What will state insurance "non-discrimination" laws mean for chiropractors?

What will state insurance "non-discrimination" laws mean for chiropractors?

Section 2706 of the Affordable Care Act prevents "discrimination" by health insurers against all health care providers acting within their scope of practice. According to an American Association of Naturopathic Physicians spokesperson, Sec. 2706

"suggest[s] that if insurers cover a health condition, they must pay any providers that are licensed to treat that condition. If the insurer covers a service provided by medical doctors . . ., for example, it must also cover that service when provided by another legal provider, such as NDs, acupuncturists or chiropractors."

Much to the chagrin of naturopaths, acupuncturists and chiropractors, this outcome doesn't appear to have "suggested" itself to the health insurers themselves. Nor to the Department of Health and Human Services. HHS issued an interpretation more narrowly defining Sec. 2706's mandate. This led to a rebuke from three of alternative medicine's stalwarts in the Senate, Tom Harkin, Barbara Mikulski and Bernie Sanders. Fortunately, Sens. Harkin (the force behind NCCAM/NCCIH) and Mikulski (who annually introduced a "naturopathic medicine week" resolution) are no longer there to push this agenda. Sen. Sanders is very much still around, as we know.

With the possibility of either total repeal or substantial amendment to the ACA looming over them in today's political climate, chiropractors are leaving nothing to chance.  They have moved to the state legislative level to push for provisions similar to the ACA's Sec. 2706. Oregon and Rhode Island have already passed such laws.

Wisconsin already has a law on the books preventing an insurer from excluding diagnosis and treatment of a condition by a chiropractor if the same diagnosis and treatment is covered for a physician. Senate Bill 650 and Assembly Bill 809 beef up those requirements by stating that insurers are prohibited not only from excluding coverage, but also restricting or denying coverage. And, by making insurers 

  • provide insureds with reasonable and timely access to chiropractic care; and
  • apply the same standards to chiropractors that are applied to primary care physicians to ensure that insureds receive the same reasonable and timely access to chiropractors that they receive to primary care physicians, including such standards as geographic accessibility, waiting times, and provider-to-insured ratios. [emphasis added.]

Insurers will also have to file annual reports showing that they have complied with the law.

A particularly disturbing feature of the existing law, retained in the bill, mandates coverage when the chiropractor is "acting within the scope of the chiropractor's professional license." That scope of practice is quite broad in Wisconsin:

"To examine into the fact, condition, or cause of departure from complete health and proper condition of the human; to treat without the use of drugs . . . or surgery; to counsel; to advise for the same for the restoration and preservation of health . . . ."

As with Sec. 2706, Wisconsin law implies that, no matter what the actual education and training of the chiropractor is, if state law grants him a broad scope of practice, insurance must cover his diagnosis and treatment. Actual competency need not be demonstrated.

Unfortunately, as we know, chiropractors are in complete control of their education and training. What they say they can do controls, without oversight by any responsible medical or scientific authority. This is how they manage to "detect" and "correct" subluxations without ever having to prove they subluxations exist. They don't have to demonstrate that subluxations can be diagnosed, that "adjustments" have any effect on this elusive subluxation, or that any of this has a positive effect on the patient's health.

With the current push to sell chiropractors to the public as "primary care physicians" and expand their scope of practice to include prescribing, it is alarming to contemplate not only that state legislators will fall for the illusion that DCs can act as PCPs, but also that insurers would be forced to cover their doing so.

Notably, not only medical organizations, but also a number of insurers oppose the Wisconsin bills. Insurers, perhaps better than any group, realize the penchant of chiropractors to overtreat, which has itself led to legislation barring excessive treatment. They must be horrified at the prospect of chiropractors expanding their billing to cover anything within their scope of practice.

Kentucky House Bill 288 is similar. It would require the same reimbursement to chiropractors for the same services rendered by a physician. It would also prohibit an insurer from requiring additional terms and conditions for a chiropractor to participate in a health plan when those terms aren't required of a physician.

Interestingly, Kentucky's chiropractic practice act is of the old-fashioned, straight, subluxation-based variety.

" 'chiropractor' means one qualified by experience and training and licensed by the board to diagnose his patients and to treat those of his patients diagnosed as having diseases or disorders relating to subluxations of the articulations of the human spine and its adjacent tissues by indicated adjustment or manipulation of those subluxations and by applying methods of treatment designed to augment those adjustments or manipulation."

Does this mean that the insurer will have to reimburse a chiropractor treating otitis media or a concussion by "adjustment" of the nebulous "subluxation" the same amount as for a physician treating those same conditions? The bill is an amendment to an existing health insurance parity law for optometrists. These laws are based on the optometrists' argument that routine eye exams and treatment of uncomplicated eye diseases are within their scope of practice. Because of this, they argue, insurers cannot discriminate against them in payment for these services, or require conditions physicians need not meet, under Sec. 2706. Chiropractors will certainly make the same arguments.

It will be interesting to see how these laws play out in the states. Currently, insurers use coverage restrictions to avoid paying for quackery. How these laws might undermine those restrictions remains to be seen. It will, at the least, require increased vigilance to guard against paying for pseudoscience.

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