August 2003

see also: ACA Medicare bill draws criticism from Washington Post, White House

Two paths to Medicare reform

Two different efforts are under way in Congress to help eliminate problems inherent in the Medicare system.

HR 2560, the aptly named "Chiropractic Medicare Freedom and Benefit Protection Act," has won support from the International Chiropractors Association (ICA), the World Chiropractic Alliance (WCA), and the Federation of Straight Chiropractors and Organizations (FSCO) -- who, working together as equal partners, make up the Chiropractic Coalition. If passed, this bill would set up a separate category for doctors of chiropractic, making chiropractic services uniquely theirs. No longer would an M.D., D.O., or physical therapist be able to provide or receive reimbursement for subluxation correction services.

HR 2560 was introduced into the House by staunch chiropractic supporter Rep. Donald Manzullo, who said the bill will "not only reshape the definition of chiropractic in federal policy...it will blow the lid off the definition of chiropractic in federal policy... We will make it clear once and for all that chiropractic is equal, but unique."

The bill specifically states that its purpose is "to clarify the scope of chiropractic services that may be furnished under the Medicare Program and that chiropractors are the only health care professionals qualified under that program to furnish those services" (emphasis added).

The bill also adds a provision to the Medicare code that states that the term "chiropractic services" means "clinically necessary care by means of adjustment of the spine (to correct a subluxation) performed by a chiropractor legally authorized to perform such adjustment by the State or jurisdiction in which such care is provided."

This wording was carefully chosen to ensure that the bill protected a D.C.'s right to correct subluxation, and to perform services as specified by his or her state statutes. To avoid the use of the "medically necessary" criteria, the bill further states that services are considered "clinically necessary, "when examination by a chiropractor demonstrates objective evidence of a subluxation." The bill, therefore, gives D.C.s -- and only D.C.s -- the authority to determine when chiropractic care is needed.

The bill also states that such examination may include physical examination, radiological examination, and "specialized diagnostic instruments used in the practice of chiropractic." This provision will be used to obtain Medicare reimbursement for a broad range of examination services, including x‑rays.

The presidents of all three Coalition organizations have endorsed HR 2560 and are encouraging all chiropractors, students and chiropractic patients to contact their legislators and ask them to support the bill.

Ron Henrickson, ICA Executive Director, said all doctors should welcome this bill and not be misled by rumors that it could limit a chiropractor's ability to bill for evaluation and management codes.

"Medicare is a limited reimbursement program only and HR 2560 would have no impact at all on chiropractic scope of practice, ability to bill for evaluation and management codes, or the status of the D.C. as a doctor-level professional," he explained. "The notion that HR 2560 denies the chiropractor 'physician status' is a false notion as only state laws govern such issues. Medicare law only deals with what D.C.s are paid for under this one program. Presently, the only reimbursable Medicare service is subluxation correction. HR 2560 would significantly expand the list of chiropractic services recognized by the Medicare program."

Also making its way through Congress is American Chiropractic Association (ACA)‑endorsed legislation that would establish a prescription drug benefit in the Medicare program. The Senate version of the bill (S.1) contains a provision (Section 441) that would establish a pilot program allowing selected doctors of chiropractic to be reimbursed for all covered Medicare services that are within their state scope of practice.

The pilot program would be carried out in six locations and would focus on determining if chiropractic could reduce health care costs. According to the ACA, the program would have to show positive results for Congress to enact permanent legislation providing for "full scope" chiropractic inclusion in Medicare on a nationwide basis.

At press time, the House version of the Medicare bill (HR 1) did not contain a similar chiropractic provision and such an omission could doom the bill's ultimate passage. The ACA has launched its own grassroots letter‑writing campaign to win support for the bill.

Although the Chiropractic Coalition has not opposed the S‑1 plan, its members are united in their efforts to focus on HR 2560.

Clarification

The bills have caused some confusion within the profession. Christopher Kent, D.C., a member of the WCA Board of Directors and president of the Council on Chiropractic Practice, clarified the differences in a comparison of the two bills.

"The American Chiropractic Association proposal, S1, would provide for a limited demonstration project, where at a handful of selected sites, D.C.s would be permitted to bill Medicare for anything within their state scope of practice," Dr. Kent explained. "It would not affect most D.C.s." He added that he believes the ACA hopes to expand the program in the future.

"In contrast, HR 2560 seeks to rectify the errors made in the original Medicare statute including chiropractic care," Kent continued. "A significant error in this legislation was classifying D.C.s as limited scope 'physicians.' Thus, the chiropractic benefit was characterized as a 'physician service,' permitting M.D.s and D.O.s to provide what is purportedly a 'chiropractic' benefit."

Medicare originally required doctors to take X‑rays to determine the existence of a subluxation (although this service was not reimbursable). While this requirement has been removed, a limitation was added restricting chiropractic services to persons with "neuromusculoskeletal disorders." Kent noted that, "This has been interpreted to mean that care is restricted to persons with pain or similar symptoms."

HR 2560 would correct this problem since it provides that chiropractic care is indicated when there is objective evidence of subluxation, removing the requirement that a patient have pain or another musculoskeletal symptom. "In contrast to S1, HR 2560 does not seek to expand chiropractic practice to include a duplication of services already offered by other providers," Kent stressed.

WCA President Terry A. Rondberg, D.C., made it clear that there is no "competition" between the bills and that the different approaches should not be cause for any divisiveness in the profession.

"The Coalition members, including the WCA, ICA and FSCO, have reviewed both approaches and, although we feel HR 2560 is our best chance of achieving true chiropractic parity and protecting the unique characteristics of chiropractic, we are not actively opposing the ACA in its bid to pass S‑1. Such an action would violate the Coalition's firm stance on intra‑professional cooperation and would undermine chiropractic in Congress. We trust that the ACA will likewise refrain from taking any action that could interfere with the Coalition's efforts."

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NOTE: The Chiropractic Coalition, founded in November 2002 by three major chiropractic organizations -- the International Chiropractors Association (ICA), the World Chiropractic Alliance (WCA), and the Federation of Straight Chiropractors and Organizations (FSCO) -- brings together diverse subluxation‑based chiropractic organizations working in the best interest of the public and the profession.

Organizations currently affiliated with the Coalition include: The Australian World Chiropractic Alliance, The Chiropractic Association of Ireland, Chiropractic Awareness Council of Ontario, Chiropractic Fellowship of Pennsylvania, Colorado Chiropractic Wellness Alliance, Florida Chiropractic Society, Israel Doctors of Chiropractic, Michigan Chiropractic Association, Oregon Doctors of Chiropractic, Palmetto State Chiropractic Association, The Peruvian Chiropractic Association and the Santa Clara District of the California Chiropractic Association.

For more information on the Coalition and HR 2560, visit http://www.chiropracticcoalition.org.