Current Trends in Reimbursement for Alternative Medicine
July 1998; Volume 1: 84
Source: Pelletier KR, et al. Current trends in the integration and reimbursement of complementary and alternative medicine (CAM) by managed care, insurance carriers and hospital providers. Am J Health Promotion 1997;12:112-123.
To assess the status of complementary and alternative medicine (CAM) insurance coverage, Pelletier et al conducted telephone interviews with 18 insurers and a representative subsample of seven hospitals. Twelve insurers said that market demand was their primary motivation for covering CAM. Factors determining whether insurers would offer coverage included potential cost-effectiveness based on consumer interest, demonstrable clinical efficacy, and state mandates. Among the most common obstacles the authors found to incorporating CAM into mainstream health care were lack of research on efficacy, economics, ignorance about CAM, provider competition, and lack of standards of practice.
COMMENT
Many people believe that the future of complementary medicine is conventional: the best of "alternative" approaches-whether botanical, physical, vegetable, or mineral-will likely be offered by allopathic institutions, practitioners, and practices. As physicians become responsible for formulary costs, and the therapeutic value of other medical systems is evaluated in Western terms, who pays for CAM will become big business.
Pelletier et al at Stanford used structured and open-ended interviews to query 18 insurers who had developed or were developing policies about CAM coverage. The investigators asked about 34 specific therapies named in the NIH Office of Alternative Medicine classification.
Reimbursement reportedly depended upon market-driven rates; the practitioner's license; CPT codes; and the particular health plan. Most insurers felt existing CPT codes could be appropriately used; five insurers reported using "dummy" CPT codes for CAM. Medical necessity-here scientifically provable efficacy, medical professional administration, and case-by-case decisionmaking-was necessary.
Although the sample is small and selective, and the data were gathered in mid and late 1996, this is the first peer-reviewed study in the medical literature to examine and document CAM coverage as reported by insurers. A detailed table on hospitals associated with CAM centers and services is useful.
Conclusion
Insurers are beginning to decide what to cover on the basis of specific data to assess medical efficacy, effectiveness, and safety. Small, local pilot studies may be helpful in achieving local coverage.
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