Are your patients opting for more expensive, riskier health care based on issues of reimbursement due to uninformed decision-makers?
As the cost of health care skyrockets, the discovery of the most effective therapeutic methods becomes a critical issue for individuals purchasing health care services. Although the accumulation of a large body of information provides evidence of conservative chiropractic treatment’s overwhelming superiority in select areas of health care, many decision-makers who regulate access to treatment by Doctors of Chiropractic remain uninformed of the potential benefits of chiropractic methods.
Patients fortunate enough to have health insurance policies covering chiropractic treatment often find that those same policies place arbitrary limits on the number of visits allowed or on the types of treatment methods provided by the chiropractor. These policies are written in a manner that limits chiropractic services by one or more of the following strategies:
- A specific dollar amount per year is allowed towards chiropractic treatment (Example: $1,000 maximum/year) or a specific dollar maximum per treatment is allowed (Example: a flat rate per day or a percentage limit of a maximum per day charge, such as 50% of up to $50 per day).
- Only charges for chiropractic manipulation are eligible. No other services provided by the chiropractor are reimbursable under the plan such as x-rays, examinations, therapy, braces, etcetera.
- A specific limited number of treatments are reimbursable under the plan contract.
- Reimbursement for manipulative treatment is confined to that performed during general anesthesia, during a cutting operation or while the patient is confined to a hospital.
There are many more strategies used to limit chiropractic treatment and some of the above are used in combination to further limit chiropractic utilization. The shortcomings of these coverage limitations are often not readily apparent; however, an attempt will be made to describe some of the associated disadvantages.
How arbitrary limits affect patients’ treatment decisions
In one of the above examples, specific maximum dollar amounts placed on chiropractic treatment are the method used to restrict treatment methods access. For example, suppose a patient with uncertain indications for surgery presents to either a chiropractor or a surgeon for treatment of a herniated lumbar intervertebral disc. Both the surgical and the conservative methods have been shown to be effective in resolving this problem.1,2,3 Typically, the surgical intervention would be reimbursable under the patient’s regular major medical coverage policy. This benefit is usually 80% coverage subject to a deductible and possibly 100% coverage after a specific maximum out-of-pocket amount is met by the patient.
A conservative estimate for the cost of the hospital charges could run in excess of $4,000 for an average stay.4 This amount does not include physicians’ charges, medications, post-surgical follow-up care and so forth, which could push the costs over the $8,000 mark. The cost for chiropractic services would likely be much lower, perhaps as much as 87% lower, as indicated by a recent cost comparison study.5 However, due to the severe maximum dollar amount limits imposed by the language of the health care contract, the patient may choose the more invasive, riskier and much costlier surgical procedure versus a chiropractic alternative.
The decision, made in the harsh light of the patients’ financial obligations, may result in the patient opting for an expensive unnecessary surgical procedure that would probably leave him or her at similar recovery levels as individuals choosing the less expensive non-surgical care.1
Another example of how arbitrary limits may affect the health care choices of patients involves the practice of restricting the number of chiropractic treatments per year. Suppose, for example, a health care policy limits the maximum treatments per year to 30 per subscriber. Let’s say in January the subscriber injures their cervical spine, requiring 22 treatment sessions to reach maximum recovery. Next suppose the same subscriber suffers another traumatic injury to their lower back, this time in July of the same year, requiring an additional 18 treatment sessions to resolve the injury. If a maximum number of allowable treatments clause is in effect, this patient will be without coverage for the final 10 treatment sessions required to rehabilitate their lower back. Again, financial burden may force the patient to choose a less effective and possibly more costly medical alternative.
This author has found arbitrary policy limits such as those described above have often resulted in patients making decisions about their care and treatment based solely on issues of reimbursement, rather than clinical effectiveness, overall cost effectiveness or the inherent risks of more invasive treatment methodologies. This is an unfortunate situation and forces a growing number of suffering patients to choose methods of medical treatment that are vastly inferior to those used by Doctors of Chiropractic.
This is an especially disappointing circumstance when one realizes a growing number of studies clearly demonstrate the superiority of chiropractic treatment versus traditional medical care in select areas of health care.5-11
It can be shown that arbitrary limits placed upon certain treatment methods may adversely affect the decision-making process of those patients’ health care choices. Furthermore, this author contends many health care policy limits imposed on chiropractic services could be due in part to residual biases against the chiropractic profession held by the insurance industry. After all, wouldn’t it seem reasonable for the insurance industry to encourage utilization of methods shown to be more effective? Especially in light of considering clinical results and cost effectiveness by more than 37 clinically controlled trials and retrospective studies.12
The contention becomes even more evident when it is known that approximately 15% of standard medical interventions have been validated by formal scientific investigation.13 What defense of these practices can be raised by our health insurance industry when arbitrary limits force purchasers and health care recipients to select forms of treatment that may be more costly, more risky and possibly unproven for their effectiveness?
