J Chiropractic Humanities 2020 (Dec 7); 27: 29–36 ~ FULL TEXT
Robert A.Leach, DC, MS
Nutrition and Health Promotion,
Mississippi State University,
Davis ~ J Am Board Fam Med 2015
Objective: The purpose of this article is to discuss evidence that supports the resolution of inequities for Medicare beneficiaries who receive chiropractic care.
Discussion: Medicare covers necessary examinations, imaging, exercise instruction, and treatments for beneficiaries with back pain when provided by medical doctors, osteopaths, and their associated support staff such as nurse practitioners, physician assistants, clinical nurse specialists, and physical therapists. However, if the same patient with back pain presents to a chiropractor, then the only service that is covered by Medicare is manipulation of the spine. Current evidence does not support this inequity in Medicare beneficiary service coverage. There is no evidence to show an increase in serious risks associated with chiropractic treatment of neck or back pain in Medicare beneficiaries. Chiropractors support national public health goals and endorse safe, evidence-based practices.
Chiropractic care for Medicare beneficiaries has been associated with enhanced clinical outcomes such as faster recovery, fewer back surgeries a year later, reduced opioid-associated disability, fewer traumatic injuries and falls, and slower declines in activities of daily living and disability over time. Further evidence points to lower costs, fewer medical physician visits for low back pain, less opioid-related expense, and less back-surgery expense with chiropractic utilization. Use is lower among vulnerable populations: seniors, lower income women, and black and Hispanic beneficiaries who may be most affected by current inequities associated with the limited coverage. In this era of evidence-based and patient-centered care, beneficiaries who receive chiropractic care are very satisfied with the care they receive.
Conclusion: The current evidence suggests a need for change in US policy toward chiropractic in Medicare and support for HR 3654. Ending inequities by providing patients full coverage for chiropractic services has the potential to enhance care outcomes and reduce health disparities without increasing program costs.
Keywords: Chiropractic; Healthcare Disparities; Medicare
From the FULL TEXT Article:
Currently, Medicare has limited coverage for chiropractic
services. Medicare Part B (medical insurance) covers manual manipulation of the spine if medically necessary to correct a subluxation when provided by a chiropractor or other qualified provider. Medicare does not cover other services or tests ordered by a chiropractor, including xrays, massage therapy, and acupuncture.  Of all health care provider types whose services are covered in the Medicare program for treatment of spine pain, only patients of chiropractors have no coverage for the exams, radiographs, and necessary therapeutic procedures such as exercise instruction and lifestyle advice that are critical to attaining longterm improvement and preventing recurrence. [1–6]
In 1973, when chiropractic was added as a Medicare
Part B (outpatient) benefit, it was primarily in response to a
public outcry to include the popular treatment in the federal
program for seniors and persons with disabilities.  The final compromise of chiropractic coverage that was worked out by the House and Senate purportedly was influenced by the American Medical Association. The result was that chiropractors were required to take a radiograph (ie, a diagnostic imaging study that uses x-rays to create an image) prior to being allowed to give chiropractic care. Although the radiograph requirement has since been removed, radiographs taken by chiropractors have never been a covered service. Experts believe this language was an attempt by the American Medical Association to create a barrier for
patients seeking chiropractic care. [1, 7, 8]
The debate over coverage of chiropractic has continued,
with the Office of the Inspector General of the Department
of Health and Human Services examining chiropractors
billing for follow-up care.  According to the Department of Health and Human Services, “Medicare covers chiropractic services for active/corrective treatment for subluxation of the spine but does not cover maintenance therapy.”  Maintenance care has been traditionally offered to patients who
see clinical gains after initial services are rendered. However,
without evidence to support the use of preventive
maintenance care by chiropractors, the department concluded
that it was not medically necessary, despite continued
popular use of the service by patients of chiropractors.  To help address these questions, Congress authorized a Medicare demonstration project whereby beneficiaries in certain areas within 5 US states were able to access the full range of chiropractic services allowed. 
