June 2008

Insurance: Wag the dog?

by Dr. Christopher Kent

The last 35 years have seen radical changes in chiropractic education and research. A growing number of chiropractic educators and researchers actively eschew traditional chiropractic philosophy. Modern students of chiropractic are often taught that chiropractic is a subset of medicine, specializing in the manipulative treatment of a narrowly defined array of spinal pain syndromes. Standards of care, insurance reimbursement guidelines, and state board policies are beginning to reflect this paradigm.

The 1970s saw events which radically altered the direction of the profession. Chiropractors successfully lobbied for the passage of "insurance equality" laws. These laws mandated payment for chiropractic services by PIP, major medical, and Worker's Compensation carriers. Limited Medicare coverage was also obtained. Chiropractors were encouraged to bill only for musculoskeletal conditions by a new species -- the practice management consultant.

"You want to get paid, don't you?" was the battle cry. Just bill for sprains, strains, back pain and whiplash injuries. You can make lots of money. If you start talking about infections and visceral disorders, you won't get paid." Almost all DCs heeded the consultants' advice. The result? Millions of insurance claim forms providing data suggesting that DCs are practitioners specializing in the symptomatic treatment of a narrow range of musculoskeletal disorders.

Carried to its extreme, "insurance driven care" began to emerge. Some practice management consultants encouraged DCs to determine the amount an insurance program would pay prior to initiating care. Some DCs began to base their care recommendations on the insurance coverage of the patient. If a patient's insurance would pay for 30 visits, the patient would require 30 visits. A 20‑visit limit meant the patient would get 20 visits. If physical therapy was covered, patients got it. If not, it was omitted. When coverage was exhausted for a given condition, a new diagnosis was generated to "reset" the limits, and the process was repeated.

However, such abuses by a handful of practitioners were not the most pernicious aspect of the plethora of DCs developing insurance‑dependent practices. Most policies pay only for the treatment of a specific condition. Insurance generally does not cover preventive, maintenance, or wellness care. There is no CPT code for the chiropractic adjustment -- only Chiropractic Manipulative Therapy. Today, insurance will typically pay chiropractors only to diagnose and treat a narrow range of NMS conditions using physical medicine procedures. Thus, the very essence of chiropractic's unique perspective on health care -- correction of vertebral subluxations to maximize human potential -- was compromised. Insurance doesn't pay for that, so many DCs told insurers what they wanted to hear. Some altruistic practitioners compromised themselves by manufacturing musculoskeletal diagnoses so that their patients could "get the care they needed."

Things are getting worse as third party payers are continuing to limit chiropractic care. As we move forward, the fundamental issues are simple. Are we a profession with a clearly defined mission, or are we a profession simply seeking any niche which offers access to a tiny sliver of the health care pie? Are we driven by principles or politics? Is our political position defined by our mission statement, or do we grovel to get whatever crumbs the insurance industry tosses our way? Do we have an identity defined by our purpose, or are we chameleons who change our colors to blend into the existing environment?

(Dr. Christopher Kent, president of the Council on Chiropractic Practice, is a 1973 graduate of Palmer College of Chiropractic. The WCA's "Chiropractic Researcher of the Year" in 1994, and recipient of that honor from the ICA in 1991, he was also named ICA "Chiropractor of the Year" in 1998. He is director of research and a co‑founder of Chiropractic Leadership Alliance. An attorney as well as a chiropractor, Dr. Kent is a member of the California bar. With Dr. Patrick Gentempo, Jr., Dr. Kent produces a monthly audio series, "On Purpose," covering current events in science, politics and philosophy of vital interest to the practicing chiropractor. For subscription information call 800-892-6463.)