The American Chiropractic Association (ACA) and other chiropractic industry groups are promoting the “Chiropractic Medicare Modernization Act of 2019” (H.R. 3654), now pending in the U.S. House of Representatives, which would expand government-funded Medicare coverage of chiropractors’ services beyond “manual manipulation of the spine.” According to the ACA, which had a heavy hand in its drafting, the bill would mean Medicare coverage for chiropractic’s “broad-based, non-drug approach to pain management” including spinal and extremity manipulation, evaluation and management services, diagnostic imaging and “utilization of other non-drug approaches” to prevent opioid abuse.
The bill accomplishes this, per the ACA, by “appropriately defining” a Doctor of Chiropractic as a “physician” in the Medicare program and providing patients
access to all Medicare-covered benefits allowable under a chiropractor’s state license.
On reading the ACA’s description, one could be forgiven for thinking that a chiropractor’s scope of practice under state law is limited to treatment of pain, primarily via use of manual manipulation, and that this bill would simply allow patients to access additional means of pain management and attendant services, such as evaluation and diagnostic imaging. After all, a majority of the public sees chiropractors as “back doctors”.
This assumption is reinforced by Congressional “findings” contained in the bill itself, stating that the H.R. 3654 would bring Medicare coverage “more in line” with that of the Veteran’s Administration, Department of Defense (also here), federal employee coverage, and private health insurance. When these cover chiropractic services at all, it is limited to treatment of musculoskeletal issues, primarily pain.
But as the ACA damn well knows, chiropractic scope of practice under state law goes far beyond diagnosis and treatment of musculoskeletal issues and manual therapy. In fact, the ACA aggressively promotes the notion that chiropractors are fully capable of acting as your primary care physician under current state laws, a topic we’ve covered extensively on SBM: “The DC as PCP” (posts listed here).
Medicare and chiropractors: a contentious history
By way of background, let’s take a brief look at Medicare and how it covers chiropractic services, as opposed to that of MDs and DOs, a sore subject among chiropractors and the genesis of H.R. 3654.
In the U.S., Medicare (Part B) covers people 65 years and older for “medically necessary” services and “preventive services”. “Medically necessary” services are broadly defined as “services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice”. “Preventive services” are “health care to prevent an illness (like the flu) or detect it at an early stage, when treatment is most likely to work best.” This includes a yearly “wellness visit” to create a “personalized prevention plan” designed to help prevent disease and disability, as well as many other preventive and screening services, such as tobacco and alcohol abuse screening, obesity education, nutritional counseling, colonoscopies, mammograms, bone mass measurements, PAP smears, and so on. (Hospital services are covered under Part A.)
For MDs and DOs, Medicare will pay for any covered service. Coverage for chiropractic services is limited, however,
only to treatment by means of manual manipulation of the spine to correct a subluxation.
This translates into just 3 of the 15,000 procedure codes used to bill Medicare. Chiropractors don’t like this, hence they want “parity” with MD and DO physicians and the ability to bill Medicare for any service that is within their expansive scope of practice, the ACA’s top regulatory and legislative priority.
[The ACA’s promotion of H.R. 3654 doesn’t mention the “subluxation” part, presumably because they are well aware that subluxations don’t exist and don’t want to open that whole can of worms by having to explain (1) why they haven’t pointed this fact out to Congress and (2) why HR 3654 permits continued Medicare coverage of the “correction” of a fictional pathology.]
Congress authorized limited Medicare coverage of chiropractic services in the early 1970s over objections of the Department of Health, Education and Welfare, as it was then called. Regulations further limit coverage to neuromusculoskeletal conditions for which manipulation is an appropriate treatment. Since inception, chiropractors and the Department of Health and Human Services, whose Centers for Medicare and Medicaid Services (CMS) administers the Medicare program, have been locked in a near-continuous battle over claims submitted for “maintenance care”,
a treatment plan that seeks to prevent disease, promote health, and prolong and enhance the quality of life; or therapy that is performed to maintain or prevent deterioration of a chronic condition.
This so-called “maintenance care” (sometimes called “wellness care”) basically consists of regular “spinal checkups” for the detection and correction of (fictional) “subluxations”, advertised by chiropractors as necessary to prevent health problems. There is no evidence that maintenance care is effective for this or anything else and it is not covered by Medicare, which hasn’t stopped chiropractors from submitted hundreds of millions of dollars in unauthorized claims. They are also notorious, as detailed in several HHS Office of the Inspector General reports, for failing to adequately document their Medicare claims.
This ongoing conflict is the reason H.R. 3654 contains a provision requiring chiropractors to take a course on documentation. [The ACA conveniently omits the substantial history behind the documentation requirement in its discussion of the bill.] Oddly, the documentation requirement does not apply if the chiropractor is seeking Medicare payment for “manual manipulation of the spine to correct a subluxation”, the very portal through which they are being paid millions of dollars for unauthorized treatment. Go figure.
