Last August, amidst no fanfare or hoopla, an important window of opportunity opened for Medicare patients and the chiropractic profession. Hardly anyone noticed.
The opportunity was revealed when the Journal of Alternative and Complementary Medicine, a respected, peer-reviewed medical journal, published rigorously developed chiropractic best-practices guidelines for the management of chronic pain.1 A few may have noticed that these guidelines make a clear, scientifically-derived distinction between the treatment of acute pain and the management of chronic pain, an area of proven efficacy within the chiropractic healing arts. Some also may have observed that, in light of our ongoing opioid crisis, this critical distinction is in direct contradiction to the Medicare/CMS chiropractic benefits coverage policy mandating that chiropractic care is only medically necessary when treating an acute condition.
Why Does Medicare Have a Problem With Evidence-Based Guidelines?
Closer inspection of this best-practices document brings to light a number of other interesting departures by Medicare from the world of evidence-based health care when it comes to chiropractic benefits.
For example, according to the best science available, when doctors of chiropractic are helping a patient manage chronic pain, it is medically appropriate (and in the patient's best interests) that the patient be initially evaluated, and then periodically and routinely re-evaluated. Medicare denies coverage of evaluation and management services by doctors of chiropractic, effectively dis-incentivizing Medicare patients from seeking care from their DC.
Here is another example: Medicare mandates that a patient's chiropractic coverage ends when the "medically necessary" acute episode ends. Medicare dictates that any chiropractic care beyond that point is "maintenance" care and is not a covered benefit. This policy is in direct conflict with the newly published best practices, which clearly demonstrate the medical necessity for diligent, well-supervised care on an ongoing basis when managing chronic pain, not just when pain levels rise enough to seek acute care.
These guidelines also identify the well-established fact that spinal manipulative therapy, therapeutic exercise and other conservative forms of care are medically necessary for the management of chronic pain when combined as part of the patient's treatment plan. They state that doctors of chiropractic should be encouraged and allowed to provide physical medicine and other conservative modalities for their chronic pain patients if they wish to provide them with appropriate and sufficient care.
Putting Patients at Risk
While Medicare considers this type of treatment to be medically necessary (and therefore a "covered service") when performed by, for example, a physical therapist, they deny that same patient the identical care if provided by a doctor of chiropractic (who, unlike a physical therapist, has "physician status" as a Medicare provider).
Medicare's position on this not only flies in the face of recognized science; it also creates significant potential risk to Medicare patients.
A disproportionately large percentage of people with Medicare coverage suffer from chronic pain and are therefore at elevated risk of opioid addiction and subsequent death. With the publication of scientifically valid, rigorously developed best-practices guidelines for chiropractic management of chronic pain, it is now time for Medicare/CMS to recognize that its current chiropractic benefits coverage policy is not only outdated, but also harmful to the large, vulnerable and at-risk population Medicare is responsible for serving.
A Pivotal Moment
When a window of opportunity presents itself in life, it is important to consider how to take advantage of it and avoid wasting what could have become a pivotal moment. One option would be to ensure that the folks at Medicare/CMS understand that their position on chiropractic is in direct contradiction to medical science. As a result of this epiphany, they might be more inclined support our profession's efforts to overhaul Medicare chiropractic benefits and contribute to resolving the chronic pain problem that plagues our nation's elderly.
Reference
Many relevant diagnostic signs are not performed deliberately by the examiner or by the patient at the examiner’s direction. They are observed as the patient reacts to their condition. Fortin’s finger sign, Minor’s sign, and Vanzetti’s sign are three examples of this principle.
Spearheaded by burgeoning scientific and clinical research literature, psychedelics have reached a level of media coverage and popular interest that has not been seen for over half a century. By “psychedelics,” we are referring to the unique class of substances that includes psilocybin (the active compound found in so-called “magic mushrooms”), LSD, dimethyltryptamine (DMT), ayahuasca, 5-MeO-DMT, and mescaline – each of which occurs in the natural world (except for LSD, which is a semi-synthetic compound).
While working at the Lovelace Medical Center in Albuquerque, N.M., one of the primary care physicians stated that imaging every patient prior to receiving chiropractic was not medically necessary. It was at that point I reconsidered the need for the imaging of every patient to avoid malpractice.