Although findings from the demonstration pointed to an
overall slight increase in program costs, the demonstration
treated chiropractic as an add-on service (ie, chiropractic
was not treated as a service that can stand alone, but rather
costs were expected to accrue in addition to all other physician, diagnostic imaging, and surgical expenses covered by
Medicare). Unfortunately, the demonstration did not take
into account such offsets as possible reduced orders for
advanced diagnostic imaging or back surgeries, or reduced
physician visits that may have been incurred had patients
not gone to a chiropractor.  The program also did not address whether clinical outcomes improved when beneficiaries were able to fully access chiropractors for the full range of services they normally provide. [11, 12]
There are still questions underlying chiropractic care
within Medicare that need to be explored. The purpose of
this article is to discuss an evidence-based rationale for
why equity is needed for Medicare beneficiaries who seek
chiropractic treatment and for permitting full coverage for
services, as would be expected when seeking care for back
pain from any other Medicare health care provider in the
United States. I discuss whether full coverage for chiropractic
might help to reduce health disparities by improving
access to chiropractic for the vulnerable populations presently
underserved by chiropractors, including those in
lower income, elderly, and racially diverse groups.
Comparing types of providers whose services are covered
in the Medicare program for treatment of spine pain,
only patients of chiropractors have no coverage for the
exams, radiographs, and necessary therapeutic procedures
such as exercise instruction and lifestyle advice that are
critical to attaining long-term improvement and preventing
recurrence. Table 1 shows services related to back pain
covered by Medicare, by provider type. [1–6] Regarding reducing inequities for patients who go to chiropractors, an important concern for policy makers and taxpayers is cost. The answer may be complex, especially if it involves looking at divergent variables such as safety, actual costs (what patients spend for an episode of care compared to another provider), possible offset savings (fewer physician visits, less expensive advanced imaging procedures, fewer back surgeries, or less opioid-related disability and expense), and the effectiveness of chiropractic care.
If physical therapists and medical doctors were able to provide more effective care, then prohibitions against coverage for
chiropractic services might be justifiable, because some
goals espoused by the Affordable Care Act advocate for
enhanced coverage of evidence-based treatments.  Another issue is whether chiropractic care is cost effective — even if it is equally or more effective compared to other care, what is the cost of its addition? In attempting to address these issues, information may be found in recent large-scale epidemiologic inquiries involving the entire US Medicare database, in addition to multiple other studies from the past few years that have dealt with these and additional questions raised by the Medicare demonstration project and several that may even shed a different light on the
Office of the Inspector General reports.
Chiropractors Engage in Health Promotion
Detractors of chiropractic expansion have argued that
chiropractic is dangerous [14, 15] and that chiropractors refrain from endorsing and advocating for public health preventive measures.  In response to these arguments, 2 large-scale epidemiologic studies in the United States have addressed the issue of association of chiropractic and stroke. An earlier epidemiologic study had looked at more than 100 million person-years of data from 1993 to 2002 and found that there was no greater association of vertebral artery stroke for patients seeing a chiropractor than those seeing a medical doctor.  It also found that for older patients, stroke was correlated with a prior recent visit to a medical doctor. More recently in the United States, a report of a total of 1,829 vertebral artery strokes reported among commercial and Medicare Advantage patients from 2011 to 2013 showed an association between strokes and visits to primary medical care but not chiropractor providers. 
It concluded that the positive association between primary medical visits and stroke was likely due to patients seeking care for the headache and neck pain associated with these lesions. [17, 18] A second study reported on a sample of Medicare Part B beneficiaries aged 66 to 99 years, including 1.1 million claims where patients complained of neck pain.  Differences in risk for subsequent stroke of any type, not merely allegedly manipulation-induced vertebral artery strokes, between patients who saw a chiropractor or a primary care physician were not clinically significant. The authors concluded that associations reported in case reports were likely due to patients going to a chiropractor while having symptoms of a stroke in progress. Another inquiry addressed the relative safety of chiropractic care, reporting that the risk of traumatic injury for all Medicare Part B beneficiaries after presenting with a neuromusculoskeletal complaint was greater for those seen by a primary care doctor (153 incidents per 100,000) than for those seen by a chiropractor (40 incidents per 100,000).  And where previously some medical doctors offered individual reports of alleged serious spine injuries such as herniated discs after spinal manipulation, [21, 22] a recent study of 100 million person-years of data revealed no more emergency treatments of herniated discs after initial presentation to chiropractors than after initial presentation to medical doctors. 
