Recently, I addressed a local chiropractic group in Connecticut regarding statin myopathy as a common cause of chronic pain.
To my surprise, only a couple of chiropractic physicians in attendance admitted to diagnosing chronic pain syndrome and none claimed to treat patients for this malady. When I asked why, the responses were similar: "The insurance companies won't pay chiropractors for the treatment of chronic pain, but they will pay for the treatment of acute pain."
Letting Insurance Dictate Your Diagnosis: 10 Important Questions
On the way home from the meeting, I reflected on the position of these Connecticut chiropractors regarding the diagnosis and treatment of patients suffering with chronic pain. Let's address 10 questions I believe are relevant to the chiropractic profession regarding chronic pain syndrome:
- How does this position affect the chiropractic profession overall?
- Is it ethical to underdiagnose in order to receive third-party reimbursement?
- Are these chiropractors practicing "third-party chiropractic medicine"?
- Why would the insurance companies not permit chiropractic physicians to evaluate and manage chronic pain patients?
- Does the Affordable Care Act permit chiropractic physicians to care for patients suffering with chronic pain syndrome?
- What is the position of the Joint Commission regarding chronic pain care and chiropractic care?
- What is the definition of chronic pain syndrome promulgated by the National Pain Strategy?
- Are all of the insurance companies using the same definition of chronic pain syndrome?
- Would it help if doctors read the Institute of Medicine report, Relieving Pain in America: A Blueprint for Transforming Prevention,Care, Education, and Research? (It is available free online.)
- Why should chiropractors care for patients suffering with chronic pain?
If chiropractors avoid treating patients with chronic pain because of third-party reimbursement restrictions, it appears access to chiropractic care will be diminished and patients in need of our services will seek other services, including the use of opioids. In addition, if chiropractors do not bill insurance companies for the treatment of chronic pain, I believe the third-party data will demonstrate chiropractors do not diagnose chronic pain and are not capable to treat patients with chronic pain.
The above-mentioned book (Relieving Pain in America) recommends that the National Center for Health Statistics, the Agency for Healthcare Research and Quality, other federal and state agencies, and private organizations improve and accelerate the collection and reporting of data on pain. Data should be collected in the following domains:
- The incidence and prevalence of pain, particularly chronic pain
- Interference with activities of daily living and work, as well as disability, related to pain
- Utilization of clinical and social services as a result of pain
- Costs of pain and pain care, including indirect costs of lost employment, and public- and private-sector costs for disability payments
- The effectiveness of treatment in reducing pain and pain-related disability, determined through research on the comparative effectiveness of alternative treatments (including in different patient populations), to identify people most likely to benefit (or not) from specific treatment approaches
Appropriate Diagnosis of Chronic Pain: Your Ethical Responsibility
If the chiropractic profession is going to demonstrate its effectiveness in treating chronic pain, it appears necessary to submit invoices to third-party payers for the evaluation and management of patients with chronic pain.
It is my opinion that it is unethical to underdiagnose a patient with chronic pain syndrome, for a few reasons. Diagnosis is the key to successful treatment. The attending doctor has an ethical responsibility to make the correct working diagnosis and recommend appropriate care. A chronic pain patient may need the services of the chiropractor, primary care provider and a mental health care provider in order to gain better health and relief.
If chiropractors are intentionally underdiagnosing or not providing appropriate care for patients with chronic pain syndrome because of insurance company reimbursement restrictions, they are definitely practicing "third-party chiropractic medicine" or "third-party chiropractic health care." It is embarrassing to realize doctors practice any form of medicine based upon insurance company reimbursement restrictions. Hopefully, health care reform will eliminate this unethical behavior by both health care providers and insurance companies.
Steps Toward Change: Legislative, Strategic and Our Call to Action
I do not know why insurance companies elect to restrict reimbursements to chiropractors for evaluation and management of chronic pain. It could be economic credentialing or ignorance of the evidence, which demonstrates the need for chiropractic services for patients suffering with chronic pain. Section 2706 of the Affordable Care Act permits chiropractors to receive equal reimbursement for the treatment of patients with chronic pain, providing the services are within the doctor's scope of practice.
Section 4305 of the ACA required the secretary of HHS to enter into an agreement with the Institute of Medicine for activities "to increase the recognition of pain as a significant public health problem in the United States." As a result, HHS, working through the NIH, commissioned an IOM study to assess the state of pain care. The resultant IOM report, issued in June 2011, included 16 recommendations for improvements in data collection and reporting; the availability and effectiveness of pain care; public, patient and professional education about pain; and related pre-clinical, translational and clinical research.
This year the Joint Commission recognized the need for chiropractic services for pain management. Clinical experts in pain management who provide input to the commission's standards affirmed that treatment strategies may consider both pharmacologic and nonpharmacologic approaches. Services provided by doctors of chiropractic (who were recognized in 2009 as "physicians" by the commission) and acupuncture practitioners are now included in the standard of care for pain management effective Jan. 1, 2015.
The National Pain Strategy defines chronic pain as pain that occurs on at least half of all days for six months or more. Chiropractic colleges, associations and providers should promulgate the use of this new definition and stress to insurance companies the need to expand the scope of reimbursement of chiropractic services for the treatment of chronic pain.
I also emphasize that every chiropractor should read Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. As mentioned, it is available online and without cost. It is time to discontinue the practice of third-party chiropractic medicine. Chiropractic clinicians, associations and colleges must fight for the right to evaluate and manage patients experiencing chronic pain syndrome. Access to chiropractic care should be a right, not a privilege!
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