As the ACA explains, H.R. 3654 won’t add new services, “it only allows access to all Medicare-covered services that DCs are licensed to provide”. Of course, the unspoken corollary here is that each dollar that goes into a chiropractor’s pocket is a dollar of Medicare’s $702 billion in benefit payments (2017) that is not going into an MD’s, DO’s, or allied health professional’s pocket for the same service. Hopefully, this means they’ll fight this bill tooth and nail.
The DC as PCP (again!)
With this in mind, let’s take a look at what chiropractors claim they are capable of, and authorized to do, under state law. This is what chiropractic organizations had to say on the subject in “The Chiropractic Profession and Primary Care,” part of a white paper put out by an group of alternative medicine practitioners touting “the potential contributions of chiropractors . . . as providers of primary care.” Here’s how I summarized their position in a previous post:
The chiropractors claim, right off the bat, that they are primary care physicians. This is based on the Council on Chiropractic Education, the American Chiropractic Association, International Chiropractors’ Association and other chiropractic organizations saying that they are. The authors say that chiropractors can practice as a first-contact provider for patients of all ages and genders, assess a patient’s health status, formulate a clinical diagnosis, develop a case management plan that includes treatment, prognosis, and any necessary referrals. They can (according to the ACA) address “a large majority of personal health care needs.” The ICA says that the chiropractor can “provide all three levels of primary care interventions and therefore is a primary care provider, as are MDs and DOs.” The authors further claim that chiropractors “are trained to appropriately diagnose and manage the majority of healthcare issues that may present to their offices.”
The ACA has gone so far as to establish the ersatz specialty of “chiropractic internist,” billing it as “the only natural primary care doctors that are licensed in all 50 states”. One can become a “chiropractic internist” after a series of weekend classes in hotel conference rooms, taught by other chiropractors and containing little to no clinical training, and taking a test that, as far as I can tell, no one but chiropractors has evaluated, or even seen. Perhaps realizing the obviously oxymoronic character of the term “chiropractic internist”, the ACA is now pushing the more nebulous term “ACA internist.”
According to the ACA Council on Diagnosis and Internal Disorders, in answer to its rhetorical question: “Can a Chiropractic Internist treat anything a medical doctor can?”
The simple answer is YES! Chiropractic Internists use the same diagnostic tests commonly utilized by other medical professionals. . . . While it is true that the scope of practice varies from state to state, Chiropractic Internists practice in most states of the US as primary care practitioners helping people with a wide breadth of conditions and diseases.
The list might include things like eczema, thyroid problems, diabetes, parasitic infections, cold sores, Irritable Bowel Syndrome, heartburn/reflux, autoimmune diseases (like lupus, or rheumatoid arthritis, or Crohn’s Disease), infertility, constipation, and vast amount [sic] of other diseases.
Many illnesses that modern medicine has no cure for can be treated by ACA Internists with much success. Illnesses such as fibromyalgia, Crohn’s disease, IBS, migraine headaches, Lyme disease, heart disease, thyroid disease, infertility, low testosterone and diabetes can be greatly improved and often completely resolved with natural therapies offered by these natural physicians.
Of course, there is not one whit of proof offered for these statements.
According to the ACA, chiropractic/ACA internists are also
trained and licensed to draw blood, . . . [and] order saliva, urine, and stool tests . . . And since Chiropractic Internists are the natural version of a Medical General Practitioner, you’ll find they are trained to order and read a wide variety of tests (e.g., abdominal ultrasound, EKG, breathing tests, MRIs, CT scans, etc.)
The breadth of state chiropractic scope of practice was exposed in a 2014 chiropractic journal article based on a survey of chiropractic regulatory officials. The survey reported that chiropractors are authorized by state law and regulations to order or perform a stunning variety of diagnostic and therapeutic procedures. Here’s a partial list, with the percentage of states including the listed practice in parentheses:
Barium studies (74), cholecystography (X-ray visualization of gallbladder after administration of radiopaque substance) (80), thermography (95), electrocardiography (88), venipuncture (98), blood analysis (100), urinalysis (98), sputum analysis (95), fecal analysis (95), semen analysis (84), throat swab (92), skin scrape (92), school physicals (86), US DOT physicals (98), pre-employment physicals (95), pre-marital physicals (77), sign birth certificates (38), sign death certificates (50), EENT exam (90), abdominal exam (95), stethoscopic exam (98), sphygmomanometry (blood pressure) (95), bi-manual pelvic exam (73), speculum exam (72), recto-vaginal exam (72), Pap smears (79), female breast exam (80), rectal exam (85), male genital exam (85), prostatic exam (digital) (85), hernia exam (85), ultrasound (treatment) (100), IFC (interferential therapy) (100), microcurrent therapy (100), iontophoresis (not with prescription medication) (100), Russian stimulation (100), non-ablative laser therapy, nonadjustive treatment of female pelvic conditions (72), ear irrigation (83), TMJ (100), oral chelation therapy (76), IV chelation therapy (39), vitamin injection (43), limited prescription privileges (7), oxygen therapy (57), dry needling of trigger points (64), minor surgery (9), obstetrics (22), extremity casting sprains (71), extremity casting uncomplicated fractures (58), hypnosis (66), electrolysis (44), hyperbaric chamber (62), manipulation under anesthesia (71).
