United Healthcare (UHC) recently issued a special bulletin (Network Bulletin Volume 21, September 2007) terminating reimbursement for chiropractic services for certain populations and conditions.
The bulletin states, "United Healthcare had previously concluded that certain services provided as a part of chiropractic care were unproven. A recent review of the clinical evidence in published peer-reviewed medical literature leads us to further conclude that chiropractic services for treatment of children and adolescents is unproven and services for treatment of headaches is unproven."
Chiropractic Organizations Unite
The UHC policy has evoked vehement opposition from the entire chiropractic community.
The Council on Chiropractic Guidelines and Practice Parameters (CCGPP), American Chiropractic Association (ACA), International Chiropractors Association (ICA), Association of Chiropractic Colleges (ACC), Congress of Chiropractic State Associations (COCSA) and the Foundation for Chiropractic Education and Research (FCER) have banded together in a joint letter to UHC. The letter states:
"Attached is an analysis which demonstrates that the above policy is not only flawed but more importantly, poses a threat to the health of children, adolescents and those individuals suffering with headache pain who may be insured or otherwise covered under United Healthcare programs and policies. We view your recent policy determination to be a material denial of essential benefits and coverage paid for by employers and other insureds. The broad stroke elimination of these important benefits is, in our view, not only unconscionable but is an abrogation of the promises made to cover chiropractic services to employees, individuals and their dependants.
"We note that none of our organizations were contacted or consulted in connection with your drastic and unprecedented denial of benefits to adolescents, children and those suffering with headache pain. In our opinion, this raises serious questions as to your intentions and we question whether your motivation for the bottom line outweighs your responsibility to provide coverage for appropriate and needed healthcare services."
Arguments Against the UHC Policy
The various organizations in the joint letter contend that chiropractors are uniquely qualified to address all types of childhood and adolescent ailments. The CCGPP issued a separate statement asserting, "Chiropractic physicians are primary care physicians/portal of entry physicians recognized by statute at both federal and state levels" and that treatment of children, adolescents and headache patients have been established as within the scope of chiropractic for many years.
Further, the CCGPP stated, "Chiropractic physicians clearly possess more education and clinical skills in the area of musculoskeletal diagnosis and treatment compared to general allopaths and physical therapists. If this policy is permitted, young patients and those suffering will have nowhere to turn except to general medicine." The ACA Council on Chiropractic Pediatrics agrees, pointing out, "All chiropractors are trained in pediatrics during their doctoral education. Chiropractors may also further their pediatrics training through post-doctoral programs and receive board certification in chiropractic pediatrics."
Another major criticism of the policy is that it is unclear whether "chiropractic services" includes services in addition to spinal manipulation, such as active and passive therapeutic modalities, evaluation and management services, instruction on lifestyle modifications, diet and exercise, posture and nutritional advice, and so on. The bulletin does not specify whether these aspects of "chiropractic services" are reimbursable.
The chiropractic organizations also have attacked the UHC policy because the standards do not appear to apply equally across all health care professions. The CCGPP asks, "What evidence does UHC have in its possession indicating that the spines of children and adolescents respond any differently to spinal manipulation and numerous other passive and active interventions used not only by chiropractic physicians, but medical and osteopathic physicians and physical therapists?" Medical treatments on children of any kind are not supported by significant literature, and yet it's unclear whether UHC is denying payment to medical and osteopathic physicians and physical therapists as well as chiropractors. According to the ACA, "It would appear that UHC is applying a separate and more stringent standard to chiropractors than to other providers. ... It is unethical to deny services from one provider licensed to provide such a service, while covering those same services when delivered by another provider."
The hope is that UHC will release the literature in support of its decision for review by the various chiropractic organizations. In its response to the bulletin, the ACA asked for a further explanation of UHC's criteria in developing its health policies, as well as citations backing its findings. The ACA also argued that the effective date of the policy is ambiguous and that UHC issued two contradictory bulletins: one apparently terminates reimbursement for children and adolescents strictly for the treatment of headaches, while the other is much broader, indicating that no chiropractic services for any children or adolescent patients will be covered.
The profession also hopes that, faced with staunch opposition from the chiropractic community, UHC will rescind the policy and agree to provide full coverage to families who wish to choose a chiropractor to provide health care services for their children. The joint letter of the chiropractic associations concludes, "We would therefore request the immediate rescission of the above-referenced policy. We offer our assistance to provide whatever input your organization may need to craft policies that are reflective of health needs of chiropractic patients under your programs. We intend to inform our patients, state and federal regulatory authorities, members of the various state legislatures, members of Congress and the public of what we view as your inappropriate and reckless action in the denial of needed healthcare benefits to adolescents, children and those suffering with headache pain under your program."
"We stand ready to engage in constructive dialog on these matters, but the first step in the process must be the immediate rescission of the policy contained in the above-referenced network bulletin." Watch for further action on this policy in the coming months.