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Chiropractors Organize Significant Response on Accountable Care Organizations PDF Print E-mail
Written by John Weeks   

Chiropractors Ask CMS to Reconsider Their Roles in Accountable Care Organizations (ACOs)

SummaryWhen the Centers for Medicare and Medicaid Services called for comments on guidelines for Accountable Care Organizations, the chiropractic profession responded with strength. Over 30 DC organizations filed responses. That of the American Chiropractic Association (ACA) is printed in full here. The ACA's case Is one that other licensed "CAM" and integrative practitioner groups might have made had they responded: the circle of provider types in ACOs is too small. Notably, the ACA has also been involved in tracking and responding to similar guidelines from the NCQA. 
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Requested comments on ACO rules
The December 2010 Integrator Round-up included a comment that few, if any, integrative practice professionals or organizations had responded to the Centers for Medicare and Medicaid Services' (CMS) request for comments on preliminary standards for Accountable Care Organizations. No responses had been sent to the Integrator to share with the community following a November 29 Integrator Alert

A chiropractic educator and colleague quickly sent a note that corrected me. The chiropractic profession had organized (independent of the Alert) a significant response. Over 30 state and national associations submitted testimony, as did some individual chiropractors. John Falardeau, vice president for government relations with the American Chiropractic Association sent the ACA letter. It is printed, in full, below.

The chiropractors began tracking the ACO issue closely when the National Committee for Quality Assurance, requested comments on their Draft Accountable Care Organization Criteria, the end-date for which was November 19, 2010. (A copy of that letter from the ACA to NCQA is available on request.) I follow with a few comments.



November 29, 2010

Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-1345_NC
P.O. Box 8013
Baltimore, MD 21244-8013

Re: Medicare Program; Request for Information Regarding Accountable Care Organizations and the Medicare shared Savings Program

The American Chiropractic Association (ACA) is a professional society composed of doctors of chiropractic whose goal is to promote the highest standards of ethics and essential patient care, contributing to the health and well being of millions of patients. The ACA is the largest association in America representing the chiropractic profession. Below are ACA's comments in response to CMS' request for information regarding
Accountable Care Organizations and the Medicare Shared Savings Program.

What aspects of patient centeredness are particularly important for us to consider and how should we
evaluate them?

Doctors of chiropractic (DC) utilize a natural, whole-body, patient-centered approach to health care. As such, ensuring patient centeredness in ACOs is a high concern of the chiropractic profession. The ACA strongly believes that doctors of chiropractic should play an important role in bringing their patient centered focus to the ACO structure. DCs have been shown to be effective portal of entry, primary care providers, examining, treating, diagnosing, managing, co-managing or referring patients who present for care. Reports published in the Journal of Manipulative and Physiological Therapeutics in 2004 and 2007 show significant cost savings for patients who used doctors of chiropractic as primary care physicians.1 Notably, chiropractic patients experienced a more than 60 percent decrease in hospitalizations, 59 percent fewer hospital days, 62 percent fewer outpatient surgeries and an 85 percent decrease in pharmaceutical costs compared to patients who saw medical doctors. Including DCs in the ACO structure and rewarding DCs for the cost savings they are able to achieve would be an important key to ensuring patient centeredness in ACOs.

What policies or standards should we consider adopting to ensure that groups of solo and small practice providers have the opportunity to actively participate in the Medicare Shared Savings Program and the ACO models tested by the CMMI?

The ACA appreciates CMS' awareness of the difficulties that face solo and small practice providers and CMS' effort to adjust the Shared Savings Program to increase participation of these providers in ACOs. For the Shared Savings Program to be effective, the ACA believes that the program must be inclusive of various healthcare provider types who come from a variety of practice structures. The ACA is concerned; however, with how "eligible ACO providers" are defined within the Patient Protection and Affordable Care Act (PPACA) and the ACA is concerned that this limited definition will negatively impact the success of the Shared Savings Program.