Lest you be misled into thinking chiropractic scope of practice indicates actual competency in this expansive array of diagnostic methods and treatments, it does not. As is true with H.R. 3654, chiropractors have had a heavy hand in drafting their state licensing laws. While the scope of this article does not permit a deep dive into the murky waters of chiropractic education and training, suffice it to say that the whole business is controlled by the chiropractors themselves and they alone decide what they are sufficiently educated and trained to do, something they are known to vastly overstate. For example, a real primary care doctor, SBM’s Harriet Hall, MD, has ably dissected their claim that they can competently practice primary care. (For one thing, many are anti-vaccination, a position that defies good primary care. For another, chiropractic clinical training is grossly inadequate for primary care and consists almost exclusively of seeing patients with musculoskeletal issues, like back pain.) A recent cross-sectional analysis of marketing claims made by chiropractor and other alternative practitioner websites found that a substantial number of chiropractors claim to treat allergies and asthma, despite the fact that there are no chiropractic treatments shown to offer meaningful objective benefits for these conditions. Nonetheless, efficacy claims were common.
Put another way: Why would you trust anyone who promotes something called a “chiropractic internist” to accurately determine competency to do, well, anything?
Even as they tout themselves as primary care physicians under current state law, chiropractors, with the support of the ACA, are vigorously lobbying for the expansion of chiropractic scope of practice, a campaign we’ve covered extensively here on SBM. They’ve lobbied for expanding chiropractic scope of practice to include diagnosis and treatment of all human ailments and removal of restrictions on treating infectious diseases, endocrine disorders and abnormal histology. They’ve lobbied, with some success, to add diagnosis and treatment of student athlete concussions, performing school physicals and unnecessary scoliosis exams, prescription privileges, and nutritional counseling. The latter is a favorite – coupled with the authority to order or perform diagnostic testing, chiropractors can fashion themselves into “functional medicine” practitioners, a lucrative alternative medicine “specialty” comprised of massive overtesting and prescription of dietary supplements, which they can turn around and sell to patients for a tidy profit. In several states, chiropractors have successfully included themselves in laws that allow direct primary care agreements with patients, which one lobbyist frankly admitted was aimed at positioning chiropractors as PCPs. Or they want to tack on anything they are taught in chiropractic school as a catch-all category to their scope of practice, leaving it to themselves to add whatever they wish.
Given their sweeping claims of competence and aggressive push for an ever-expanding scope of practice, one thing is certain: Despite giving lip service to pain treatment and alternatives to opioids, if H.R. 3654 passes, chiropractors are going to go full bore in forcing CMS to cover much more than musculoskeletal problems. If they had merely wanted more expansive coverage for the diagnosis and treatment of musculoskeletal conditions, including pain, it would have been easy enough to draft language to that effect. But the drafters (that is, the chiropractors) intentionally chose these words:
It is the purpose of this Act to expand recognition and coverage of a doctor of chiropractic as “physician” under the Medicare program in connection with the performance of any function or action, including current service of “manual manipulation of the spine to correct a subluxation,” as is legally authorized by the State in which such doctor performs such function or action.
While agencies have some wiggle room in interpreting what Congress tells them to do (a subject that is complicated, in flux, and far beyond the scope of this post), HHS and CMS will be hard pressed to regulate around the plain language of this putative statute. “Any function or action . . . legally authorized by the State” is fairly unambiguous. Based on their history of unauthorized claims under a fairly simple, albeit scientifically deficient, coverage mandate from Congress, just imagine what they could do with “parity” and the authority to bill Medicare for the entire panoply of diagnoses and treatments bestowed upon them by credulous state legislators. Think of the possibilities for colossal battles between chiropractors and CMS over whether a treatment is “medically necessary” or just whose standard should apply when making that determination: evidence-based “conventional” medicine or “chiropractic medicine”?
H.R. 3654 is part of a larger strategy to “remove current limiting scope of practice language” in all federal legislation, such as the Medical Leave Act, Workers’ Compensation and Indian Health Care Services. According to an article in The American Chiropractor:
This proposed bill, if passed, will be the initial gateway law that will guide other federal healthcare laws. While it will take time, we must also work through many current laws, rules, and regulations that will need to conform to the new full-scope coverage legislation. Some federal laws that limit chiropractic coverage include those that guide nutrition [and] wellness exams.
(Told you! Nutrition and wellness exams.)
Don’t let this happen. The bill’s primary sponsors are Rep. Brian Higgins (D-NY-26) and Rep. Tom Reed (D-NY-23). Co-sponsors are Rep. Collin C. Peterson (D-MN-7), Rep. Kurt Schrader (D-OR-5), Rep. Don Young (R-AK-At large), Rep. Guy Reschenthaler (R-PA-14), Rep. Peter A. DeFazio (D-OR-4) and Rep. Brian K. Fitzpatrick (R-PA-1). If you are a constituent (and even if you’re not), let them know the error of their ways. If you don’t live in one of these districts, contact your representative in Congress and let him or her know H.R. 3654 is a scam.