It’s Your Right!

[originally published in KCN, June 2000]

Bill of RightsWe have many rights in this great land of ours:  the right to free speech, the right to bear arms, and the right to vote are a few that come to mind;  and starting next year, Washingtonians will have a brand new right that’s sure to deepen their constitutional pride — the right to direct chiropractic access.  No longer will patients be faced with the obstacle that some managed-care insurance companies have placed in their way, which require them to obtain a referral from their primary doctor before seeing a chiropractor.  This new “right” falls under the Patient Bill of Rights that was recently written into law in our Evergreen State a few months ago and is set to take effect on all insurance plans regulated by our state “entered into or renewing after June 30, 2001.”   

Not only does the Patient Bill of Rights allow for direct chiropractic access, but it also gives patients many other rights with insurance companies.  Key sections of this law also include (1) guaranteeing patients the right to an outside, independent board of review when insurers deny lifesaving treatments; (2) requiring insurers to better protect patient privacy; (3) setting standards for improved disclosure of insurer benefits, policies, and practices; (4) establishing fair, prompt, and impartial grievance procedures for all insurance carriers; and (5) granting consumers the right to seek redress when damages occur as the result of a managed-care carrier’s denial of care.

We have the countless hours of hard work and dedication from many concerned patients, doctors, and legislators to thank for this new law.  For without their persistence, many of the frustrating circumstances that are spawning from our managed-care health insurance industry would continue unchecked.  As a chiropractor, one of the most frustrating and illogical situations that I encounter is when an insurance company requires a medical doctor to make the judgment as to whether or not chiropractic care is appropriate for my patient.

With direct access to chiropractic, many patients — including some of my own — will be breathing a sigh of relief.  Failure to jump through the referral hoop that some health plans have imposed has literally “separated”  patients from the very chiropractic benefits their hard-earned insurance premium dollars pay for each month — forcing them to accept a reduced benefit, or in some cases, not offering any benefit at all for the unauthorized care.  The result:   the patients either don’t see the chiropractor and suffer needlessly, or they pay out-of-pocket getting the care they need, all while questioning their insurance company’s real concern for their health.

The whole notion of managed-care is to contain health care costs as much as possible (ie. getting the most done with the least amount of intervention).  One of the ways insurance companies have attempted to obtain this goal is via a gatekeeper.  The gatekeeper is your primary provider.  It is his or her responsibility to manage your care by acting as a health care maestro, orchestrating your treatments and referring to appropriate providers (perhaps a chiropractor) when necessary.  By doing this, the theory is that your health care costs will be more controlled and won’t get out of hand.  Sounds good on paper, and certainly might work in some instances — but definitely does not with chiropractic referrals.  Let’s look at the facts.

Archive of Internal MedicneDespite a plethora of positive research on the efficacy, high patient satisfaction,  and cost effectiveness of chiropractic, not all medical doctors are quick to refer to chiropractors — some won’t even entertain the idea.  And while generally, medical doctor’s attitudes towards, and understanding of,  the chiropractic profession has been improving, it still has a ways to go.  A 1998 article appearing in the Archives of Internal Medicine revealed, after reviewing 25 separate survey studies with medical physicians conducted between 1982 and 1995, that 53% of the doctors on average believed in the usefulness or effectiveness of chiropractic and 40% of the doctors on average had referred to chiropractors in the past.  Embarrassingly, one of the surveys they reviewed only showed 2% of the doctors ever referring to chiropractors!   Looking at these numbers alone should raise a red flag about the objectiveness of requiring a medical referral for chiropractic care.  With these figures, more than half of the patients that depend on an M.D.’s approval in order to access their chiropractic insurance benefits will probably never get the chance to use them because their physician’s personal belief stands in the way.   What’s more disturbing, as you’ll soon see, is that these figures were independent of the insurance industry.  In other words, the surveys weren’t questioning the medial doctors who have the added responsibility of being a  gatekeeper for their patient’s insurance benefits.  For when we mix physician bias with insurance industry perks and incentives for limiting referrals to specialists, a very scary things happens — the referrals virtually disappear.

In January 1999 a report  reviewing chiropractic utilization in  managed-care organizations for Medicare enrollees was prepared by the Office of the Inspector General at the request of the Heath Care Financing Administration.  The Inspector General’s report fleshed out the appalling fact that medical gatekeepers for these plans referred patients to chiropractors less than 0.5%  of the time — an 87 % drop in usage when compared to the non-managed care, fee-for-service Medicare patients who were allowed direct access to chiropractors.  This ridiculously low referral rate is down-right criminal.  And with the knowledge of the Archives of Internal Medicine report mentioned above, it should be very apparent that something much more powerful than physician bias is driving this.  Thanks to our new Patient Bill of Rights, at your request, your insurance company must provide you with “descriptions and justifications for provider compensation programs, including any incentives or penalties that are intended to encourage providers to withhold services or minimize or avoid referrals to specialists.”  So, while you may not be able to get that referral you were hoping for, at least you’ll sleep better at night knowing that your doctor is one step closer to getting the Hawaii trip.

