With Obamacare rapidly taking shape and health care reform in the daily news, what better time to hear from John Falardeau, senior vice president for government relations, American Chiropractic Association? This interview appeared originally in its entirety in the June 2013 issue of Health Insights Today, a newsletter published by Cleveland Chiropractic College – Kansas City.
Provider Nondiscrimination Policy: A Historic Breakthrough
What's your sense at this point of the provider nondiscrimination policy in the Affordable Care Act? I know it doesn't go into effect until January 2014. What is in that policy and is it a step forward? It's a huge step forward. That's not just something I'm saying. It was said by the National Association of Chiropractic Attorneys, which is comprised of the counsels for all the chiropractic associations. They called it "historic." Not only will this apply to plans that are in the newly formed exchanges in the small group market [which open in January 2014], but it will also apply to ERISA, which at this point still regulates the plans that the majority of Americans get their health insurance from.
It's the first time that we've been able to pierce that ERISA shield. That took a lot of effort, specifically from our folks in Iowa and Connecticut, who had developed relationships over the years with Senator Harkin and Senator Chris Dodd, who was the chair of the Senate HELP committee following the death of Senator Ted Kennedy, before Senator Harkin became the chair. It took a great deal of work with our doctors in those states. They helped the senators see the problem that has been around almost as long as chiropractic has – that insurance companies have discriminated against doctors of chiropractic. So it was a huge win! There will most likely be a rule for this.
Rule-Making: Public Comments Do Matter
For people who may not be familiar with this, we should probably explain what a rule is. When you say there will be a rule, are you basically talking about an interpretation by the Department of Health and Human Services to guide insurance companies, state governments and others as to how to interpret the legislative language in the nondiscrimination section of the Affordable Care Act? Exactly. Prior to that proposed rule being drafted, it will be published as a proposed rule and the public will have 30-60 days to comment on it before they come up with a final rule.
In your experience, do the comments that people submit to the government during these comment periods sometimes actually influence the content of the final rule? I can give you a great example of that. Back in 2011 (and so much happens so quickly these days that when I talk about 2011, it feels like I'm talking about 1963), there was a proposed rule for the Medicare Accountable Care Organizations section of the Affordable Care Act. There was nothing in there about doctors of chiropractic. And when doctors of chiropractic are not mentioned, they're pretty much out.
We said, "Look, if the goal of these ACOs is to achieve cost savings, based on our evidence of cost-effectiveness, you have to ensure that doctors of chiropractic are included in this program." That was in our comments and that template was also sent to all chiropractic state associations so they could weigh in as well. So in the final rule, HHS basically said, you're right, based on the quality and cost-effectiveness of the services that doctors of chiropractic provide, they can become part of ACOs and take part in any cost-reduction incentives that the ACO attains. Basically, they told ACOs that they could hire doctors of chiropractic. That was huge.
I'm also hearing in this language a critical difference between "may" and "shall." ACOs may include DCs, but are not required to do so. In that rule, they never did that for any kind of practitioner. The ACOs are independent and the rule writers did not think it wise to dictate who and how many people they should employ. But even putting the words cost-effectiveness and quality in a federal regulation when referring to doctors of chiropractic was huge.
The Road Forward
I don't know if you feel it's helpful to make long-term predictions, but at least in terms of what you hope will happen, what kind of chiropractic legislation would you like to see Congress pass in the next 10 years? First, we're going to work to have the bills that we now have in play enacted sooner rather than later. There's a bill to commission doctors of chiropractic in the Public Health Service Commissioned Corps. I believe this has a good chance of passing in the current Congress and I would certainly like to see that happen. There's support. Right now, we're one of the only provider groups that is not included. Even the veterinarians have representation. If you're going to have veterinarians in a corps like this, you should certainly include doctors of chiropractic. We have a House bill for that and we'll soon have a Senate bill.
Another key goal is to further integrate doctors of chiropractic in the VA, as I spoke about earlier. We have both a House and a Senate version [of current legislation] for that. We think that given the evidence provided by the VA itself, that the majority of vets coming back from Afghanistan and Iraq have musculoskeletal problems. Who better to address those [problems] than doctors of chiropractic?
We're also working to gain further inclusion in TRICARE [the insurance plan for active-duty military, retirees and their dependents]. General Halstead is a perfect example, in that when she was in uniform, she had a chiropractic benefit and the day she walked out, she lost it. This may take a little longer, because TRICARE is always under the microscope. As I mentioned, the Congressional Budget Office does not consider savings that would come from including chiropractic services, only costs.
Also, we're in the midst of a multi-year clinical demonstration project within the Department of Defense, which we hope will further show that chiropractic is effective and cost-effective. It's likely that any further progress on integrating chiropractic into military health care services will have to wait until this project is done.
That clinical trial is the one funded by a $7.5 million Congressionally-directed research grant, which involves three different studies, each of which is a randomized trial. We did an interview with the lead investigator, Dr. Christine Goertz, in a recent issue of Health Insights Today where she described this project. Hopefully it will show a benefit from chiropractic care. But it will take a number of years to be completed and published. When this first was first announced, we were a little upset, because our feeling was, "How many more studies do you guys need?" But in talking to the staff of the House Armed Services Committee, this is something that they've done in many other instances [not related to chiropractic], such as with PTSD [posttraumatic stress disorder]. I also think this clinical trial is going to have effects beyond DoD because it will be the biggest clinical trial in the history of chiropractic.
So afterward, I felt better about it. It is part of the grant, and part of the law, that it include Special Forces units, who I understand are our biggest fans – SEAL teams, those folks who really go through a physical beating as a normal part of their work. We'll be embedded with those folks as well. I expect these trials to go very well, and if they do, I expect the effects to bleed over into Medicare and even private insurance.
Step by step. What can chiropractors and chiropractic students do to enhance a positive profile for the profession? We've seen greater acceptance of chiropractic among policy-makers. I believe there are other things that can further the evidence that we are in the big leagues. Two things come to mind. One is the Physician Quality Reporting System, which is a Medicare program. It basically says that if you can report quality [through filling out certain forms], and for us it's only two measures, you get a bonus. It's not much, a few hundred bucks here and there. But it shows that we do report quality, that we are equal with our brethren among the MDs and DOs; that we do participate. Currently, the participation level of doctors of chiropractic in this program is small. A lot of it has to do with the bonuses being very minimal. But this is how we exhibit our place in the system.
So, by participating in this, the individual chiropractor, beyond any small amount of money that they receive, is helping the profession as a whole and helping you to make our case in a stronger fashion. That's a great way to put it. It's how we show that we have matured, that we have ripened. And that we can play on a level playing field. Related to that is the whole electronic health records incentive program, which is another Medicare program. We're doing better in the levels of participation by doctors of chiropractic. We worked hard to be sure that doctors of chiropractic were included in the legislation and DCs can now earn up to $44,000 over a few years by going electronic. All the information about this is available on the ACA website.
When these types of programs come out, and we publicize them in ACA News and Week in Review, we want doctors to take part. I know that some people think, "This is another opportunity for the federal government to audit me," which I can understand. But it's much more than that; it's an opportunity for chiropractors to really exhibit their place in the health care delivery system.
Dr. Daniel Redwood, the interviewer, is a professor at Cleveland Chiropractic College – Kansas City. He is the editor-in-chief of Health Insights Today (www.cleveland.edu/hit), associate editor of Topics in Integrative Healthcare, and serves on the editorial board of the Journal of the American Chiropractic Association. Visit Dr. Redwood's website and health-policy blog at www.redwoodhealthspeak.com.