Another multicenter study found that benefits outweigh risks for patients with serious neck pain.  A large medical trial suggested that there may not be a long-term benefit of back surgery, and that surgery not only is expensive but may have more risk compared to conservative care.  Hence, for Medicare Part B beneficiaries, safety would likely be enhanced by adding chiropractic care rather than reduced by it. In the past decade there has been growing evidence to support the contention that chiropractors are advocating for evidence-based public health policy. There has been discussion within the chiropractic community regarding public health that aligns with US Centers for Disease Control and Prevention initiatives and goals.  There is evidence for strong support among chiropractors for goals espoused by the US Centers for Disease Control and Prevention, from recommendations on nutrition to exercise and staying active, and from preventing falls to reducing substance abuse and offering counseling advice and other goals. [26, 27] Based on current evidence, chiropractors have developed and updated guidelines for best practices including radiology, care for patients with neck and back pain, and care for older adults, all of which emphasize safe, effective, and patient-centered care. [28–34]
Chiropractic Care Enhances Clinical Outcomes
Some have argued over research regarding the effectiveness
of chiropractic compared to physical therapy or usual
medical care. One study was commissioned to determine
whether chiropractic should be included in the British
national health insurance program. The lead investigator
argued that the statistically significant improvement after
chiropractic (compared to Maitland manipulation/mobilization
as used by physical therapists) was clinically meaningful
and that lowered disability with chiropractic care
persisted after a 3 year follow-up. [35–39]
The United States Agency for Healthcare Policy and Research argued that spinal manipulation was “safe and effective” for acute back pain, and that commonly used physical therapy procedures, other than self-care and exercise advice, and even back surgery, were not effective for the majority of patients with low back problems.  Similar conclusions were reached in a meta-analysis of randomized clinical trials, which reported that there was moderate-quality evidence that both manipulation (a treatment used by chiropractors) and mobilization (a treatment used by physical therapists) are likely to reduce pain and improve function in patients with
chronic back pain.
Spinal manipulation appeared to produce a larger effect, and the researchers noted that both treatments appeared safe, concluding that programs using a variety of treatments may be a promising option.  Focusing on treatment for Medicare beneficiaries seeing a chiropractor,
researchers analyzed 12,170 person-years of data
and found that chiropractor-treated beneficiaries had slower
decline in activities of daily living, disability, lifting, stooping, walking, self-rated health, and worsening health after 1 year, compared with patients receiving usual medical
care.  The authors reported that a year later, they also found higher satisfaction ratings for chiropractic care for back pain.
Although many studies have found consistently higher satisfaction with chiropractic for treatment of back
pain, one study has also suggested that patients receiving
chiropractic manipulations for neck pain were similarly
more satisfied with their general care than patients randomized
to home exercise and advice or to medications.  A study that sampled midlife and older US adults found that many had used chiropractic health approaches (chiropractic, herbs, massage, and yoga) for either acute care or wellness, with wellness and combined users reporting benefits compared with treatment only for acute pain. 
And there are additional questions surrounding the
Office of the Inspector General reports of chiropractors billing
for maintenance care (sometimes called extended maintenance
or preventive or wellness care).  Typically, chiropractors stop billing Medicare for extended maintenance care following the Centers for Medicare and Medicaid Services guidance to have patients sign an Advance Beneficiary Notice of Noncoverage form acknowledging that Medicare does not pay for this service. However, there are some patients who opt for this chiropractic service and pay for it out of pocket.
It has been reported the that benefits of extended chiropractic
care (ie, preventive maintenance) include reduced back disability a year later compared to patients receiving only initial chiropractic or no chiropractic.  Further studies by physical
therapists and chiropractors have shown that patients have
less time lost from work and less disability when they receive
spinal mobilization less frequently but on an extended basis
after their initial care is completed. [45–48]
Chiropractic Services Would Not Increase Overall Medicare Program Costs
For decades, various state worker’s compensation departments
or insurance carriers reviewed and published chiropractor-
related expenses, and almost all found chiropractic
services to be cost-effective, even in lowering unemployment
compensation payouts. [49–52] More recently, a number of studies have looked at actual costs of chiropractic care. The Congressional Budget Office has traditionally scored chiropractic as an add-on that does not save costs elsewhere, even looking for ways to further restrict the limited coverage provided, such as by use of preauthorization for spinal mobilization.  The large 5–state Medicare demonstration project allowed for full coverage of regular chiropractic services and yielded slightly increased costs for the Medicare program. 
