Insurance for Complementary Medicine: Learning from Chiropractic Leader Rehberger and ACA's Efforts
Written by John Weeks
Reimbursement and Complementary Medicine: Learning from Chiropractic Leader Rehberger and the ACA's Efforts
Summary: Of the licensed natural healthcare professions, chiropractic has far and away the most third-party coverage. That profession's inclusion, despite a hostile environment, is a function of an ongoing campaign involving education, litigation, legislation and relationship-building. James Rehberger, DC is chair of the Insurance and Managed Care Committee for the American Chiropractic Association (ACA). I interviewed Rehberger about the outcomes of ACA's multi-year campaign to better relationships with insurers. I also asked about action related to discount products, health savings accounts, battles with the CAM network American Specialty Health Plans and the endorsement by another national association of a managed care company, Alternative Medicine Integration Group.
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Decisions about what healthcare services are covered by 3rd party payers - whether conventional or natural health - are rarely as simple as the two-step presented in the dominant story line: Show us the scientific support, and we'll cover it. Other forces play in - relationships, politics and history. Mature professional organizations in healthcare devote significant energy to shifting the decision matrix.
James Rehberger, DC, Chair, ACA Insurance and Managed Care Committee
Among professions representing the complementary and alternative healthcare disciplines, only the American Chiropractic Association (ACA) attempts to continuously play across the whole chess board. The titular leader of the ACA's multi-faceted campaign is James Rehberger, DC. Rehberger, a delegate to the ACA from the state of Illinois, is chair of the ACA's Insurance and Managed Care Committee. I contacted him to learn about the ACA's current strategy.
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Integrator: So what is your basic charge as the Insurance and Managed Care Committee?
Rehberger: Our responsibility with the Committee is to be apprised of what's going on in insurance and managed care that impacts our ability to provide services.
Integrator: The history of relationships between chiropractic and insurers has been one fraught with litigation and legislative mandates. You've sued insurers. Chiropractors have fought for mandates at the state level and at the federal level, through requirement that DCs be covered under Medicare. I recall a program the ACA developed a few years back that tried to shift this oppositional thrust by trying to create better relationships.
On Meetings with Insurers:
"It's difficult for us as a small profession to
make major dents in the armor that's gone up in the 3rd party world.
"We've argued with information and research. The response has been: 'This is the way it's going to be.' How do you battle that?"
- James Rehberger, DC
Rehberger: That is the Claims Solutions Work Group. When we started, we had two face-to-face meetings a year, involving 30 to 40 insurance companies. After a time, the face-to-face meetings became less cost effective. Now we stay in touch through an electronic newsletter.
Integrator: Was there value created?
Rehberger: The meetings helped the ACA leadership understand how payer groups are thinking and helped us come up with some reasonable solutions. For instance, we created documentation manuals for our members, to help them better understand what a payer wants to see. The meetings also helped insurers get to know chiropractic better. But there has been a problem with these meetings in that we're not always talking with decision-makers.
Integrator: So you haven't been able to develop any more affirmative relationship with insurers? I mean, mainly they seem to focus on how to limit costs related to chiropractic care rather that how to best use chiropractic. This tends to be the case with all of the licensed natural healthcare disciplines. So you haven't been able to shift that basically negative approach to create more of a partnership? Rehberger: I would have to be not honest to not say I haven't seen enough of that at this time.
Integrator: Why haven't you seen a change? Rehberger: That's a good question to ask the payers. I have personal opinions. It's difficult for us as a small profession to make major dents in the armor that's gone up in the 3rd party world. We've argued with information and research. The response has been: "This is the way it's going to be." How do you battle that?
Integrator: Why am I thinking of Sisyphus? Rehberger: It's an extremely frustrating situation. We continue to march forward with good efforts.
Integrator: So with all that frustration, what do you think of
the recent action of the Council on Chiropractic State Associations (COCSA).
They actually endorsed a managed care company, Alternative Medicine Integration
Group. Have you looked at the joint venture COCSA is engaging with AMI?
Rehberger: We are trying to learn more. However, the ACA has held no
formal meetings with AMI and no relationship has been attempted or created. I’m personally interested in AMI's approach, not
only from a clinical standpoint but a business perspective. It seems to level
the playing field for the patients the profession serves. It feels like almost
a breath of fresh air from what I have seen.
