Integrative Health Care for a Medicaid Population: Interview With Alan Post, DC (Part 2)

Editor's note: This interview with Dr. Alan Post regarding Rhode Island's Medicare pilot program appeared originally in its entirety in the Nov / Dec 2012 issue of Health Insights Today, a newsletter published by Cleveland Chiropractic College – Kansas City. It is reprinted in DC in two parts with permission from the college; part 1 appeared in our Aug. 15, 2013 issue.

How is integrative health care defined in Rhode Island for the purposes of this project? From the materials I've read, it clearly includes access to chiropractic, acupuncture and massage, upon referral by a primary care physician. Does it include other approaches as well, perhaps mind-body methods? To what extent is it about referring to particular providers and to what extent does it involve a broader overview, in which the case managers or navigators prepare a broad, integrated holistic treatment plan? The intake process includes analyzing the population for diagnostic criteria, pharmaceutical usage, and many additional factors. Even though there might be a PCP [primary care physician] provider in the Medicaid system whom the patient has seen, oftentimes it's so fragmented that the PCPs don't even know all the physicians the patient has contacted, specialist encounters or prescription drugs the patients are on. Even though our Rhode Island pilot has only been up and running for three months [nearly a year at the time of this reprint], the success it's showing with ER diversions and more – and it's going to be a while before we have the data to document it all – the preliminary information we're seeing and the health plans are seeing, indicates that it is very successful.

The program design is that a particular person is targeted, there's an outreach call from trained a holistic-nurse case manager, they do an intake and they know their provider network. The provider network is chiropractors, acupuncturists and massage therapists. They're credentialed above and beyond NCQA [National Committee for Quality Assurance] guidelines. The holistic-nurse case manager has gone out and done a site visit to each provider's facility, has met the provider and has a sense of how they practice.

The case manager makes referrals based on that person-to-person knowledge. It may be a headache, back pain or fibromyalgia patient, but just because they have a particular diagnosis, it doesn't mean they automatically end up referred to a certain provider. It depends on the big picture that the nurse case manager considers in order to determine which provider in the network she or he thinks will be aligned best. So if it's a massage therapist and they think this patient would benefit from craniosacral technique, for example, they can do it.

There's another thing I should mention that is very exciting. There are certain guidelines and parameters that have to be met by doctors and providers in the holistic network, and they are required to spend a 30-minute office visit with patients, which includes therapies, home recommendations, activities of daily living, and other modalities. The reimbursement rate is $55, which is an unusually high reimbursement rate for a Medicaid population.

In some states the reimbursement rate is as low as $8 for a chiropractic visit. I think that chiropractic is included in Medicaid in about 23 or 24 of the 50 states. But it is usually at a severely discounted fee structure. To the contrary, in Rhode Island, because of the savings achieved through the integrative model, providers can be paid a wage that is worthy of their time, energy and expertise.

Since treatment by a chiropractor, acupuncturist or massage therapist requires a medical referral, how would you characterize the frequency of such referrals thus far in Rhode Island? Is this working out as you and other chiropractors had hoped? Actually, the patients chosen for this program are a very difficult population for the PCPs. When the PCP learns about how the program is coordinated and functions, sees the outcome studies, and realizes that they have a new treatment option for these problem patients, most are enthusiastically supportive.

Also, the PCP is not making the specific holistic provider referral. They are just allowing the patient into the program after they've been contacted and informed that the patient meets the criteria allowing them to be enrolled. The holistic nurse case manager does the specific provider referral.

I know that one component of the Affordable Care Act was to bring Medicaid reimbursement rates up to a level equivalent to Medicare rates. Do you know whether that's just for primary care physicians, or does it apply to Medicaid providers across the board? For example, does it apply to chiropractors? I don't know the answer. I can tell you from some of the work I do in my consulting that the Medicaid expenditure trendline is not sustainable by the states. It used to be, when Medicaid was created back in the 1960s, that there were 18 workers for each person covered under Medicaid. There was a recent article about this in The Wall Street Journal, in which the director of the Pennsylvania Department of Public Welfare was quoted.

