Medicare Part C: Today's most serious challenge to chiropractic

Medicare Part C, the section designed to establish managed care coverage for the Medicare patient, has received much attention from the ACA over the past few months. One of the larger issues revolves around wording in the proposed regulation that would permit Medicare Part C (Medicare+Choice) programs to allow nonchiropractors to deliver chiropractic services. Past experience by the chiropractic profession suggests that some HMOs would designate osteopaths, physiatrists, and, in some instances, physical therapists, as providers to deliver spinal manipulation to correct a subluxation" (the precise authorizing language from the 1972 Medicare law) for the requested chiropractic care, while at the same time excluding chiropractors from their panels. Even if DCs were included in the HMO panel, it's not possible to know if patients would actually be directed to them for chiropractic services.

The ACA is challenging these regulations as written, by both administrative avenues and by legal intervention. It is too soon to determine the eventual outcome of these new regulations, but we are closely montoring all developments.

Most DCs find even the suggestion that disciplines other than chiropractic can provide spinal manipulation to correct a subluxation a laughable sham. In 1972, other professions termed the legislated chiropractic service as "quackery." Now that patients are demanding chiropractic services and our alternative care has become recognized as beneficial, the Health Care Financing Administration (HCFA) and the other professions are attempting to claim it as their own. The fact is that the profession is now facing the threat of losing its grip on this once discipline-specific procedure. The truth is-and every chiropractor must remember this-the chiropractic adjustment IS manipulation of the spine to correct a subluxation and it was thus designated by Congress in the 1972 statute that allowed the entire profession to apply for government-funded reimbursement.

For more than 100 years, doctors of chiropractic have been concerned with the health of the patient. This concern relates to more than just a biomechanical dysfunction or a neuromusculoskeletal disorder or lesion. Chiropractors work to help the patient achieve a balance between the body and its innate ability to maintain good health. They also feel obligated to instruct the patient in lifestyle choices that are conducive to maintaining optimum health.

To accomplish this homeostasis, the chiropractic tenet focuses on the nervous system and its ability to regulate bodily responses. To achieve and influence this response mechanism, chiropractors have adopted a nearly universal approach: the chiropractic adjustment or manipulation of the spine to correct a subluxation. To those of us in the profession, the chiropractic adjustment or manipulation of the spine to correct a subluxation needs little explanation as to what it is, what it does, and the art of its delivery.

Statistically, the chiropractic profession delivers 94 percent of all spinal manipulation annually. Chiropractic has become identified by the public as the specialist group with expertise in this area.

The profession has approached chiropractic care as a broad, sometimes complex, system of health care, of which spinal manipulation or adjustment to correct subluxation is a part. Chiropractic also includes patient examination, counseling on nutrition and lifestyle, exercise, and many other components. Nevertheless, the core Medicare legislation mandating chiropractic services focused on manual manipulation of the spine to correct a subluxation (our adjustment), and chiropractors have been reimbursed for that procedure for some 25 years. Now, HCFA and other professions are attempting to make the specifically chiropractic service a generic one. Make no mistake. If they succeed, the medical world in general will utilize its friends to deliver the chiropractic service within HMOs controlled by it.

Can we do anything? We must. Our window of opportunity will not be open long. If the profession will unite in recognizing that manipulation of the spine to correct a subluxation (i.e., the chiropractic adjustment) is a uniquely chiropractic service that no other profession even claimed to offer when the enabling statute of Medicare was passed in 1972, we should be able to thwart the present effort of organized medicine to contain and eliminate our profession.

The profession is facing a genuine threat. It cannot be totally resolved by legislation, grassroots efforts by our patients, litigation, or any of the other tactics that have served the profession in the past. The response to the threat must include academic achievement and clinical experience. In a world soon to be governed by outcome measures, reproducible clinical research, referenced literature, and managed care, the chiropractic profession must demonstrate that behind our philosophy and basic tenets, we are competent clinical professionals. This can only be achieved through increased educational requirements, the adoption of professional interaction with other health care disciplines, i.e., integration, and the willingness to remember that for the past 25 years, the chiropractic adjustment or manipulation of the spine to correct a subluxation has been the key to Medicare reimbursement for chiropractors and their patients. Others are now, we contend, illegally claiming that key.

In the meantime, the legislative pressures of Medicare Part C have led us to treat this matter with great urgency. George McAndrews, the attorney who led Wilk rs. AMA to victory and a court-ordered mandate against further covert acts against chiropractic by the AMA, says Medicare Part C represents "the most serious challenge to the welfare of the chiropractic profession since the AMA conspiracy to destroy chiropractic." For that reason, ACA has filed emergency legal action against HCFA-a move designed to force HCFA to abide by the will of Congress and permit Medicare patients covered under Part C to enjoy their rightful access to chiropractic care.

We cannot allow the present suggested regulations to prevail unless we, as a profession, are prepared to suffer a domino effect. If chiropractic services delivered by chiropractors are allowed to be effectively eliminated from most Medicare HMOs, they may well be eliminated from the nation's private sector managed care plans, as well.

Therefore, our membership must grow in size and in courage. Give thought, time, energy, and financial support to this campaign. Our patients deserve no less than full access to chiropractic. We must make absolutely certain that they get it.

Copyright American Chiropractic Association May 1999
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