Mainstreaming Chiropractic: The Miserable Medicare Model

By Michael Schneider, DC, PhD, Donald Murphy, DC, DACAN and Gary Ierna, DC, DABCR

As the 21st century unfolds and the chiropractic profession tries to expand its role in the mainstream health care system, the Medicare Model continues to hang around our collective necks like an albatross of failure. For the past 30 years, the Medicare model has boxed chiropractors into a small corner of the health care marketplace by limiting payment to the treatment of spinal subluxation by manual manipulation. No other diagnostic or therapeutic services provided by a chiropractor or under his or her order are covered by Medicare.

We can not receive reimbursement for Evaluation and Management (E & M) services for initial or follow-up examinations, nor can we receive reimbursement for rehabilitative exercise, soft-tissue therapy, extremity manipulation, traction or any other physiotherapy modalities. We are unable to order or interpret diagnostic tests such as X-ray, MRI, or CT scans, and have the costs of these services covered under Medicare. Finally, we are not allowed to order procedures such as epidural steroid injections or facet and sacroiliac joint blocks. These limitations severely hamper our ability to manage patients.

Although we like to think of ourselves as "doctors" of chiropractic, Medicare relegates us to the role of "subluxation technician." Of great concern is the fact that the miserable Medicare model is used to drive the benefits of all HMO and PPO Medicare policies, and may eventually be used by other managed care carriers as a template to define the chiropractic benefit in non-Medicare plans. There are several reasons it is critical that the chiropractic profession expand the scope of Medicare coverage beyond the narrow confines of a subluxation-correcting technician.

First, by refusing to cover any E & M services provided by a chiropractor, Medicare is effectively stating that chiropractors do not possess the right to perform differential diagnosis. In elderly patients, the need for comprehensive case history and physical examination is critical, as these patients often have comorbid medical conditions that require careful evaluation. This necessitates additional time and energy in the initial evaluation.

However, we cannot get appropriately reimbursed by Medicare for our expertise. This allows third-party payors to potentially use the Medicare model to justify the elimination of benefits for E & M services by using a rather straightforward explanation: "If the Federal Government (Medicare) does not recognize chiropractors' right to diagnose and evaluate patients, why should we?"

The denial of E & M services by Medicare eliminates coverage for many instances in which the chiropractor needs to provide a separate and distinct service from spinal manipulation. It effectively stops chiropractors from acting as physicians or clinical "managers" in certain important situations. Such situations include a patient who is considering spinal surgery for advanced stenosis and wants a chiropractic second opinion; a patient who has slipped and fallen on the stairs and now presents with constant back pain; or a patient who has lost weight for no apparent reason, looks severely ill, and has not seen any other doctor for several years and seeks chiropractic care.

Should chiropractors be expected to only provide manipulation to these patients without performing differential diagnosis and clinical evaluation services? Should chiropractic physicians spend their time, utilize their expertise, and expose themselves to inherent risk in properly evaluating the patient, including ordering special tests and possibly coordinating specialist referral, without getting paid? Our role as physician requires us to be able to take the appropriate time to examine and discuss treatment and diagnostic options with these patients.

Second, the Medicare model sets a dangerous precedent by the excluding coverage for physical medicine services such as rehabilitative exercise, extremity manipulation, manual soft-tissue therapy, and physiotherapy modalities. Again, the chiropractor is relegated to the position of a subluxation-correcting technician. Many chiropractors have available to them a wide variety of manual, mechanical and exercise-based approaches beyond traditional joint manipulation. Many also have been trained to address extremity problems. Do senior citizens deserve to receive effective conservative treatment for these extremity complaints? Would they not benefit from myofascial release techniques and stretching applied to their muscles? Should they have the benefit of therapeutic exercises and spinal stabilization techniques to prevent recurrence of pain? Do elderly patients deserve the full breadth of methods that may be beneficial to them, and that chiropractic physicians are capable of providing?

The Medicare model, by limiting us to manual manipulation of the spine, promotes inappropriate treatment strategies. It limits the potential benefits patients can receive from the comprehensive eclectic approach that we have to offer.

Last but not least, because the Medicare model constrains the chiropractic profession to one service only, manual manipulation of subluxation, which places us in the precarious position of having all of our eggs in one basket. This means if budget cuts or other economic issues drive the health care system to contain costs, our service could be eliminated in one fell swoop of the legislative pen. Ask the chiropractors in Ontario, Canada, what it feels like to have your one and only service eliminated overnight.

If the literature fails to demonstrate a reliable way for chiropractors to identify the elusive "subluxation," will we be legislated out of Medicare and other insurance plans? In Pennsylvania, certain Blue Cross plans allow employers who purchase group health insurance to eliminate the "manipulation benefit" while retaining the""physical therapy benefit," in an apparent effort to reduce the monthly cost of premiums for their employees.

