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I think physicians, whatever their letters (DO, MD, ND), and other types of healthcare providers too, want and deserve to make a fair living and compete in the health care marketplace on a level playing field, but I doubt that the profit motive is the prime driver for any of the health care professions. Wilson: Third party payment seems to hurt chiropractic more than others for some reason. They just keep getting chipped away at and they seem to be forced to work for less and less. That said, I can see some similarities. I had hoped that by including naturopathic medicine in managed care that we could extract some data about us and our practice that would be helpful in advancing the profession. But it has not really worked. Insurance has boxed us in just as chiropractors have been to certain codes and procedures and certain spending caps that patients and docs seem to bang their heads against. ![]() CPT advisor Bruce Milliman, ND Milliman: If the chiropractic community, or the naturopathic community, has been wrongly limited, this is a scope issue, not a reimbursement issue. As I understand the CPT [Current Procedural Terminology] codes, they are intended to be 'provider type blind.' They describe a service or a procedure. Whether that service or procedure constitutes a covered benefit is one question, and whether a particular provider is authorized to deliver or perform that service or procedure is a totally separate question.
Integrator: I am surprised that you view the CPT, which is controlled by the American Medical Association, as an "eminently democratic process." I would venture that a group dominated by MDs is hardly a jury of one's peers, for either chiropractors or your own profession. Milliman: True enough. But the Editorial Panel is the current custodian with the responsibility for guiding the form our system takes. So why not engage in the process rather than complain that it is not perfect? Wilson: My exprience tells me that insurance companies will not pay for some procedures that are in our ND scope of practice, yet they will pay for them when performed by an MD. One example is injections that are in our scope in Oregon. I've seen rampant discrimination in managed dcare with the insurance company deciding what they will and will not cover, and by them. Integrator: I know that this has been an issue with chiropractic because in some cases "manipulation" or manual therapy may be covered, but only when performed by an osteopath, or in some cases, a physical therapist. Milliman: When such and issue has been perceived to be discriminatory by our professional association's Insurance Committee in our state (Washington) we have successfully worked through the state OIC's (Office of the Insurance Commissioner) grievance process. Other concerns have required legislative change. Medicine is one third art, one third science and one third politics. Integrator: Well, you both have mentioned to me in the past that you believe there are positive impacts and benefits from participating in managed care, whatever the imperfections.
Milliman: It is my contention that this is 'welcome to the club.' The problems encountered by any one health profession are experienced by all health professions - electronic, cyberspaced, bureaucratized, regulated and scrutinized to the Nth degree. This has some good consequences, some bad. One good consequence of having some ground rules via evaluation and management guidelines is that quality of documentation improves. I would assert that the quality of care, too, improves commensurately. Wilson: It is interesting what the coverage can do to our relationships with our patients. I have seen patients which I had for a long-time as cash-paying patients get insurance coverage which is nominal at best. They then become lousy insurance patients who balk at spending anything beyond their "benefit." They subsequently truncate their care, abandoning a program before you could really get it going. Having practiced a long time now and having billed insurance companies for years, I have seen three significant changers. Initially, we just bundled everything in our treatment of the whole person that we did together, and for a very modest price. Then low and behold, insurers told us to put a code and price on all we did. Because naturopathic doctors are very eclectic, we did a lot with patients and had a lot of codes to mark. Suddenly, we were getting paid a lot. I'll be honest - I loved it. But as one can imagine the insurers did not. They forced bundling back, with a vengeance
Wilson: I wish insurance would go away in its present form. It has damaged the practice of all kinds of medicine. And yet, I believe that it has had beneficial effects on naturopathic medicine. Helping it to grow up, but as I have grown up in this way, I have gotten stiffer. I hope that a more mature form of naturopathic medicine is not a stiff one. I am proud of my colleagues who have jumped off the cliff, going on a cash-only practice basis. Many have found that they can fly and have done exceedingly well both financially and clinically. But I am also proud to have helped my patients afford my care by billing their insurance all these years. It is a Faustian deal though, letting an entity get between you and your patient. So, as you know, we love our cash paying patients. It's a clean and unencumbered relationship that is all the better now for what I have learned from my ventures into managed care.
Milliman: Modern naturopathic medicine cares for people who have evaluation and management needs, preventive needs and health promotion needs. The profession, in other words, is 'needs driven' and not modality driven. These needs can be addressed for a larger number of people by participation in third party reimbursement. The problems with the health plans are more attributable, in my view, to the emergence of third party administrators, or middle men like networks which basically drive down reimbursements for all types of participating providers. The provider's defense against this potentially adverse effect is to contract exclusively with health plans - or with networks, where unavoidable - which have coverage plans and fee schedules they feel they can live with. Finally, I have a point to make which is philosophical or organizational, perhaps more than immediately practical. 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 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.
"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. 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.Send your comments to for inclusion in a future Your Comments article. Note: To read the other articles in the IAYT series on the Future of Yoga Therapy go to: IAYT Sponsors Series on the Future of Yoga Therapy: Context and Current Initiatives Insurance Coverage and Development of the CAM Professions: Perspective of Agostino Villani, DC, Triad CEO (Another Kind of) Integration in Georgia - Yoga, TCM, Mindfulness Plus at Athens Regional Medical Harvard Researcher Sat Bir Khalsa on Hygiene for the Body-Mind and Yoga's Emergence
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