Naturopathic Insurance Leaders on 3rd Party Payment, the CPT, Villani's Views, and CAM-IM Maturation

Summary:  What does taking 3rd party payment change in a clinical practice? What role does such payment play in the development of a healthcare profession? Tino Villani, DC, a long-time chiropractic leader and CEO of Integrator sponsor Triad Healthcare, provided a wonderfully frank assessment. Villani focused on some of the corruptive pressures. This article looks at views of two insurance-savvy leaders of the naturopathic medical profession, Kevin Wilson, ND, and Bruce Milliman, ND, who read Villani's comments and reflected on their own views. These are their remarks - plus some responses from Villani. This article is part of a sponsored series on the future of Yoga Therapy from the International Association of Yoga Therapists.

Inclusion in 3rd party payment is often viewed as a sign of arrival by the emerging complementary and alternative health care professions. Insurance coverage is a literal gold ring of inclusion.

This article is part of an Integrator exploration of professional development engaged as part of a series on the Future of Yoga Therapy which is sponsored by the International Association of Yoga Therapists

Yet like so many fabled rewards, there are dark sides. Witness the way conventional primary care has been hammered down by an insurance payment system which tells MDs and their administrators that the most money they can churn is a function of how many short visits they can line up, back-to-back. The end product is a system in which they no longer have the time to engage the responsibilities which are suggested by "primary care."

Tino Villani, DC, a chiropractic leader in his state of Connecticut and CEO of Integrator sponsor Triad Healthcare, provided the Integrator a wonderfully candid, personal view of the impact of insurance coverage on his profession. (See

• Kevin Wilson, ND, has held state and national leadership positions for his profession and is a past-president of the Oregon Association of Naturopathic Physicians and current chair of its legislative committee. He also serves as chair of the Formulary Council of the Oregon Board of Naturopathic Examiners. He has been the principal naturopathic doctor involved with the development of CAM network Complementary Healthcare Plans which manages CAM benefits for employers and insurers including Kaiser Northwest Permanente.
  


• Bruce Milliman, ND, negotiated his profession's ground-breaking role as recognized primary care providers (PCP) with Regence Blue Shield, one of Washington State's most significant carriers. Milliman also serves as the representative of the American Association of Naturopathic Physicians on the Health Care Professional Advisory Committee of the American Medical Association on its Current Procedural Terminology (CPT) Editorial Panel, the codes which govern much of insurance reimbursement. He is the acknowledged insurance expert of the Washington Association of Naturopathic Physicians as it has found its way into significant insurance coverage over the past decade of experience with the state's legislation which required all health plans to include "every category of provider."
  

Integrator: What was your initial response to Villani's comments?

CAM network ND lleader Kevin Wilson, ND (photo from the author's file)

Wilson: The Villani article was impressive and largely accorded with my experience.

CPT advisor Bruce Milliman, ND

Integrator:  I do know from talking with other naturopathic doctors in Washington that some time-intensive 'procedures' are not as likely to be offered. Examples are services which do not pay very well, or are not covered, like craniosacral therapy, massage and hydrotherapy. True, some are now referring to massage therapists for some of this care rather than delivering it themselves. We don't know what this kind of limiting of a practice, or external referral, may be doing to the doctor-patient experience.

If a patient suffers from a condition, there is a way of expressing that condition, however imperfectly, in the form of an existing ICD-9 [International Classification of Disease] word and number. It's called ICD-9 because it's the 9th edition and number 10 is rolling down the tracks. This is an obscure way to point out that change is possible. So, again, why not engage in the process rather than bemoan the fact that the billing system, like our own form of government, is not perfect or does not perfectly represent our perceived needs as a profession.

Integrator: Well, the chiropractors have been pretty significantly included in 3rd party payment for 20-30 years, a significantly longer period than the NDs. This will be an interesting conversation in 2015, to see what changes may have taken place in the interlude.

Agostina Villani, DC, CEO, Triad Healthcare

Comments in response from Tino Villani, DC:

Regarding Milliman's comments on patient-centric vs provider centric:

"I do not remember where I suggested that the chiropractic profession has responded to 3rd party reimbursement in a patient-centric way, but nonetheless, Dr. Milliman is correct is observing that I am of the opinion that my profession has responded in a provider-centric way. This generalized behavior on the part of chiropractic as a profession occurred gradually over the course of two or three decades.

"Possibly, in the hindsight of thirty years, my perspective on why chiropractic pursued 3rd party reimbursement may seem cynical. But I am not being disingenuous when asserting that the move to insurance was wholly provider-centric in intent.

"My profession’s history is rich with accounts of a time when this was not so - a time when anyone who sought chiropractic care received it, regardless of their ability to pay, and without a thought for insurance. Patients paid with promises, services and apple pies when necessary. Chiropractors accepted these forms of reimbursement, forged strong, meaningful relationships and (as the story goes) had fulfilling careers as healthcare providers to the public. It was a two party transaction in which both parties appeared highly satisfied (as individuals) with the mutual exchange of value. It suggests that chiropractic was a very patient-centered profession.

"I question the decision to pursue 3rd party reimbursement from this perspective. To me, it represented a less personal, more institutional perspective that the dollar was more valuable than the pie. We began a move towards a less patient-centric path."

Regarding Milliman's comments on the role of the CPT

"It’s a nice theory, but practical experience suggests otherwise. Scope is defined by regulatory language. When this language is compromised as part of contract language and financial policy within a 3rd party system, I think there can be little argument that the basis for this is reimbursement."

Regarding the recommendation that a profession work in the CPT system to change codes.

"My point exactly. Over time, this becomes the prevailing professional discussion, as it has with chiropractic. Energy, resources, influence have been directed at this negotiation for codes and the reimbursement associated with those codes. These issues have eclipsed the patient as a focus on the profession’s agenda."

Regarding Milliman's final comments on the ND's being "needs driven" organizing to make changes

"The conflict is, as you suggest, good healthcare professionals are 'needs driven' and patient-centric. 3rd party systems, including their coding and standardization methods, are 'modality driven.' Promoting a patient-centered CAM agenda in a modality-driven industry is difficult and requires so much compromise from the provider that I question its true value.

"If this conflict was between parties of equal size, organizational integrity and political influence, compromise might lead to mutual benefit. But in the current environment this is impossible. We have yet to find a way to balance this environment and my fear is that we have stopped trying and have resigned ourselves to short-term benefit and fighting battles for their own sake."