And now, is it just a few workers per person covered by Medicaid? It's between two and three to one. The point is that the numbers are unsustainable. I understand they are talking about bringing reimbursements up; I'm watching this whole health care reform process closely. I go to meetings and I see what is happening. And I can tell you that as much as they're moving all the chess pieces to different places on the board, they're pretty much still playing chess.

In other words, it's still the medical model and they're not really going to significantly reduce costs, improve health outcomes and enhance patient satisfaction through their model as our integrative program has achieved. Only when they start to embrace what chiropractic offers, what the alternative and integrative medicine community offers, and put that right in at the front end of the system, will these changes will be attainable. What I envision is basically a reallocation to a more efficient use of the limited health dollars to more effectively deliver services with our finite health care resources.

If the Rhode Island program is able to show high-quality results that include improved patient outcomes and/or lower costs, what do you anticipate or hope for in terms of it spreading more broadly in Rhode Island, to other states in New England, or to other areas as well? What's your highest goal? I think given the current environment that is ripe for change and improvement, there is an incredible window of opportunity to do just what I was talking about: to see the health care system make more efficient use of resources by using our chiropractic physicians and other integrative medicine providers appropriately at the front end of the system to better serve the patients' needs and the nation's needs.

In practical terms, I'm already on the phone speaking with directors of Medicaid, and medical directors and chiefs of staff in other states, who are on some levels already aware of needing change in their system and dealing with changes in many ways. But from my perspective, they don't fully understand their problem because they're looking at it through their own allopathic eyeglasses. It's very hard to open them up. These are very intelligent people who've gone to the best educational institutions in our nation, if not the entire world, and they cannot imagine that there could be such a big aspect that they're missing, one they weren't trained in or told about in school, that could play such an important role.

So, it's very difficult to open their eyes, but there's a more receptive audience now than there ever has been before. So when the outcomes and the results of the pilot come in, I see Rhode Island expanding it. Right now we're in a turf war over the health insurance exchanges being created in our state. They've designated chiropractors into a limited number of visits, and by prescription, whereas our state law is one of the best in the country. It basically says you can do everything except prescribe drugs or perform major surgery. And we are now in a fight to maintain our profession's rights.

What's going to happen, I think, is that we are going to be used downstream in four or five years in a much more major way in the system. Actually, I'm very excited about the future of our profession. There's the saying from A Tale of Two Cities: "It was the best of times, it was the worst of times." The pendulum swings far in both directions. Our profession has been pretty beat up over the past decade and a half. I believe that the pendulum is starting to swing back.

Any final thoughts for our readers? These next few years are going to be very important. I know chiropractic students form a large part of your readership. I'm on the advisory board of a chiropractic institution and I have to share with you that one of the biggest problems our profession has is apathy. I've seen it in the past and I see it now. Recently there was a meeting of the state association where the director of our state's Department of Health came to speak on the current status of health care reform. We only had 20 percent of the association's members there.

How can you be a doctor and not attend such a meeting? These are your own interests, your family's interests, your patients' interests – how can you not come to find out what's going on? We happen to be facing a policy decision that breaks the state law with regard to chiropractic licensure by limiting the role chiropractors will play in insurance policies approved for the new state insurance exchange. The fact that our doctors did not attend baffles me. So I really think that a major part of the chiropractic schools' emphasis has to be on creating doctors who are involved in their profession. I mean, it's going to take a lot of hands on deck, and the biggest problem I see is that there are too many hands "off deck."

Dr. Daniel Redwood, the interviewer, is a professor at Cleveland Chiropractic College – Kansas City. He is the editor-in-chief of Health Insights Today, associate editor of Topics in Integrative Healthcare, and serves on the editorial board of the Journal of the American Chiropractic Association. Visit Dr. Redwood's website and health-policy blog at www.redwoodhealthspeak.com.