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

Article Outline

• Abstract
• Methods
• Results
• Discussion
• Conclusion
• Acknowledgment
• References
• Copyright

Abstract 

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 a market 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 health survey data between 1990 and 2004 were analyzed.

Results

Between 1990 and 2004, the total number of chiropractic registrants in Ontario doubled, with an average annual rate of growth of about 5.4%; however, recent data suggest that the number of nonpracticing chiropractors is increasing, whereas the number of new registrants is decreasing. The rate of applications to a chiropractic institution rose sharply and peaked in 1996-1997, thereafter declining but leveling off in 2002-2003. Despite the continued growth in the number of practicing chiropractors, the utilization of chiropractic services among the Ontario population has remained relatively 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 the chiropractic profession in Ontario is in long-run oversupply. Competition from other providers, changing population demographics, 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 population health needs may contribute to influencing the demand for chiropractic services. A concerted effort by professional and educational institutions is required.

Key Indexing Terms: Chiropractic, Manpower, Income, Health Resources, Supply and Distribution

From its humble and unconventional beginning, the chiropractic profession continues to develop according to its interest to best service the needs of the population. This ongoing development occurs despite the external constraints imposed upon it by the state, special interest groups, and the specific health care system in Canada.¹ The profession has obtained self-regulatory status in all Canadian provinces, maintains high patient satisfaction, and is the most frequently sought complementary and alternative health care group.² Yet despite this apparent acceptance, its future role within the health care system remains controversial.³ In addition, chiropractors are beginning to realize the potential economic threat of an increasing supply within a market of questionable demand.⁴

Cooper and McKee⁴ recently noted that the chiropractic profession in the United States has experienced little of the rapid growth in market share it encountered in the early 1980s. They questioned how much unmet demand there is for chiropractic services, especially given the increasing numbers of other health care professionals vying for the same market share at a time when coverage for its services is decreasing. Moreover, the practicing chiropractor, impacted by the increases in the number of new graduates,⁵ the low barriers to entry for other complementary and alternative health care providers,⁶ a dampening of the strength of its once convincing evidence base,⁴ and the ongoing divisiveness within the profession,³, ⁶ is being forced to more aggressively market his/her services and products⁴ in a market where the demand for chiropractic services has decreased from an estimated 10% of the US population in 1997 to about 7.5% in 2002, despite an about 13% increase 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 assessing manpower needs, Grier and Lepnurm⁷ used administrative data collected over a 10-year period from the Saskatchewan Medical Care Branch to generate a provider-population ratio model to estimate the number of chiropractors needed to effectively serve the people of Saskatchewan. They reported that during the period under study, both the number of licensed chiropractors and the percentage of the population using chiropractic care grew. Their model predicted that the ideal chiropractor to population ratio would be 1:2588, or 397 chiropractors, concluding that there was a shortage of chiropractors in the province at the time. Grier and Lepnurm's⁷ model assumed that all patients with a musculoskeletal complaint would seek chiropractic services; however, no consideration of a change in demography, condition severity, or utilization of other provider groups was considered.

In a 1996 unpublished internally produced report undertaken 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 chiropractors registered in each of the provinces with estimates of the number of Canadian students enrolled in chiropractic colleges in Canada and in the United States and a conservative projection of the number of chiropractors retiring or leaving practice, and population values from national census data. Assuming the utilization rate would remain constant at 12.5%, they concluded that the uncontrolled growth of chiropractic manpower would result in an oversupply by the early 2000s, with some provinces being more affected. They proposed that incomes would decrease, fees would rise, bankruptcies of new graduates would increase, and unfavorable practice activities would impact on professional image.

The growth in the competitive market for managing common musculoskeletal problems and the continued increase in the numbers of practicing chiropractors and other health care professionals raise serious questions about the relationship between the supply and demand for chiropractic services. The demand for health care services is a derived demand. The level of this demand along with the existing stock of providers determines the wages, the number of providers employed, and their participation rate. Professional licensure requirements and enrollment capacity determine the long-run supply or stock of manpower for the health care professions. The interaction between manpower and educational markets impacts upon the number of providers and their wages, and the price and quantity of their services, as well as being important in accurately forecasting health manpower requirements.⁸ The decrease in the utilization rate for chiropractic services and the drop in enrollment seen in chiropractic colleges in the United States may be providing warning signals of an oversupply of providers and changing market forces.⁹

This paper evaluates the chiropractic manpower status in Ontario, Canada, and makes a unique contribution by incorporating various data sources to triangulate the findings to enhance accuracy and serve as a template for other jurisdictions and future studies.

