Senator Thurmond Questions Shalala's Report

COMMITTEES
ARMED SERVICES
JUDICIARY
VETERANS' AFFAIRS

United States Senate

WASHINGTON, DC 20510-4001

The Honorable Donna Shalala
Secretary
Department of Health and Human Services
200 Independence Avenue, S.W.
Washington,D.C. 20201

Dear Secretary Shalala:

The purpose of this letter is to bring to your attention a matter involving the report you submitted to Congress on April 12, 1999 entitled Chiropractic Services in Medicare Managed Care. I have received the report and have some concerns that I wish to bring to your attention. They can best be summarized as follows:

a. The report covering 1991-92 data, when combined with the referenced preliminary survey of the Office of Inspector General (OIG) covering the 1995-96 data, leads me to conclude that the chiropractic benefit has all but disappeared from Medicare HMOs and Medicare+Choice plans.

b. The report has no data on actual use -- simply "availability" and the OIG Survey shows that actual use is virtually non-existent.

c. The report states that, by law, physical therapists are not physicians and thus cannot provide the chiropractic benefit. Nevertheless, the report states 29 percent of the plans indicated that the physical therapists would deliver the service.

d. Congress mandated the inclusion of chiropractic services for senior citizens in 1972 because of a national illegal boycott of chiropractors by the medical and osteopathic professions. The report indicates that no chiropractor serves on any HMO panel. Moreover, it acknowledges that HMO physicians refer patients to outside practitioners less than one percent of the time. The OIG survey shows that medical gatekeepers have referred patients to chiropractors .5 percent of the time, an 87 percent drop from fee-for-service usage of chiropractors by senior citizens.

Please allow me to expand on the above themes since I respectfully suggest that HCFA failed to see that the laws have been executed and have left senior citizens with no practical remedy. HCFA has failed to implement any clear regulation or policy that ensures meaningful access by Medicare HMO enrollees to chiropractic services and HCFA has continued to grant licenses to Medicare HMOs which fail to provide this service. Moreover, the only remedies suggested by the report for those denied coverage of chiropractic services -- appeal or disenrollment -- are useless for poor senior citizens.

My conclusions appear to be fully supported by the survey performed by the Inspector General of Medicare HMOs for the period 1995-96 entitled Chiropractic Services Covered by Medicare Managed Care Organizations which was submitted to HCFA on January 13, 1999 (the "OIG Survey").

The OIG survey indicates that chiropractic service has almost disappeared as a practical matter from Medicare HMOs ostensibly operating under contract with your department (HHS). These consequences are currently affecting the Medicare+Choice organizations to which you make reference.

Madam Secretary, I am very concerned about the findings of your report. I would appreciate your reviewing the letter ... and providing me with your response to my concerns as soon as possible. It is apparent that senior citizens have been and are being severely prejudiced contrary to the will of Congress by Health and Human Services' many delays in this matter.

Sincerely,

Senator Strom Thurmond