To be fair, the insurance companies are really putting our friendly M.D.’s in a tough position by asking them to judge the need for chiropractic care.  For one thing, they are in economic competition with us — referring out to a chiropractor for a neuromusculoskeletal complaint before running them through what they have to offer, just doesn’t make good business sense.  Unfortunately, it’s the patient that really loses because as consumers they are robbed of the fundamental right to choose their service of preference.  Ironically, they ultimately lose in another way in that the medical gatekeeper system which was designed to save them money, actually adds cost to the process and costs them more (the gatekeeper’s fee, other medical treatment fees, administrative costs, physician and patient time loss, and goodwill loss).  As a matter of fact, late last year, United Healthcare, one of the largest HMO’s in the country, realized an 8 percent  drop in their overhead  when they experimentally scaled-back on some of their “in house” gatekeeper protocols.  As a result, they’ve made the obvious decision to return more decision making power regarding treatments back to the patients and their doctors.

Law BookSecondly, asking M.D.’s the judge the necessity of chiropractic care is technically asking them to break the law!  The next time you’re in a law library, find the medical doctor’s scope of practice law for Washington state (RCW 18.71.011).  In this statute, you’ll find a statement that reads, “A person licensed under this chapter shall not engage in the practice of chiropractic as defined by RCW 18.25.005 [the chiropractor’s scope of practice laws].”  Flipping to the chiropractic scope of practice section, you’ll note that it defines chiropractic in part as “the practice of health care that deals with the diagnosis or analysis and care or treatment of the vertebral subluxation and its effects, articular dysfunction, and musculoskeletal disorders….”  Reading the M.D. and the D.C. practice laws in tandem, it is clear that asking an M.D. to render a diagnosis regarding the presence of the vertebral subluxation and its effects runs against his or her scope of practice.  Later on in the D.C. law, medical doctors are specifically prohibited from the performing of an adjustment by hand of any articulation of the spine.  In an article written by attorney Richard Adler regarding this subject, he begged the obvious point, “If the law prohibits a medical doctor from adjusting by hand any articulation of the spine, then how can he or she determine whether an adjustment is necessary, whether the treatment regimen is reasonable, whether a specific adjustment technique is appropriate, or whether the frequency and duration of care is reasonable and necessary?”  This was formally declared in a 1995 ruling by the Chiropractic Quality Assurance Commission, a branch of the Health Professions Quality Assurance Division of the Washington State Department of Health, when it stated that “medical physicians are not educated, trained, or experienced in the practice of chiropractic science and treatment as it relates to chiropractic and/or the vertebral subluxation complex.  As a consequence, medical physicians are not competent to render an opinion regarding the necessity and reasonableness of chiropractic care generally or on a case specific basis.  Properly educated and licensed chiropractors in the State of Washington are competent to determine the necessity and reasonableness of chiropractic care.”  The ruling went on to strongly say,  “Decisions rendered by medical physicians on the necessity and reasonableness of chiropractic care pose a significant health risk to the public of Washington State.”

So, the Patient Bill of Rights is truly a win for patients and doctors (both medical and chiropractic alike).  The patients are granted more freedom and control regarding their health care.  The chiropractors are able to treat their patients.  And the medical doctors are allowed to obey the law.  Everyone’s happy.  As for the insurance companies, if their smart, they’ll let it all happen without a hitch — who knows, they just might save a buck.

_____________
Sources used for this article:

Adler, R. Can a medical doctor evaluate the reasonableness and necessity of chiropractic care?  A ruling by the chiropractic quality assurance commission.  Article published and distributed by Adler Giersch, P.S.  Attorneys at law.  November 1995.

Astin, et. al.  A review of the incorporation of complementary and alternative medicine by mainstream physicians. Archives of Internal Medicine.  158: 2303-2310. 1998.

Brown, J. Inspector General.  (letter to HCFA) Chiropractic services covered by medicare managed care organizations. January 13, 1999. (http://docs.google.com/gview?a=v&q=cache:U8I7-cv3a7gJ:oig.hhs.gov/oei/reports/oei-04-97-00494.pdf+Chiropractic+services+covered+by+medicare+managed+care+organizations+Brown&hl=en&gl=us&sig=AFQjCNEgXYj4JgX6uzqCeeeC8PzewVw27g).

Commissioner Senn praises state representatives for strong vote affirming patient’s bill of rights.  Press release issued by the Washington State Insurance Commission. February 15, 2000. (http://www.insurance.wa.gov:80/newsrel/).

Commissioner Senn says powerful coalition of consumers and legislators produced patient’s bill of rights. Press release issued by the Washington State Insurance Commission. March 15, 2000. (http://www.insurance.wa.gov:80/newsrel/).

Ensuring access by eliminating the MD gatekeeper requirement for chiropractic amendment for the patient rights bill of 2000, SB 5776/HB 1847. Alert issued by the Washington State Chiropractic Association, 1999.

Locke signs ‘patient bill of rights’ legislation. Press release issued by the Governor’s communication office. March 15, 2000. (http://www.access.wa. gov/news/).

Patient bill of rights – second substitute senate bill 6199.  Passed by the senate March 6, 2000.  56th Legislature, 2000 regular session. (http://www.insurance.wa.gov:80/Health/6199pl.htm).

Patient’s bill of rights lauded by chiropractors.  Plexus. 9(3). 2000.

Patient rights act authorizing direct access to DC’s now law.  Plexus. 9(3). 2000.

Senator Thurmond questions Shalala’s report – asks her to respond to chiropractic being shut out of medicare managed care.  Dynamic Chiropractic. 17(4) 1999.

UnitedHealth eliminates pre-auhorization review.  ACA Today. Newsletter of the American Chiropractic Association. December 1999/ January 2000.

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