Health Care Reform Is Already Happening

I was about a month late writing and submitting this column, and for good reason. I was patiently waiting for both the House and the Senate to vote on health care reform legislation, as promised, before Congress' annual August recess. And there were signs that this deadline would be met. In early June, Iowa Senator Charles Grassley (labeled earlier this summer as the "one guy who may hold the whole health-care world in his hands" by the The Wall Street Journal) sent a twitter message to the president stating that Congress was still on schedule and even working weekends. ("Pres Obama you got nerve while u sightseeing in Paris to tell us 'time to deliver' on health care. We still on skedul/even workinWKEND.")

We are now beyond Aug. 7 and while some progress was made, health care reform legislation remains largely unfinished. Many issues, including cost estimates, financing and the concept of a public plan, remain controversial. Current guesses of when legislation might actually be forthcoming range from Sept. 15 to sometime around Thanksgiving to never. While I remain optimistic, it is difficult to say with absolute certainty that comprehensive health care reform legislation will be passed this year. It is also hard to predict how reform plans currently on the table will ultimately impact health care delivery in general, and more specifically, how they will impact doctors of chiropractic and our patients.

As we wait for our elected officials (and our lobbyists) to take positive action after the August recess, it is important to remember that legislation passed by Congress is not the only road to reform. In fact, there were several health care reform documents that did get released this summer specifically directed toward the chiropractic profession. For example, while we were waiting for the Senate's Health, Education, Labor and Pensions (HELP) Committee to pass the Affordable Health Choices Act (which it did on June 15), the Department of Health and Human Services Office of Inspector General (OIG) issued a report in May titled "Inappropriate Medicare Payments for Chiropractic Services" (OEI-07-07-00390).

As reported in DC, the OIG report concluded that 1) Medicare inappropriately paid $178 million (out of $466 million) for chiropractic claims in 2006; 2) Efforts to stop payments for maintenance therapy have been largely ineffective; 3) Claims data lack information to identify maintenance therapy; and 4) Eighty-three percent of claims filed failing to meet one or more documentation requirement. The OIG recommended that Medicare implement several health care reform policies relative to chiropractic. These include prevention of future payments for maintenance care and ensuring that chiropractic claims are not paid unless documentation requirements are met.

Then in July, while we waited in vain for the Senate Finance Committee to get its act together and the House to pass its three separate health care reform bills out of committee, the Centers for Medicare & Medicaid Services released its Proposed Rule for revisions to Medicare payment policies for 2010. The rule included the first results available on the Demonstration of Coverage of Chiropractic Services Under Medicare project, a two-year study developed to analyze the impact, in terms of both cost and patient outcome, of expanding chiropractic services to a more full scope of practice for Medicare beneficiaries.

Specifically, findings were presented from Brandeis University's "Analysis of the Budget Neutrality of the Demonstration of Coverage of Chiropractic Services Under Medicare," which was released three days before the Senate HELP Committee passed the Affordable Health Choices Act. Brandeis found that the overall cost of the demonstration project was $114 million, with $34 million of that cost directly attributed increased payments for chiropractic services.

Based on these numbers, they estimate that the yearly costs for a national rollout would range somewhere between $1.27 billion and $468 million. These estimates are especially interesting since more than half of the total increase in demonstration project costs were found in patients who did not even receive care from a doctor of chiropractic; and the increased cost of the demonstration was "completely due" to the costs related to neuromusculoskeletal care delivered in the Chicago area.

Regardless of substantial weaknesses in the OIG report and the curious findings of the Brandeis study, which are as likely to be artifacts as causal effects, these documents will undoubtedly impact health care reform policy related to chiropractic. Let me rephrase that: They already are making an impact. Medicare carriers have begun tightening their claims review processes related to chiropractic and a 2 percent decrease in chiropractic Medicare fees is slated to begin in 2010 to offset the costs of the demonstration project. It is imperative that we do not become so distracted by the health care reform debate that we forget to pay attention to the health care reform that is already happening.