The ACA believes that PPACA's limited definition of an ACO eligible provider will not appropriately reward all of the healthcare providers who are responsible for creating cost savings in patient healthcare. For example, low back pain is the fifth most common reason for all physician visits in the United States2 and treating low back pain has been historically proven to be very costly. Annual national spending on spine-related problems is estimated to be $85 billion in the United States, an inflation-adjusted increase of 65% since 1997.3 In addition, indirect costs related to days lost from work are significant, approximately 2% of the U.S. work force compensated for back injuries each year.4 Doctors of chiropractic are well trained to diagnose and treat a broad range of healthcare conditions, including the especially prevalent condition of low back pain. Further, chiropractic physicians have demonstrated great cost-effectiveness in this area. A 2003 study published in the British Medical Journal indicated that "...clinical outcomes measures showed that manual therapy resulted in faster recovery than physiotherapy and general practitioner care. Moreover, total costs of the manual therapy treated patients were about one-third of the costs of physiotherapy or general practitioner care."5 In another recently published study reporting data on 250,000 Blue Cross Blue Shield insureds in Tennessee, patients who saw a doctor of chiropractic before seeking care from other provider types had 40% reduced health care costs compared to patients who saw an MD/DO first.6 The ACA believes it would be ineffective and inappropriate to have ACO teams that do not include doctors of chiropractic who are well trained to cost effectively treat many common ailments, including this most common of health conditions. Further, if chiropractic physicians are not included in ACO teams, but treat beneficiaries attributed to ACOs and achieve cost savings, it would be inappropriate to reward only those providers who are delineated within the legal structure of the ACO, rather than those providers responsible for the cost savings. Excluding doctors of chiropractic might also adversely affect research and data collections by altering direct access for patients and not identifying treating chiropractic physician as primary provider.

We appreciate the diligent work of CMS in developing the Shared Savings Program criteria. Ultimately, ACO's are intended to bring about cost savings and to reward those healthcare providers who have demonstrated successful and cost-effective patient results/outcomes. To that end, the ACA requests a reconsideration of the practitioners that are needed in an ACO and to expand this list to include doctors of chiropractic. As noted above, chiropractic physicians are well trained in primary care and directly provide a broad array of professional health care services for a wide variety of health conditions. These professional services include, but are not limited to evaluation and management, physical medicine, diagnostic imaging, laboratory services, prevention and wellness services, referral for other specialized diagnostic and treatment services and counseling on lifestyle changes, ergonomics, diet, exercise, risk avoidance, etc. Conservative chiropractic care and the use of chiropractic physicians as primary care providers has been shown in the literature to be safe, clinically-effective and cost-effective. Again, we assert that Doctors of Chiropractic should be included in the ACO structure and rewarded appropriately for the cost-savings they achieve.

Thank you for the opportunity to provide input towards the development of this important program.

Respectfully submitted,

Rick McMichael, DC
ACA President

1 Sarnat RL, Winterstein J, Cambron JA. Clinical utilization and cost outcomes from an integrative medicine independent physician association: an additional 3-year update. Journal of Manipulative and Physiological Therapeutics, May 2007.
2 Deyo RA, Mirza SK, Martin BI. Back pain prevalence and visit rates: estimates from U.S. national surveys, 2002. Spine. 2006;31:2724-7.
3 Martin, Deyo and Mirza-Expenditures and health status among adults with back and neck problems-JAMA 2008; 299: 656-64.
4 Andersson GB. Epidemiological features of chronic low-back pain. Lancet. 1999;354:581-5. [PMID: 10470716]
5 Korthals-de Bos et al (2003), British Medical Journal
6 Liliedahl R, Finch M, Axene D, Goertz C. Cost of Care for Common Back Pain Conditions Initiated With Chiropractic Doctor vs Medical Doctor/Doctor of Osteopathy as First Physician: Experience of One Tennessee-Based General Health Insurer Journal of Manipulative and Physiological Therapeutics, October 2010.

Comment:  First, credit the chiropractic profession for responding so thoroughly. Second, the point is well made that if
chiropractic physicians are not included in ACO teams "but treat beneficiaries attributed to ACOs and achieve cost savings, it would be inappropriate to reward only those providers who are delineated within the legal structure of the ACO, rather than those providers responsible for the cost savings." No crap Sherlock!

My guess is that the ACA speaks for more than one profession in calling for a "reconsideration
of the practitioners that are needed in an ACO and to expand this list to include ... [your non-included profession here]."

Notably, the ACA also represented the non-included or limited professions similarly in its response to the NCQA:
"The limited nature of the practitioners who will be considered primary and specialty care practitioners in NCQA's definition of an ACO will seriously limit the ability to reduce per capita costs."
Note, for instance, the cost-savings in this report on the whole practice of naturopathic physicians. Given public use of chiropractors and other "CAM" practitioners, broad inclusion would seem to be required if an entity is to meet the NCQA definition of an ACO as an organization in which "providers will need to be clinically integrated and work together to seamlessly coordinate care for assigned patients."

Good for the ACA to make the case that the millions of citizens who use chiropractors [and other "CAM" practitioners] ought to be part of the seamless coordination of care. Congress would have better served the people if the "may" in the federal legislation Section 3502 (medical homes/ACOs) were incentivized toward "should."

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