You can win the fight for insurance coverage for integrative therapies
The key: Patients do better at a lower cost
Your patient with chronic migraines is sitting in front of you, hunched in a chair, clutching her head in obvious pain. What are your options? Standard treatment calls for you to rule out mitigating factors and wade through the usual alphabet soup of CT scans, EEGs, and MRIs, which frequently yield no conclusive cause. Then you relegate her to any of a variety of meds that may or may not help. Such a course is likely to leave you feeling helpless and your patient feeling depressed, angry, and perhaps desperate.
You tell her there is a complementary solution that involves acupuncture, massage, chiropractic treatment, and herbs. She undoubtedly will tell you her insurance won’t cover those options. But with a little help from you and others concerned about presenting effective and cost-effective options to insurance companies, the door is opening for mainstream HMOs, preferred provider organizations (PPOs), and other forms of insurance to cover the therapies.
Insurers are beginning to respond to a few carefully presented strategies to persuade them to cover alternative therapies. After all, an estimated 83 million Americans choose complementary and alternative medicine (CAM) therapies every year and spend billions of dollars doing so — most of those dollars right out of their own pockets.
Linda Bedell-Logan, president and CEO of Solutions in Integrative Medicine in Saco, ME, started the company 11 years ago following the deaths of her 25-year-old sister from cancer and her 33-year old brother from AIDS. She says insurance companies increasingly are becoming responsive to that popular demand and to the cost savings it can mean.
A case in point involves patients with lymphedema following lymph node biopsies usually related to breast cancer. The standard treatment is to place them on a pneumatic pump; the treatment is marginally effective and functions mainly to move lymphatic fluid from the extremity into the trunk. Lymphangiosarcoma and amputation are distressingly common outcomes of this type of therapy.
"There is no reason in the world for a patient to have to suffer through this when massage — called manual lymphatic drainage — can drain lymphatic fluid very effectively," says Bedell-Logan.
Bedell-Logan’s company went to bat and hit a home run for lymphedema patients (and those with a host of other diseases) under the auspices of the physicians, whom she views as the ones with clout in such situations. "We went to the medical directors of the major insurers and HCFA [the Health Care Financing Administration] and showed them all the peer-reviewed medical journal articles on the efficacy of the pumps and the literature showing that the treatment Medicare was reimbursing at a rate of $13 million a year even though the procedure is actually banned in some countries," she explains.
"We gave them CPT [current procedure terminology] codes," says Bedell-Logan. "Then we showed them the data on CAM therapies that showed they work and they’re cost-effective. They went for it."
When insurers are convinced through scientific data that a complementary therapy works, many of the barriers start to come down for patients with cancer, migraines, chronic fatigue syndrome, multiple sclerosis, and other debilitating and chronic diseases, Bedell-Logan adds.
"Claims kept coming through, and insurers kept denying. Some we had to take through the appeals process. Then we sent up efficacy manuals to the heads of the insurance companies, and in every case, they agreed with us," she says. The key to getting insurers to pay attention and pay for complementary therapies is sometimes no more complicated than finding an appropriate CPT code, Bedell-Logan explains.
It makes sense to insurers to consider CAM therapies when patients with chronic diseases are likely to be taking expensive pharmaceuticals and possibly facing multiple surgeries for the rest of their lives, she says. "We studied the cost of migraine therapy and found the efficacy and the cost effects were huge."
Team approach saved thousands
The average migraine sufferer costs an insurance company between $3,000 and $6,000 a year. (See table.) Bedell-Logan and her company went to one insurer and presented a plan to spend that much money per patient per year in an integrative setting in Boston that included a physician, acupuncturist, massage therapist, a chiropractor, and a mind-body therapist working together as a team.
| Costs of Integration Strategies for Migraine Patients | ||
| Conventional approach (on yearly basis) | ||
| Primary care physician (10 visits) | $650 | |
| Emergency room visits (10 visits) | 2,400 | |
| Medication | 600 | |
| Neurologist | 400 | |
| CT scan | 600 | |
| EEG | 245 | |
| MRI | 1,200 | |
| Total cost per year | $6,095 | |
| Over a six-year period | $37,495 | |
| Average per year | $6,249 | |
| Integrative approach | |
| Chiropractor (5 visits) | $400 |
| Acupuncture (5 visits) | 400 |
| Massage therapy (5 visits) | 350 |
| Nutritionist (5 visits) | 375 |
| Mind-body therapy (5 visits) | 840 |
| Naturopath (3 visits) | 300 |
| Medication | 600 |
| Physician (2 visits) | 300 |
| Diagnostics | 1,200 |
| Total cost per year | $4,765 |
| Over a six-year period | $21,117 |
| Average per year | $3,852 |
"We told them, Let us spend it in a model of individualized and natural caring for the patients.’ We were able to get many of them off pharmaceuticals and to stop the migraines completely for some. Why? Because they were being treated by a medical team that worked together and got them on a program that included herbs and pharmaceuticals interacting appropriately and a combination of other therapies that worked extremely well," she adds.
The team approach rolled primary care into a kind of "one-stop shopping" that was consumer-friendly, focused on prevention of disease, and care-coordinated so there were no vacuums or gaps, Bedell-Logan says. "Several studies have shown that if a patient has a choice in care, no matter what it is, he will do better," she adds. "If that’s because of a placebo effect, so be it."