The Medicare model highlights and exposes the chiropractic profession's Achilles heel: our traditional undivided attention on spinal manipulation as the sole domain of our clinical skill. We have traditionally focused on spinal subluxation and manipulation as our solitary gift to the health care marketplace, when in fact, our greatest asset is the ability to act as neuromusculoskeletal (NMS) specialists. The health care system is crying out for a NMS specialist who can evaluate and differentially diagnose the wide array of physical conditions that are amenable to conservative treatment methods, and to differentiate these conditions from those that require more aggressive treatments. Primary care physicians are not adequately prepared or trained to evaluate and manage NMS conditions, and the need for such a NMS specialist will become increasingly more important as the baby boom generation soon enters the Medicare market.

Of course, if the profession expects Medicare to change its policies related to chiropractic care, we must live up to the expectations that we would be creating. That is, chiropractors would have to be able to function within the new Medicare model as full physicians, capable of handling difficult diagnostic situations and providing evidence-based, patient-centered, and broad-scope care. We have to demonstrate to policy-makers that we are experts in the diagnosis and management of patients with NMS problems, and not just subluxation technicians. The extent to which we can back up the image of physicians who have a high degree of diagnostic, treatment and patient-management expertise, and who can be reliable and trustworthy in their application, is the extent to which we will be successful in bringing about Medicare reform.

If chiropractic is to flourish as a viable health care option for the largest influx of Medicare patients the country has ever seen, the Miserable Medicare Model must change. Fortunately, there is some hope on the horizon for such a change, as Senator Chuck Grassley (R-IA) and other members of Congress have supported an expanded role for chiropractic care in the Medicare system by sponsoring a pilot program that allows for a select number of chiropractors to provide the full range of services they are authorized to provide under state scope of practice laws. This would include E & M services, extremity manipulation, manual soft-tissue therapy, X-ray services, and physiotherapy modalities.

This pilot program is called the Medicare Chiropractic Demonstration Project** and was included in the Medicare Modernization Act of 2003 by Congress, as a result of heavy lobbying efforts by the American Chiropractic Association (ACA). The program was implemented in April 2005, and will continue for a period of two years, during which time the Centers for Medicare and Medicaid Services (CMS) will collect data on the utilization and billing practices of the selected chiropractors involved in the pilot program. At the end of the two-year pilot period, CMS will analyze the recorded data and prepare a report for Congress that will hopefully include recommendations for making permanent this expansion of chiropractic Medicare benefits. We can only hope that our colleagues in this program practice good ethical judgment and provide evidence-based, patient-centered, and broad-scope care. The rest of the profession is counting on it.

A successful outcome of this pilot program is crucial for the survival of the chiropractic profession, for the reasons previously cited in this article. An expansion of the Medicare chiropractic benefit would likely create a trickle-down effect to other managed care health plans that look to Medicare as a role model for creation of their own benefit structure. It would greatly improve the bottom line economic picture of the average chiropractic practice that is presently limited to billing for manipulation services. It would solidify the position of the chiropractor as a physician and not a technician, and help to mainstream our profession. And, if it leads to expanded involvement of chiropractic physicians in the treatment of Medicare recipients, it may well lead to improved quality and cost-effectiveness of care for patients with NMS disorders. That part will be up to us.

Chiropractic simply must win the important battle for expansion of our practice rights under the Medicare model. Our very future depends on it.

Michael Schneider, DC, PhD (c)
Donald R. Murphy, DC, DACAN
Gary Ierna, DC, DABCR

**Editor's note: Dynamic Chiropractic has reported on the Centers for Medicare & Medicaid Services (CMS) Chiropractic Demonstration Project in several previous issues. For more information, please read the following articles online:
  1. CMS announces four-state chiropractic demonstration project. Dynamic Chiropractic, Dec. 16, 2004:
  2. New chiropractic demonstration project gets an adjustment: one state, 19 counties added to list of test sites. Dynamic Chiropractic, Jan. 15, 2005:
  3. Details of CMS demonstration project revealed. Dynamic Chiropractic, April 9, 2005:

Dr. Michael Schneider is a 1982 graduate of Palmer College of Chiropractic and has been in private practice for 30 years. He obtained a PhD in rehabilitation science from the University of Pittsburgh in 2008, where he now works full-time as an assistant professor in the School of Health and Rehabilitation Sciences. Dr. Schneider is a founding member of the West Hartford Group, a chiropractic think-tank devoted to advancing the identity of chiropractors as primary spine care physicians.

Dr. Donald R. Murphy graduated from New York Chiropractic College in 1988 and thereafter obtained three years of postgraduate education in neurology. He is the clinical director of the Rhode Island Spine Center in Pawtucket, R.I., as well as clinical assistant professor at the Alpert Medical School of Brown University. He maintains a busy primary spine care practice and lectures worldwide on various topics related to spinal disorders. Dr. Murphy also serves as president of the West Hartford Group.

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