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Insurance Coverage and Development of CAM Professions: Perspective of Triad's Tiino Villani, DC PDF Print E-mail
Written by John Weeks   

IAYT is the Sponsor of an IBN&R Series on the Future of Yoga Therapy
Insurance Coverage and Development of CAM Professions: Perspective of Agostino Villani, DC, Triad CEO

Summary:  When the International Association of Yoga Therapists (IAYT) chose to sponsor a series of articles on the future of Yoga therapy, a core question regarded the pros and cons of insurance coverage. The recent IBN&R poll  found that most readers believe 3rd party coverage is critical to CAM-IM's future. But what might inclusion bring? IBN&R turned to Agostino (Tino) Villani, DC, a chiropractor and now a managed care executive, for his views on the influence of 3rd party coverage on chiropractic over the last 20 years. He speaks of an influence that runs across professional development, educational practices, and self image.

Agostino Villani, DC, Triad CEO
I e-mailed a quick query to Tino Villani, DC, six weeks ago.
I was just beginning work on an IBN&R project, sponsored by the International Association of Yoga Therapists. The ongoing project is exploring the pros and cons of different futures for Yoga therapy. One important area of interest is the effect 3rd party payment has had on other CAM-IM fields.

I thought of Villani for a couple reasons. He has an interesting vantage point. He has 20 years in the field as a chiropractor, including leadership roles in the profession. Chiropractic has a recent history of significant inclusion. More significantly, he is presently CEO, for Triad Healthcare (an IBN&R sponsor). In this position, Villani has responsibilities for covered CAM services for diverse clients, including some significant HMOs.

Now before you start assuming that my querying Villani will build in a managed care bias, consider that, as Triad's website shows, the firm attempts to honor
conflicts and differences between professionals and insurers in its efforts to strike a balance in its care management models. Tino did not disappoint. I was stunned by his directness.

IBN&R:  What, generally, has been the impact of insurance coverage on the chiropractic profession?

Image Villani:  While I don't feel a need to qualify my comments or balance them, for the purpose of this discussion I would appreciate the understanding that I offer these as personal observations, not as judgments or criticism.  I do not think that chiropractic as a profession, or its practitioners, have responded much differently than others have or would, given the same situation. The problems with most 3rd party reimbursement are much bigger than chiropractic.

IBN&R: A good point to make in starting out. Certainly reimbursement patterns have stimulated shifts in conventional medical practice, and even conventional medical education. So, yes, I ask readers to bring the understanding that you are sharing a personal view, and that you believe this has less to do with chiropractic, per se, than the nature of the reimbursement beast.

"It is my opinion that
this coverage has, to
this point, re-directed
chiropractic from its

Villani:   Over the last 20 years, everything, from chiropractic's identity from its schools to its scope of practice has been influenced by health insurance coverage. It is my opinion that this coverage has, to this point, re-directed chiropractic from its patient-centered origins. It has impaired the profession's ability to offer its most meaningful contribution to the public.  While my opinions are arguably in the minority, I believe inclusion has, in balance, been bad for the profession.

IBN&R:  Okay -- that's strong! -- why, then?

Villani:  I begin with the premise that the main reason a health profession seeks 3rd party reimbursement is to share in the apparent economic benefit of that inclusion. My experience suggests that other reasons for soliciting inclusion are less important, and typically insincere if not outright dishonest. So, from this premise, successful inclusion usually leads a profession into a progressively competitive and self-centered agenda. This is what I have observed in my profession.

IBN&R:  So a profession's focus on reimbursement may be viewed as extracting and manifesting the self-centered essence of its guild's purpose. Interesting. A kind of moral equivalent of the Treasure of the Sierra Madre.
I would suppose this might translate to other professions.

Villani:  I am not sure of any reliable study that would support a meaningful economic gain to chiropractic from inclusion.

IBN&R: That is counter-intuitive. I think most assume that significant economic benefits have come to many chiropractors through inclusion in 3rd party payment. Are you distinguishing between health insurance coverage and other forms of payment like auto insurance and workers compensation programs?

" The growth of the
   chiropractic profession  
has rapidly outpaced
the opportunity.

"The now larger
profession is not
necessarily better
than the one that
existed before."


Villani:  Not really. Certainly there is more revenue flowing into the chiropractic profession today than there was anytime before third party reimbursement. Most chiropractors who have been around long enough will say that initially 3rd party reimbursement added a great deal to their practices. It made it much easier to earn an income. Over time, this fact has stimulated growth in the profession and it has resulted in the significant expansion in the size of the profession. But the initial benefit has significantly diminished. Many chiropractors who can compare their status before and after reimbursement say that today they are not any better off than they were without 3rd party reimbursement, possibly worse for their progressive dependence on that system. The growth has rapidly outpaced the opportunity and the now larger chiropractic profession is not necessarily better than the one that existed before.

IBN&RSo talk about the perceived down side.

Villani:  One area is in the personal commitment and connection to patients. As a profession, we tout the continual improvement in the caliber of professionals we turn out. There is truth here, but this is now based on medicine's metrics - degrees, test scores, etc. We are becoming more like conventional practitioners while now, (conventional) medicine is beginning its slow shift to consumerism and a patient-centered approach. (Conventional) medicine is starting to focus on communication and human interaction skills. Older chiropractors laugh at the concept because they could have taught these courses. Before insurance inclusion, chiropractic was where medicine is going (in terms of patient relationships). We were very good at patient-centered care because practice meant something more than just competing for dollars. We're seeing chiropractors today who may have to go to medical school to learn what their elders took for granted.