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Methods 

Data were collected from administrative, insurance, and education sources between 1990 and 2004 and descriptively analyzed. Data obtained from the licensing body—College of Chiropractors of Ontario (CCO)—were used to assess the total number of registrants and the numbers retiring, entering, and leaving the profession. Enrollment and tuition data from the Canadian Memorial Chiropractic College (CMCC) were used to assess trends in applications and debt loads.

Administrative insurance billing data from the publicly funded Ontario Health Insurance Plan (OHIP) were used to assess the changes in the income levels of practicing chiropractors and their practice location. Only administrative OHIP data obtained for complete years before the delisting of chiropractic services in Ontario in the fall of 2004 were used. For the purpose of this paper, the annual income of chiropractors was estimated from OHIP billing data. The OHIP billings were used as the base value from which overhead expenses (ie, estimated to be about 40% of gross income) and other income sources (ie, co-payments and other income revenue estimated to be about 60% of total income) were added as previously determined from a sample of Ontario chiropractors.¹⁰ To ensure this estimate was consistent with the actual annual income, a comparison was made with the annual income data for chiropractors from Ontario as reported in the 1995 and 2000 Canadian Census.¹¹ All net income figures were adjusted for inflation using the all goods and services Consumer Price Index¹² and compared with the base year 2002.

Ontario population health data from national surveys were used to provide demographic data on those seeking chiropractic services. The National Population Health Survey¹³ was used to provide 1996-1997 demographic data, and the Canadian Community Health Survey¹⁴ provided 2000-2001 data. Although these are 2 different population health surveys, the sampling strategies were similar; and care was taken to ensure that the same questions from both surveys were used in the analysis. The appropriate sample weights were used to adjust the reported data.¹⁵

Permission to use all nonpublic accessible databases was obtained from the source agency. Anonymity was ensured by producing aggregate data and numerically coding regionally derived administrative billing and utilization data.

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Results 

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 information from the CCO revealed that, between 1990 and 2004, the number of registrants doubled, with an average annual rate of growth of about 5.4%. The rate of growth increased in 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 increases until 2004 when there was a 4.7% increase, the lowest since 1995 (Table 1).

Table 1. Number of chiropractors registered with CCO from 1990 to 2004

Source: College of Chiropractors of Ontario. March 2005. Used with permission.

The number of active registrants (ie, those paying a general registration fee and presumed to be engaged in the delivery of chiropractic services) appears to mirror the increases seen in the number of total registrants (Table 1). The actual annual numbers of new registrants continues to vary from year to year but since 2001 appears to be decreasing. The difference between total and active registrants appears to be due to the increase in the group of “nonactive registrants” who are assumed not to be delivering patient services (Fig 1). The nonactive group is composed of retirees, inactive registrants (ie, those maintaining their registration but having confirmed that they are not engaged in the practice of chiropractic in Ontario), and those with suspended licenses due to nonpayment of dues. According to the CCO, the inactive registrants are assumed to be exiting the profession in Ontario, moving out of province, or going to the United States to practice (M Simas, personal communication).

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• Fig 1. 

  Number of new registrants compared with nonactive group.

The increasing growth in the number of registrants in Ontario appears to reflect the number of applications to the educational institution. The CMCC is the only English-speaking chiropractic training institution in Canada. Students enter the program after a minimum of 3 years of university study, with most entering with a 4-year university degree. The chiropractic program involves 4 years of intensive study. The CMCC's annual enrollment is capped but has varied from 155 from the 1980s to 1994, to 160 from 1994 to 2004. On average, about 7.3% do not graduate; however, the rate of noncompletion has been decreasing over the last several years. The rate of applications rose sharply and peaked in 1996-1997, after which it began an equally sharp decline that subsequently leveled off in 2002-2003 (Fig 1). If one assumes (derived from comparison of CMCC graduates and number of new registrants with CCO) that only Ontario students who graduate from CMCC stay in the province to establish a practice, then the proportion of new CCO registrants entering the profession from CMCC has declined from a high of 75% in early 1990s to about 55% in the 2000s, suggesting that a substantial number of the new Ontario registrants are graduating from other chiropractic schools or migrating to Ontario. More detailed demographic information regarding new 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, graduating students are entering practice with larger debt loads as evidenced by a 200% increase in the number of students reporting total debt loads of greater than $80 000 (Table 2). Data providing mean debt load of graduating students were unavailable.

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• Fig 2. 