Are health plans that arbitrarily limit chiropractic treatment in the best interest of anyone? Not if the goal of the American health care system is to provide the most effective treatment methods to the greatest number of individuals at the most affordable costs.
Steve Troyanovich, DC, is a 1987 cum laude graduate of Palmer College of Chiropractic. He is a certified instructor for Harrison’s Chiropractic Biophysics (CBP) Seminars, Secretary of the Board of Directors of CBP Non-profit, Inc, and maintains a full-time private practice in Normal, Illinois. Please write to Dr. Troyanovich at 101 East College, Suite B, Normal, IL 61761.
1. Weber H. Lumbar disc herniation a controlled, prospective study with ten years of observation. Spine 1983;8:131-140.
2. Saal J, Saal JS. Nonoperative treatment of herniated lumbar intervertebral disc with radiculopathy an outcome study. Spine 1989;14;431-437.
3. Nwuga V. Relative therapeutic efficacy vertebral manipulation and conventional treatment in back pain management. Am J of Physical Medicine 1982;61;273-278.
4. “Variances Recorded in Hospital Charges,” The Pantagraph, 21 Sept. 1991, Sec. A, pp. 1,4.
5. Jarvis K, Phillips R, Morris E. Cost per case comparison of back injury claims of chiropractic versus medical management for conditions with identical diagnostic codes. J Occupational Medicine 1991;33:847-852.
6. Ebrall P. Mechanical low-back pain: A comparison of medical and chiropractic management within the Victorian work care scheme. Chiro J of Australia 1992;22:47-53.
7. Mead T, et al. Low back pain of mechanical origin: Randomised comparison of chiropractic and hospital outpatient treatment. British Med J 1990;300:1431-1437.
8. Beregmann B, Chicoke A. Cost-effectiveness of medical vs. chiropractic treatment of low back injuries. J Manipulative Physiological Therapeutics 1980;3:143-147.
9. Leavitt S, Johnston T, Beyer R. The process of recovery: Patterns in industrial back injury. Part 1. Costs and other quantitative measures of effort. Ind Med 1971;40:7-14.
10.Wolf C. Industrial back injury. Int Rev Chiro 1974;26:6-7.
11.Wolk S. An analysis of Florida worker’s compensation medical claims for back-related injuries. J Am Chiro Assoc 1974;25:50-59.
12.Shekelle P, Adams A, et al. The appropriateness of spinal manipulation for low-back pain: Project overview and literature review (R-4025/1-CCR/FCER). Santa Monica, RAND, 1991b.
13.Smith R. Where is the wisdom: The poverty of medical evidence. British Med J 1991;303:798-799.
Insurance Carriers Find Other Means to Limit Chiropractic Benefits
In the State of Illinois, where I practice, chiropractic is defined as “the treatment of human ailments without the use of drugs or surgery.” This is perhaps the most liberal chiropractic scope of practice law in the nation. As such, I choose not to use the diagnosis of subluxation except in Medicare cases. This practice is due to several factors. First, subluxations are listed as “non-allopathic lesions” in the ICD code books. This automatically tells any insurance carrier there is something “different” about your practice and your patient’s case… Another reason to avoid the use of the diagnosis of subluxation is that in spite of state insurance equality legislation designed to protect insured clients against unfair discrimination against certain classes of providers, insurance carriers are finding other means to limit chiropractic benefits…
Some DCs would state that by not utilizing the diagnosis of subluxation, the result is that we would be abandoning the principles that make the profession of chiropractic “separate and distinct” from the other health care professions. To these individual DCs, I can only say that you have a primary responsibility to protect the health interests of your patients. If one of the barriers to receiving the proper, necessary chiropractic care that they deserve is a clause in their health care contract that attempts to exclude or limit chiropractic services, it is your sworn duty to insure they receive the necessary care they deserve and need.
Once again, let me remind the reader that when it comes to participation in the third party pay system, you are attempting to “play ball” in their “ball park…” As such, if you wish to be reimbursed by your patient’s insurance carrier, I would recommend reserving your chiropractic philosophy for your patient education class.