IBN&R:  Now that would be an ironic twist. So reimbursement has influenced education?

Villani:  Chiropractic's educational institutions had a "student boom" that followed insurance inclusion. With little concern for the future, many schools expanded, to meet the opportunity. Yet in jumping to increase enrollments, they missed an opportunity to raise the bar, to develop improved entrance criteria and tangibly improve the quality of the profession. This could have enhanced the profession for years to come. Instead, we - and particularly some schools - just expanded the number of chiropractors. The average chiropractor now has less than 10 years of experience. This is a significant shift for the field.

IBN&R:  So this was a missed opportunity among educators - going after their own gold ring, which was directly provoked by chiropractic being seen as a potentially lucrative career choice. The current lull in applications to chiro schools may be viewed as the back-swing of this pendulum, then. What else?

"Our CPT codes made us
virtually indistinguishable,
from the insurance data
perspective, from the
physical therapists.

   "Now we were back doctors  
who were essentially -
according to the codes -
a redundant physical
therapy expense."

VillaniLet's look at "what chiropractors treat". When we accepted insurance, we were faced with the need to define our patients using ICD (diagnostic) codes. In reality, there were no codes that adequately described what we did, such as the subluxation or its consequences. Yet this issue was apparently less important than the fact that we could get paid by an insurance company if we just fit the codes, somehow. The insurance companies took over. They saw that we treated the spine, surmised that we treated the conditions they had associated with the spine, applied ICD codes. We complied with little input or dissent, and rapidly became "back doctors." The designation stays with the profession to this day. We have not contributed a single new ICD code to the thousands published every year. How is that for contribution?

IBN&R:  So the recommendation to others would be to watch out for the way the system can pigeon hole you.

Villani:  Now let's talk about "how chiropractors treat." When we accepted coverage, there were no codes for what we did. One code - 97260 - was invented to describe manipulation. For everything else we used the physical therapy codes. No effort was made to differentiate chiropractic's use of these adjunctive physical therapy procedures. In short order, our CPT codes made us virtually indistinguishable, from the insurance data perspective, from the physical therapists. Now we were back doctors who were essentially, according to the codes, a redundant physical therapy expense. Now, 20 years later, we have added one new CPT code. How's that for a contribution.

IBN&R:  So it's very hard to even pull data on your outcomes.

   "Insurance inclusion,  
in my opinion, has
thus far taken a little
profession with the
potential for
contribution and
bolted it on to the tail
end of a long train."

Villani:  Current industry claims data on chiropractic can be very incomplete and often misleading when trying to examine what chiropractors do, and where the value lies.

You asked also about research. 20 years ago we did not have much of a research agenda. There was virtually no funding, or course, and its still limited. Much improvement in our research capacity has occurred and this promises to yield some contribution. This is largely due to the vision NCMIC and Lou (Sportelli) have showed, going back to the Rand study in the early 1990s. This said, I am disappointed that our research agenda is today almost totally influenced by insurance inclusion. Little or no real research is being done to uncover the nature of the conditions for which people traditionally sought chiropractic care. Instead, our research community is racing to find validation for our approach to care for currently covered conditions. It is a race we cannot possibly win because we don't own the approach and we will not achieve professional authority and recognition for validating it. Our research agenda should be focused on why what we have done for decades works, not if it works. If it works is a response to our collective competition for position in the economic chain. Why it works is a response to a need to contribute to the public good. The chiropractic profession's position is clear and it is wrong.

Insurance inclusion, in my opinion, has thus far taken a little profession with the potential for extraordinary contribution and bolted it on to the tail end of a long train. Moving forward may be easier than it was before, but I don't think we will ever have an influence on where we or the train are going. If I were in charge and had it to do over again, I would have "just said no."

This is not a pretty picture. The obvious question that comes to mind is what then are you doing in the field of insurance yourself?

"Chiropractic hasn't
mixed well with the
existing third party
systems. That doesn't
mean that it still can't.

"In my current capacity,
I can offer valid
alternatives ... I am
positive about
the future."

Villani: Well, although I haven't painted a very pretty picture, you asked what I thought about the prospects of 3rd party inclusion for currently excluded CAM disciplines. Even though I think things have gone astray, I certainly do not believe that all is lost. Health insurance and other 3rd party payment systems are important and necessary. The reality is that chiropractic is a covered benefit in most 3rd party systems. Improving the conditions of that inclusion is nearly impossible as an individual practitioner. In my current capacity, I can offer models to the 3rd party system that provide valid alternatives to discounted care, truncated scope of practice and limited market access. Chiropractic hasn't "mixed" well with the existing 3rd party systems, but that doesn't mean that it still can't. I am positive about the future.

Thank you, Tino. This is a fine, thought provoking contribution. I imagine your personal reflections will be of interest to Yoga therapists as well as a lot of other CAM and integrative medicine practitioners. I am thinking I will formally run this content by some insurance leaders in a few other professions for their comments for a follow-up piece.  And I will be getting back to you on some of the models on which you are working which make you feel positively about the future. Good stuff!

To visit the site of series sponsor International Association of Yoga Therapists, click here

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