October is National Chiropractic Health Month, a fitting designation as on Oct. 30, 1972, President Nixon signed into law H.R. 1, the Social Security Amendments of 1972, ending three years of deliberations on what would improve the program. What the president called “landmark legislation” included the significant and far-reaching provision of defining chiropractors as “physicians” in the Medicare program under Sec. 18619(r)(5) of the Social Security Act.
Unfortunately, Centers for Medicare & Medicaid Services (CMS) regulators interpreted the law to define the physician status granted to chiropractors in a way that restricted their ability to participate meaningfully, on a level of basic parity.
The two most significant restrictions CMS imposed are:
- Limiting covered services to chiropractic manipulative therapy to the spine (CMT) provided to correct a subluxation; and
- Denying chiropractors the ability to “opt out” or privately contract with Medicare patients for the delivery of services outside of Medicare fee limitations and filing requirements.
And so, in the succeeding 45 years, ACA’s Medicare policy has been to correct these restrictions by obtaining “full physician status” for chiropractors in Medicare through supporting legislative and regulatory initiatives to achieve parity among all physician-level providers in Medicare, including the ability for chiropractors to privately contract with Medicare beneficiaries as well as to practice to the fullest extent of their licensure and education.
To bring resolution to the policy, ACA has educated congressional allies who, along with ACA’s key contacts, engaged the secretaries of Health and Human Services in previous administrations to seek relief through new regulations from CMS, whose authority enabled them to provide a substantial expansion. Regarding opt-out, Rep. Rodney Davis (R-Ill.) and Sen. Barbara Mikulski (D-Md.) have introduced legislation in recent congresses that, if enacted, would amend Medicare to allow DCs to enter into private contracts.
While these initiatives fell short of the mark, ACA’s extensive education and advocacy campaigns in support of the changes created a dialogue, preparing a pathway for our current initiative: to seek legislative relief from Congress enabling chiropractic physicians in Medicare to practice to–and be reimbursed for–the fullest extent of their licensure, training and competencies.
ACA decided to prioritize this legislative fix over opt-out for several reasons, the most important of which is the sheer immensity of Medicare’s influence on current and future delivery of care. In 2015, Medicare provided coverage for more than 55 million people and was the only source of insurance for 14 percent of the United States. With coverage projections reaching more than 90 million beneficiaries in 2050, it is vital that these millions of Medicare patients can access the full range of services chiropractors could provide them.
Medicare also influences coverage and reimbursement policies of other major federal health care programs, including those of the Veterans Health Administration and Tricare. Currently, these programs provide coverage to roughly 25 million beneficiaries and typically pay 85 percent of Medicare rates. Bettering the position of chiropractic physicians in Medicare will likely improve more than just professional standing in these programs.
Beyond federal health care delivery, the private marketplace also looks to Medicare for guidance on policy and payment. Recent research indicates that Medicare influences the valuations and expenditures on physicians’ services, with data showing on average that a $1 change in Medicare’s relative payments results in a $1.30 change in private payments.
Looking forward, recent congressional and executive quality improvement, payment, and collaborative care proposals being developed will eventually lead to health care reforms that will likely use current provider participation as a starting point in debates regarding future status such as the single-payer “Medicare for all.” While these initiatives are beyond the horizon, it is imperative that the chiropractic profession prepares for future developments.
Obviously, these are only a few of many aspects to consider while discussing such a massive, multi-faceted program such as Medicare. One final comment in favor of emphasizing full scope of practice over private contracting in the quest for physician parity is that in federal lawmaking, incrementalism generally works over sweeping reforms, and the larger the role a constituent concern plays within programs and budgets, the more likely that concern is to receive future benefit.
The chiropractic-specific translation of this dictum is that by first obtaining full scope of practice in Medicare, the profession’s increased cultural authority will lend weight to its arguments and initiatives, allowing the ACA to return to opt-out from an enhanced position, significantly increasing the likelihood of victory.
In closing, I encourage you to help the ACA in its effort to advocate for chiropractors and their patients in the Medicare program. Please visit our National Medicare Equality Petition webpage where you can learn more!
Jack Dusik is senior director of federal government relations at the American Chiropractic Association. He can be reached at [email protected].