  Graphical representation of total application numbers, applicants from Ontario, and tuition rates (in $10K, adjusted to 2003 Canadian dollars) from 1990 to 2004.

Table 2. Reported student debt load at time of graduation

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.

As the number of chiropractors entering practice was increasing, the utilization of chiropractic services among Ontarians remained relatively stable and the average number of services per patient stayed about the same or slightly decreased (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 and 2002, whereas the number of chiropractors increased by almost 70% (Fig 3). Our calculation for the estimated annual real net incomes was $68 718 for the fiscal year ending 1994-1995 and $58 686 for 1999-2000, compared with that from the census data of $68 257 and $57 663, respectively. The differences in part can be accounted for by the different year-ends; that is, OHIP's year-end is the end of March and the census data's year-end is the end of December. If the 2 estimated annual incomes from OHIP-based billings straddling the census year are averaged, the difference between the estimated annual incomes for years 1996 and 2000 amounted to only $21 and $1, respectively. Therefore, the estimated annual income appears to be reflective of the actual average annual net income of chiropractors.

Table 3. Chiropractic income and utilization statistics for years 1992-1993 to 2002-2003

Source: OSRS.

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• Fig 3. 

  Graphical depiction of the estimated annual net income (in $10K) adjusted to 2002 dollars, ratio of chiropractor to general population, and number of chiropractors between 1992 and 2003.

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 the number of chiropractors to population, we made the following key assumptions: the utilization rate of chiropractic 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 includes statutory and holiday days, sick days, etc), and spends on average 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 average chiropractor would see about 710 discrete patients per year. Because the utilization in Ontario was 10% for the year 2002-2003, the number of chiropractors needed to efficiently provide the calculated maximum number of services would be about 1700, or a ratio of chiropractor to general population of 1:7099. However, the actual number of chiropractors making an OHIP claim was 2773, or a ratio of 1:4352.

During this same time, the decrease in annual income was mirrored in each of the 49 Ontario counties. Although the number of chiropractors increased in almost every county, the utilization remained relatively constant, or slightly decreased, except in 3 of the rural counties where minimal increases occurred. The greatest negative change occurred in the large urban centers and their immediate surrounding areas, where ratios were already the highest and annual estimated average income the lowest.

Finally, the estimated proportion of the population who reported seeing or consulting a chiropractor during the survey year increased between 1996-1997 and 2000-2001 from about 9.2% to 10.9% (Table 4). This proportion is slightly higher than that reported in the OHIP data (Table 3) because it may include people seeing a chiropractor for work-related injury claims or may be because of the sampling of the population, which may over- or underestimate the true number. The sex, age, and education characteristics of those who reported seeing a chiropractor appear to be relatively similar between the 2 periods reviewed. Although almost a fifth of those surveyed did not report an income level in 1996-1997, it appears that the income level of the population seeking care may be shifting to those with higher incomes. Most of the population seeking chiropractic services stated that they were in good to excellent self-reported health (Table 4). About 20% of the population who reported seeing any health care provider for chronic back and arthritis-related conditions visited or consulted with a chiropractor at least once. Of those reporting chronic back pain, 32% in 1996 and 28% in 2000 indicated they visited a chiropractor (Table 5).

Table 4. The proportion of the population who reported seeing or consulting a chiropractor at least once and the distribution of the proportion of the variables by provider type based on national population health survey data

Art; Arthritis; Rheu, rheumatism; grad, graduate; sec, secondary.

Table 5. The proportion of the general population who reported seeing or consulting any health care provider at least once and the proportion of the general population that saw a chiropractor for the stated conditions

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Discussion 

The profession continues to debate its role as a primary care provider or a primary contact health care provider,³, ⁴, ¹⁹ despite the fact that 90% to 97% of the patients seen by a chiropractor do so for musculoskeletal disorders only.², ¹⁷ If it is assumed that chiropractors would be sought primarily for musculoskeletal conditions and because the incidence of back pain and arthritis is increasing in the population,²⁰ it would be reasonable to imagine that utilization of chiropractic services would also increase. Data from the national health survey suggest that although the proportion of the population reporting chronic back pain and arthritis-related conditions increased between 1996 and 2000, the proportion that reported seeing a chiropractor remained relatively stable (Table 5). Furthermore, chiropractors appear to be seeing about a third of the population reporting chronic low back pain but only about 10% of those with nonback, arthritis, and related conditions.

In addition, the age distribution of the population reporting seeing a chiropractor has not appreciably changed since the early 1970s. Because age and chronic musculoskeletal conditions are related²⁰ and the proportion of the aging population reporting chiropractor visits is not appreciably changing, it is uncertain if this is unmet demand or uncertainty among the population as to the role chiropractic care may play in meeting their health care needs.

