Recently Dynamic Chiropractic published a front-page article about various state essential health benefits and referred to Oregon and four other states not currently providing chiropractic as a covered benefit. [See "Chiropractic as a Covered Benefit," April 1, 2013 issue] – the connotation being that "chiropractic" was not to be included in the essential health benefits of these five states. Policy-makers, insurers and others clearly have been inappropriately viewing chiropractic as a service (e.g., musculoskeletal conditions only / spinal manipulation), rather than a profession whose members, practicing within their licensure and scope, depending on the state, can and do currently provide a large number of the listed essential health benefits (or services) being recommended in each state. Additionally, many DCs currently act in the capacity of primary care providers for their patients, with many even being board-certified chiropractic internists.
Essential Health Benefits Provided by Chiropractors
For example, Oregon's recommended 10 categories of essential health benefits or essential services that insurers within the coming Oregon Health Insurance Exchange must cover include: 1) ambulatory services; 2) emergency services; 3) hospitalization; 4) maternity and newborn care; 5) mental health and substance use disorder services, including behavioral health treatment; 6) prescription drugs; 7) rehabilitative and habilitative services and devices; 8) laboratory services; 9) preventive and wellness services and chronic disease management; and 10) pediatric services, including oral and vision care. Several of these benefit categories include services that chiropractic physicians can and do provide every day in their practices
Under "ambulatory patient services," we find "primary care to treat illness/injury." As you know, many chiropractors treat more than musculoskeletal complaints; they also treat many of the 60 most common conditions that typically present to a primary care provider's office, and they do so without the use of harmful synthetic pharmacology. Chiropractic physicians can treat these conditions with evidence-based natural remedies such as micronutrients, botanicals, OTC homeopathics, custom diets, exercise and physical treatments, not the least of which are chiropractic spinal adjustments. Paradoxically, ambulatory patient services is the category where the state listed acupuncture, chiropractic and naturopathy as "non-covered," as if they are simply services, rather than professions whose practitioners currently can and do deliver primary care and provide many of the listed "essential health benefits."
Other essential benefits categories in which chiropractors already provide many of the listed services include 8) laboratory services, which include lab tests, X-ray services and pathology; and 9) preventive and wellness services and chronic disease management, including preventive care, colorectal cancer screening, nutritional counseling, diabetes education, smoking cessation programs, allergy testing and injections, screening pap test and prostate cancer screening.
Additionally, consider 10) pediatric services, including oral and vision care. Under this category we find services such as preventive care – physician services. Many chiropractors specialize in infants and children, and provide valuable preventive and curative interventions.
The point here is that we are a profession, not a service, although to date have been listed as the latter by the medically minded policy-makers. The American Chiropractic Association is in the process of educating these policy-makers to the reality that we are indeed a profession that can and does provide many of the listed essential health benefits.
Clinical Examples: Essential Benefits in Practice
What would these clinical examples look like in real practice? Consider these coding scenarios for "preventative and wellness services" and a detailed description of those services as provided by doctors of chiropractic.
Code 99381 – Initial comprehensive / preventive (younger than 1 year old): A first-time patient, 3 months of age, is brought in by his mother for a general health evaluation. A complete family, social and medical history is taken, along with a comprehensive physical examination. A complete review of systems is performed. The baby's growth and development are evaluated including height and weight, head circumference and hearing, as well as developmental milestones. Guidance is provided to the mother regarding appropriate use of an infant car seat, proper nutrition including continued breast-feeding, and sleep practices. Risk factors for injury or illness are discussed, along with methods to address them.
Code 99385 – Initial comprehensive / preventive (18-39 years old): A new patient (33-year-old male) presents for a complete health evaluation and physical examination. He has no specific complaints or problems. A complete family, social and medical history is taken, along with a comprehensive physical examination including vital signs and body-mass index. A complete review of systems is performed including screening for depression. Risk factors including poor diet, tobacco use and alcohol abuse are identified. Interventions for the risk factors identified are discussed. Cholesterol and blood glucose screening are recommended.
Code 99401 – Preventive medicine assessments counseling (smoking cessation, 15 minutes): A 49-year-old female with a history of smoking one pack of cigarettes per day over the past 30 years presents to the office to assess and reinforce progress toward smoking cessation. The history of the patient notes prior attempts to quit smoking, as well as possible reasons for failure. The clinical encounter includes a review of the health risks of smoking, the benefits of stopping, and the positive and negative issues regarding options for quitting. Referral to medical management for nicotine patch or nicotine gum is offered. Handouts for smoking cessation classes are supplied, and strategies for obtaining support from family and friends are discussed.
A Profession, Not a Service
Depending on each state's scope of practice, many DCs can and do provide many of the essential health services being adopted by the states. A Nov. 15, 2012 Oregon Legislative Counsel legal opinion clearly supports this opinion and should be instructive for other states. The opinion states, in part: "[B]ased on the language of the federal Act and the guidance issued by HHS thus far, but without an express interpretation by HHS, we believe that an insurer would be discriminating in violation of section 2706 of the PPACA if the insurer excluded coverage of a service that was an essential health benefit and was within the scope of the provider's license only because the service was provided by a chiropractic physician."
Oregon Governor John Kitzhaber, MD, and Oregon's Insurance Commission are also in agreement with this opinion. I assure you, Oregon will be far from not covering chiropractic, but just the reverse: Chiropractic physicians in Oregon will be reimbursed for all essential health benefits that fall within their scope and license to provide.
Chiropractic is a profession, not a service. Chiropractors are uniquely qualified to deliver the "triple aim" of health care reform: improving the health of Americans, reducing the per-capita cost, and improving Americans' experience with our health care system with regard to both satisfaction and safety.