Integrator: Have you looked at Health Savings Accounts (HSAs)and the other new healthcare products by which employers are limiting
their financial exposure and giving employers more choice and
responsibility?
Rehberger: We've not discussed
them much at the committee level and have no policy on them at this time. There could be something at some other level of the ACA.
Integrator: How about the so-called "affinity products," the programs by which complementary and alternative healthcare managed care networks give members access to a group of chiropractors or other providers at a discount, but don't actually reimburse for any services.
Rehberger: The ACA passed a policy that opposed these type
of insurance products. The policy was approved in 2000.
Integrator: You've been pretty vigilant regarding perceived abuses of the managed chiropractic and managed complementary healthcare companies, especially the giant in the field, American Specialty Health Networks (ASHN).
Rehberger: Yes, this is an important area for us. We have a hot-line
for members to let us know if they believe there are any abuses in any of (the
chiropractic managed care) companies. This is a hot button issue for our
members. But I can't discuss specifics on any company at the
present, other than to state that we continue to be vigilant and
encourage our members to report possible abuses.
Integrator: But can you share your experience of what provokes members to call the hot-line?
An Issue of Concern:
"The insurers will gather data that doesn't
really provide enough information to make a decision on what a patient
needs, there's no clinical information, yet they'll be making decisions
about how many visits a patient can have."
- James Rehberger, DC
Rehberger: A typical complaint may be an insurer's limitation on the scope of practice or the inability to be covered to treat the variety of conditions chiropractors are trained for. There are complaints about paper work. There's too much of it, and many members don't think (the paperwork) gives an honest view of what the patient has. The insurers will gather data that doesn't really provide enough information to make a decision on what a patient needs, there's no clinical information, yet they'll be making decisions about how many visits a patient can have.
Integrator: Other than the Claims Solution Work Group, which appears to be waning now, have you other pro-active initiatives?
Rehberger: A part of our
dialogue with insurance companies is with their Special Investigation
Units (SIU). The SIU's see the worst of everything. We've been
providing them information and educating them for years. It's
surprising how many elementary things they don't know about
chiropractic, even though they are charged to investigate fraud in the
field. Some will say, "we didn't know chiropractors were trained to
take an ex-ray." That's an ongoing service. We get calls from them for
assistance. We've also developed some policies and offered some
education for our members on multi-disciplinary practices, where a chiropractor works
with a medical doctor, or an osteopath or a psychiatrist. Insurers have
had problems here. Another proactive area is work with the National Committee for Quality Assurance (the accrediting agency for managed care plans). We're on some of their panels.
Integrator: A decade ago, one of my chiropractic colleagues in promoting more collaborative healthcare told me that the only way chiropractic has advanced has been through the 2 "L" words - litigation and legislation. Looks like there is some change but that the 2 "Ls" remain at the strategic center for the ACA.
Comments: Rehberger makes two key points. Chiropractic has suffered from insurers not gathering meaningful data. The insurers can require it. They don't. Why? I have come to view insurers as basically cost-plus enterprises. Hand-ringing aside, when all is said and done, the higher the cost of health care, the more their cut. X% of Y + 1 is greater than X% of Y. Bothering themselves with gathering meaningful data which might show value in limiting costs runs against the insurer's self interest. This is an issue for the entire integrative medicine and complementary medicine integration effort when it comes to coverage. Not to mention the perverse incentive that the typical insurer's self interest has for all of US health care.
The second point, made higher up in the interview, follows the first. Rehberger expressed the ACA's frustration: "We've argued with informationand research. The response has been: 'This is the way it's going to be.' How do you battle that?" Sounds like using science in an argument on global warming with the Bush administration. How indeed? One is to support those businesses which are gathering useful data. Do you have any ideas?
Some good news on this front came in today. Colleague Martha Menard, PhD sent a notice that the NIH National Center for Complementary and Alternative Medicine passed a concept paper that is "examining the effectiveness and cost-effectiveness of CAM as practiced in community settings." More on this soon. Now that's a start!
http://nccam.nih.gov/research/concepts/consider/outcome.htm
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