The population trends toward increasing chronic musculoskeletal-related conditions and an aging population may provide an opportunity to influence the demand for chiropractic services. Foote and Stoffman²¹ suggest that although older people may have more disposable income, they are also more demanding and expect higher quality and efficient service. Chiropractors are recognized for their access and high levels of patient satisfaction¹⁷; and cross-sectional studies suggest that chiropractic care may positively influence health outcomes and quality of life, thus addressing many of the expectations of the older patient.²² However, such an assumption of increased demand neglects the impact of other external influences such as price sensitivities on the part of patients,⁸ appropriateness of condition for chiropractic care,¹⁸ and the distribution²³, ²⁴ and competition from other health care providers.⁴

Predicting demand for services also has a direct impact in determining the ideal ratio of chiropractors to population.²⁴ One particular challenge is determining what the “ideal” ratio is. Should account be taken of how other professions may contribute to the provision of care?²³, ²⁴, ²⁵ Or should the ratio be determined simply by needs-based planning that considers the community needs and estimates of the number of services required per person and the number of chiropractors needed to meet such demand?⁹, ²⁶

The influence of demand is critical. We estimated that in 2002-2003 the ideal ratio of chiropractor to general population was 1: 7099; however, the actual number of chiropractors making an OHIP claim was 2773 (or a ratio of 1: 4352) or about 39% more than our estimated ideal ratio. Moreover, if our assumptions regarding the hours of work and number of services per hour are applied, our data suggest that the average chiropractor in 2002-2003 provided about 2 services per hour. This oversupply of chiropractors, or decreased demand for services, appears to lead to a significant amount of inefficiency. On the other hand, if all the above assumptions remained constant except that the utilization rate increased to 15% of the population, then the number of chiropractors needed would be 2550, or a chiropractor to population ratio of 1:4733, slightly more than our estimated ideal number of chiropractors.

Location theory predicts that as competition increases in large market areas, providers will migrate to smaller locations.⁹ Chiropractors as primary contact providers typically do not depend upon medical referrals³ and have been reported to be more widely distributed across Ontario than other health care professionals.²⁵ We noted that chiropractors are located in each county but in different proportions to the population. Contrary to expected theory, chiropractors entering the profession appear to locate themselves across all counties but in relatively greater numbers in urban and immediate surrounding areas. These areas have the highest ratio of chiropractor to population and the lowest utilization rate; and consequently, these chiropractors have the lowest annual incomes.¹⁰ The migration of new registrants to urban and surrounding areas may be due to perceived greater market opportunity, access to health resources,⁹ the understanding that residents would have higher incomes and greater perceived demand for health services,²⁷ the provider's balance between target income and leisure time,²⁸ or fewer graduates of rural background, which in medicine is a strong predictor of rural practice.²⁹ Regardless, relocating in urban centers makes little economic sense in consideration of the potential opportunity created by the acute shortage of physicians and other health care professionals in remote and rural areas of the province.²⁵

In December 2004, chiropractic services were fully delisted from the publicly funded insurance system by the government.³⁰ It is unclear at this time what the impact of delisting will be on utilization and demand for chiropractic services; however, previous decreases in public funding (1993-1995) appeared to have a negative effect on the amount of services demanded, although the overall utilization slightly increased.³¹ Stabile and Ward³¹ reported that the probability of seeing a chiropractor increased with higher patient income, a trend seen in Table 4. In other words, the effect of delisting shifts the provision of care toward higher-income patients who are more apt at identifying different health care services, have greater access to resources to take advantage of available services, have higher perceived quality of life, and are more likely to seek care.²⁰, ²⁷ In turn, delisting may negatively affect those in the lower socioeconomic bracket who typically have lower health status, higher levels of disability, and often limited access and use of health services.³¹, ³², ³³

Delisting of health care services will likely continue in the future because of escalating health care costs.²¹ Canadian governments are changing how health care is being delivered to meet the complex health care needs of an aging population, cope with a shortage of physicians, and reduce wait times.³⁴ A recent change has been toward team-based delivery of care involving different health care professionals. Such teams provide a potential opportunity for chiropractors to move away from their traditional isolated practice environment and participate in multidisciplinary care delivery. For example, chiropractors working in collaboration with other health care providers can effectively provide multidisciplinary care for complex spine problems, while reducing the surgical wait list by an estimated 70%.³⁵ Or chiropractors could deliver musculoskeletal care in multidisciplinary primary care settings, thus facilitating access to chiropractic services for populations that would otherwise not have done so.³⁶, ³⁷, ³⁸

