries are different in every province. In Ontario, auto injuries are split into two categories: minor injury and non-minor injury. A Minor Injury Guideline provides 12 to 24 weeks of treatment and pays the chiropractor a lump sum of $2,200 to $3,500 CDN over that time frame. A non-minor injury can pay up to $50,000 of health care if approved by the auto insurance company. In other parts of the country, the amount paid to the chiropractor is negotiated between the chiropractor and the insurance company before treatment begins.
• Applied Practice
In some US states, each chiropractic diagnosis must relate back to a spinal segment. For instance, that is the case in New York, but in Canada a sprained ankle is just a sprained ankle.
About 20% of chiropractors in the US and Canada practice acupuncture, but each state and province has a variety of different rules for DCs. In the US, chiropractors are not allowed to practice acupuncture in the following 16 states: California, Georgia, Hawaii, Kentucky, Michigan, Mississippi, Montana, New Jersey, New York, Nevada, Oregon, Pennsylvania, Rhode Island, South Carolina, Washington, and Wisconsin(3).
In Canada, the exceptions are much more interesting. In the province of British Columbia, only traditional Chinese medicine (TCM) doctors are allowed to practice acupuncture. In Quebec, chiropractors are not allowed to practice chiropractic and acupuncture on the same day. They must keep separate acupuncture hours that do not coincide with their chiropractic practice.
Cultural Differences
As for the primary differences, many DCs interviewed feel that chiropractors are more respected and more utilized in the US versus Canada. For instance, in Virginia a chiropractor can order MRIs, CTs, blood tests, and refer to neurologists or orthopedic surgeons. They can be primary care physicians and care for primary care patients. In Canada, the perception of our education is minimized. For example, during litigation of an auto injury case, insurance companies will use MDs to refute a chiropractor’s claim. In the US, the insurers will use other chiropractors because an MD’s scope would be challenged right away by an astute attorney.
Additionally, chiropractors in Canada cannot order MRIs, CTs, blood tests, or refer to neurologists, orthopedic surgeons, or any other medical doctor for that matter. Chiropractors can only order plain film radiographs. However, Canadian chiropractors licensed in Canada are able to order MRIs and CT scans in the US. My practice is located 45 miles from the US border, so I refer my patients to Buffalo to have the diagnostic imaging done so they do not have long wait times in Canada.
With the many practical, cultural, and legal differences within chiropractic in North America, the mainstay that remains common among chiropractors in both countries is their allegiance to the patients. Regardless of the state, province, country, or school - chiropractors' commitment to patient care is universal.
Footnotes:
1. https://www. nchi.nlm. nih.gov/pmc/articles/PMCl 784103/
2. http://www.canadianchiropractor.ca/opinion/wheres-the-heef-4357
3. http://councilofchiropracticacupuncture. org/state-requirements.html
4. https://www.canadianchiropractor.ca/opinion/husiness-talk-thewriting-on-the-wall-4537
5. https://www. chirocredit. com/downloads/acupuncture/acupuncturehystate.pdf
Dr. Anthony Lombardi has presided over 103,000 patient visits in 14 years of practice at Hamilton Back Clinic. You can reach him via his website: www.hamiltonbackclinic.com or www.exstore.ca / www.acupuncturemotorpoints. com
