Medicare pilot project expands coverage for chiropractic care

Washington -- Starting next spring, the Centers for Medicare & Medicaid Services will begin paying licensed chiropractors in four states for services beyond manual manipulation of the spine to correct pre-diagnosed malfunctions.

The demonstration, which was mandated in last year's Medicare reform act, will not create any new benefits. Instead, it will allow doctors of chiropractic in those areas to provide expanded care, such as diagnostic services, x-rays and physical therapy under Medicare. The four states are Illinois, Maine, New Mexico and Virginia.

The fact that Medicare has covered only one chiropractic service since incorporating the practice into its benefits has convinced chiropractors that they have a long way to go toward government acceptance.

"This has been a sore point with them since their inclusion in Medicare in 1972," said Rick Miller, a lobbyist and consultant with the American Chiropractic Assn. "And there are still pockets of resistance."

Congress has long been the primary driver behind expanding access to chiropractors, and the ACA believes that any future progress will have to come on the legislative level, Miller said. The care "is not going to be substantially embraced by CMS anytime soon," he stated.

The chiropractic community has champions on Capitol Hill. Senate Finance Committee Chair Charles Grassley (R, Iowa), who hails from a state that founded the first chiropractic college, led the effort to include the two-year demonstration project in the Medicare bill.

Responding to protests from Grassley and other lawmakers, HHS recently suspended plans that would have permitted Medicare carriers to impose coverage limits on the number of times a beneficiary could seek chiropractic services.

A need for more data

Chiropractors argue that they could improve outcomes and vastly reduce Medicare costs by helping to avoid expensive, unnecessary back surgeries.

"We believe that if you take a cohort of patients that exhibit the same type of symptoms and you look at episodes of care, patient satisfaction will be higher and global costs will be lower for the chiropractic services," the ACA's Miller said.

Such data do not currently exist in the medical literature, said Robert H. Haralson III, MD, executive director of medical affairs for the American Academy of Orthopaedic Surgeons. The very nature of the treatments precludes the availability of the type of double-blind, randomized, controlled trials that are needed, he said, because the patient knows when his or her spine is being manipulated.

"I would hope that some kind of data collection is made a part of this Medicare project. If we collect the data and [chiropractic services] improve patient outcomes, then we've learned something valuable," Dr. Haralson stated. "If you're not measuring outcomes, then you're stuck with measuring costs."

The same studies that have helped improve orthopedic practices in the last few years also have demonstrated that chiropractic treatments are not as effective at getting patients back to a permanent normal level of activity, according to the academy.

"As long as chiropractors are using [spinal] manipulation to facilitate a return to normal activity, that's fine," Dr. Haralson said. "But comparing manipulation to other passive modalities has shown that it has no benefit over [standard] physical therapy."