Finally, the trends noted above may impact upon future practitioners. Evidence suggests that income potential is a powerful determinant in specialty selection by medical students.³⁹ Comparing annual earnings and work intensity of health and nonhealth professions in Canada, a recent study reported that chiropractors had the greatest decrease in median annual income (−30.9%) between 1991 and 2001, in relation to themselves.¹⁶ Furthermore, the chiropractors' median hourly annual dollar (ie, median income/average hour worked) value of $1129 was just below that of nonhealth professionals ($1196) and the average for all health professionals ($1228). However, this lower income level may be influenced by the relatively high proportion of new graduates and registrants entering the profession over the recent years who are expected to have lower earnings in the early years of practice,¹⁰ although the trend identified in our data suggests that overall income levels are decreasing.

In consideration of the 7 to 8 years of postsecondary education, the growing direct costs of postsecondary and chiropractic education, and the expected lower earnings, there may be decreasing interest in entering the profession in years to come. Unlike the reported decreasing enrollment in US chiropractic colleges,⁴ enrollment at CMCC is maintained and the application numbers appeared to have stabilized after several years of decline. The application rate to CMCC does not appear to have been appreciably affected by the opening of the chiropractic francophone program at Université du Quebec a Trois Rivières that commenced in 1993, a time during which applications were actually increasing. However, the number of new registrants seems to be decreasing, although increasing numbers are assumed to be not engaging in clinical practice. It is unclear if these decreases are reflective of fewer Canadian applicants to other international colleges (data unavailable) or the extent to which Canadian-trained chiropractors are moving to other jurisdictions, namely, the United States.

There are limitations to this study. Data were available in summary form that did not facilitate more robust statistical analysis. Information was extracted from several databases that were limited in their content and reference. Although the results may be limited to Ontario and may not be generalizable to other provinces or jurisdictions where reimbursement mechanisms and/or structures may vary, the trends reported are similar to those observed in other jurisdictions referenced herein. Furthermore, the general factors identified as influencing the profession, such as the growth in numbers of chiropractors, changes in utilization patterns, and competition from other health care providers, can be expected to have a comparable impact across developed countries.

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Conclusion 

The evidence suggests that the chiropractic profession in Ontario is in a long-run oversupply. Chiropractic incomes have been declining because of lower prices of services and reduced demand, resulting in a decrease in the quantity of services provided to patients and lower incomes. Chiropractors who cannot meet their operating costs and achieve a reasonable return on their investment in training will drop out of the market. Those most susceptible are those with high operating costs, those entering practice with high debt loads, those entering practice experiencing lower earning potential in the first years of practice, and those practicing in urban centers. Limiting enrollment to the chiropractic college (CMCC) will not suffice in curtailing the supply of new registrants because a moderate number is presumed to be trained outside the province. The number retiring will continue to increase, but it is unlikely that this will be sufficient to offset the impact of provider oversupply in the near future. Further study is required to better comprehend the influence of supply on the practice patterns and behaviors of chiropractors.

In determining future chiropractic workforce requirements, account must be taken not only of the current chiropractor to population ratios but also of the morbidity distribution of the population and the extent to which chiropractors will be requested to meet these needs. Account must also be taken of policy changes (eg, service delisting) that can impact the extent to which chiropractic services will be covered by public and/or private insurers. Price sensitivities of older populations who are more likely to live on fixed incomes are therefore an important consideration as the population ages.

In addition to such demand-side factors, our paper indicates that consideration of the supply side of the market is also important. Specifically, the extent of competition from other providers, the number of new entrants to the provider market, and the cost of education and expected earnings all appear to have an important impact and ought therefore to be incorporated into chiropractic workforce planning models. Further study is needed to better understand the factors influencing the supply side of the market for chiropractic services so that professional schools and colleges can support new and existing practitioners and better advise them of opportunities to ensure the continued success of the profession.

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Acknowledgment 

The authors are grateful to Dr Paul Carey, President, Canadian Chiropractic Protective Association; Dr Robert Haig, Executive Director, Ontario Chiropractic Association; Ms Maria Simas, Registration Coordinator, College of Chiropractors of Ontario; and the Canadian Memorial Chiropractic College for their input and cooperation in making data available for this paper; and also to Dr Glen Roberts for his constructive feedback. The views expressed in this paper and any errors or omissions are the responsibility of the authors.

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