Solutions for Integrative Medicine offers billing, collections, and patient advocacy services, as well as outcomes tracking, practice management, and consulting for hospital-based and freestanding CAM clinics.
Increasing numbers of insurers, including government insurers, are covering CAM therapies, but the vast majority of coverage (about 90%) is for chiropractic treatment, which is hardly considered a CAM therapy these days, says John Weeks, editor of The Integrator for the Business of Alternative Medicine in Seattle. "Most HMOs and PPOs offer some coverage, usually through CAM practitioners who are subject to state licensing and, therefore, easy to credential," says Weeks. About half the providers who do offer CAM therapies contracted the coverage to other providers, and about half provide a limited network of providers within their own system, he explains.
Weeks and Bedell-Logan say virtually no insurers cover complementary therapies outside the licensed realms of chiropractic, naturopathy, acupuncture, massage, and nutrition. And the vast majority of the CAM coverage allowed is merely part of a discount program rather than coverage under the same terms as any other type of medical coverage, they add. "It’s a starting place," says Weeks. "It’s a way to respond to consumer interest, but in no way is it really integrative medicine."
CAM therapies shouldn’t be a "rich person’s option," says Bedell-Logan. Her goal is to bring CAM therapies within the reach of everyone. "If an acupuncturist charges $75 a visit, you can be sure he’s not going to be seeing many poor people. Even if the price is lowered to $30 through a discount program, that’s still a far cry from most $10 or $25 co-pays," she says.
Some CAM therapies are within the reach of the poor, even if those treatments are limited, says Terrence Steyer, MD, former Robert Wood Johnson fellow at the University of Michigan in Ann Arbor and now assistant professor of family medicine at the Medical University of South Carolina in Charleston.
The majority of state Medicaid programs provide some reimbursement for CAM therapies, but the total outlay is miniscule in the big picture. Steyer reported in a paper presented at last year’s Pediatric Academic Societies and the American Academy of Pediatrics meeting in Boston that of the 46 state Medicaid programs answering Steyer’s query most spent less than $500,000 per fiscal year and only five states spent more than that.
Many state Medicaid plans reimburse for chiropractic services, which have a long history of state and federal regulation, and which made up 74% of the CAM claims allowed by Medicaid agencies, says Steyer.
During the last two sessions of Congress, a bill has been introduced to mandate the availability of acupuncture for chronic pain. The bill never has been reported out of committee, says Steyer, so it is unlikely to become law anytime soon, but "at least people are talking about it."
"The way to approach the government and the insurers on CAM therapies is to promote more research," he says.
Many CAM therapies, particularly herbal preparations, have been used traditionally, but do not have the backing of solid science, says Steyer, because it is not profitable for companies to spend the money on research on a product that cannot be patented.
Yet some research is under way, the majority of it under the auspices of the National Institutes of Health. He contends that acceptance for CAM therapies and insurer enthusiasm will snowball as more research-based evidence becomes available. "If we can find that St. John’s wort works just as well as Prozac and it’s a lot cheaper, then it will become widely accepted," says Steyer, who says the contraindications of herbal preparations should become part of every physician’s basic knowledge.
That already is happening as more medical schools now include CAM therapies as an elective, and a new generation of physicians is much more aware of the benefits of some of these therapies, he adds. In the meantime, physicians and health care professionals can become advocates for their patients, says Steyer. A physician who is willing to go straight to the medical director of an insurance company can carry a lot of weight and benefit patients greatly.
Aetna-U.S. Healthcare is one PPO that is addressing the needs, or demands, of its patients and providers for CAM therapies, says Terry Gordon, MD, Michigan state director for the company. Aetna’s Natural Alternatives program offers all members in states where the program is available access to certain CAM practitioners as well as vitamins, supplements, and herbs at a reduced fee. The vast majority of the practitioners included in the plan are chiropractors, says Gordon, but acupuncturists, massage therapists, and nutritional counselors also are in the program. The program is included without additional cost to employers and no referrals are necessary.
Aetna is a forerunner in CAM coverage. Since 1998, members in most states have had access to the program in which they pay $30 for chiropractic and acupuncture services, and $20 per half hour of massage therapy and nutrition counseling, a discount of approximately 50% over usual rates. In addition, they get 20% discounts on vitamins, supplements, and herbs from Aetna’s approved provider and discounts on some health books and magazines.
Gordon visited every one of the 22 providers in Aetna’s Michigan Natural Alternatives program. "I wanted to be sure. If you’re not careful, you can get people of lower quality."
Aetna’s plan credentials providers who are subject to statewide licensing, says Gordon. "That ensures at least some level of adequacy and abilities."
Such a program is a start, says Bedell-Logan. Yet critics say 22 providers in a state the size of Michigan is a tiny number. And more worrisome to Bedell-Logan, it is lacking the key ingredient of a holistic team approach to health. "A patient may be seeing a chiropractor or an acupuncturist and taking herbs all under the auspices of the insurer, but his primary care provider may know nothing about it."
[For more information, contact:
• Linda Bedell-Logan, President and CEO, Solutions in Integrative Medicine, Saco, ME. Telephone: (800) 464-5110.
• John Weeks, Editor, The Integrator for the Business of Alternative Medicine, Seattle. Telephone: (206) 933-7983.]
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