Yet further analysis revealed that a small
number of Chicago chiropractors actually accounted for the
increase; some have argued that a simple cap on numbers
of visits, or auditing of records of those doctors regularly
exceeding visit norms, could eliminate this issue. [3, 11, 12] In contrast with this narrow view that full coverage chiropractic is only an add-on, a number of studies have begun looking at possible savings as a result of Medicare beneficiaries seeing chiropractors, termed “offsets.” For example, between the years 2006 and 2012, among 72,326 of the most multiply comorbid Medicare beneficiaries presenting with low back pain, those who received only chiropractic treatment had lower overall costs of care, shorter episodes, and lower incidence of back surgery a year later compared with those who sought care from a physical therapist and/or medical doctor. 
The possibility of chiropractic care helping ease the burden of spine surgery alone could be a significant cost savings to the Medicare program. Other studies similarly point to other savings or offsets that may be associated with chiropractic care. For example, several studies suggest lower opioid use among Medicare beneficiaries, military personnel, and mixed populations when chiropractic is more readily available, such as a study based on 2011 data which showed that a higher per capita supply of doctors of chiropractic and Medicare spending on chiropractic adjustments were inversely associated with younger disabled Medicare beneficiaries obtaining an opioid prescription. 
And a study of 142,539 Army veterans previously deployed to Iraq or Afghanistan found reduced opioid and drug addiction in
addition to less suicidal ideation when chiropractic or other
bodywork therapists provided care.  In addition, this year a
study of 101,221 subjects aged 18–84 years who were
enrolled in a health plan and who reported visits to a primary
care provider or a chiropractor for spinal pain reported
that recipients of chiropractic care had half the likelihood of
filling an opioid prescription, and even lower risk if they
saw a chiropractor within the first 30 days of diagnosis. 
A large study of Medicare beneficiaries found that as the
supply of chiropractors increased in a geographic area, visits
to primary care physicians for back and/or neck pain
decreased.  The study, reported by medical doctors and scientists, found that of 17.7 million Medicare beneficiaries enrolled from 2010 to 2011, overall, in areas with more chiropractors, 0.37 million fewer physician visits were made by beneficiaries, at a projected cost savings to Medicare of $83.5 million.  And unlike the congressionally funded demonstration project, which included a high-fee zone in Chicago that skewed the findings,  research from a nationally representative sample of over 5.4 million Medicare
Part B claims affirmed that chiropractor visit fees decreased
18% over the period, whereas physician visit fees increased
Adding further support to these observations,
researchers reported that of 84,679 older adults enrolled in
Medicare with a spine condition who relocated once
between 2010 and 2014, there was a negative dose
response for spine-related spending on medical evaluation
and management as well as diagnostic imaging and testing
(mean differences of $20 and $40, respectively) among
those with greater access to chiropractors.  The possibility that full inclusion of a relatively low-fee service like chiropractic may lower overall program costs while at the same time enhancing clinical outcomes, lowering opioid addiction, lowering primary care provider visits for back pain, reducing advanced imaging costs, and perhaps reducing surgeries would seem to be compelling evidence for adoption of full-coverage chiropractic as a cost efficiency for the Medicare program.
Chiropractors May Help Reduce Health Disparities
An important issue addressed by the US Centers for Disease
Control and Prevention is that health disparities should
be reduced among groups, races, ages, and sexes. In this
case, in light of the growing evidence, the question arises
as to whether federal policy regarding chiropractic over the
past half century may have unwittingly contributed to
health disparities.  In a study of 7,502 beneficiaries who used chiropractic, 72% were white, 12% Asian, only 1% black, and 14% Hispanic, with much higher utilization in areas with a large distribution of chiropractors.  A free chiropractic clinic in Buffalo, New York, saw predominantly impoverished, female, African American patients with chronic back pain.  Data published by the US Centers for Disease Control and Prevention found that in the past year, 10.3% of Americans used chiropractic, including 12.7% of white citizens but only 5.5% of black and only 6.6% of Hispanic citizens; further, 11.4% of older adults (aged 45–64 years) used chiropractic, but that dipped to 9.5% for those aged 65 years and above. The findings that female, black, Hispanic, and senior adults are underserved by chiropractic have been observed in other research,  and underscore the possibility that the present Medicare policy may act as what economists refer to as a barrier to entry for some of the most vulnerable populations in the United States. 
Whether beneficiaries are attended for back pain
by physicians or chiropractors, a preliminary physical evaluation must be performed to establish the medical necessity
for subsequent treatment. However, beneficiaries who go to
their medical doctor find that physical exams and radiographs
are paid for as needed, whereas beneficiaries who call to check what Medicare pays for at the chiropractor’s office find out these services are not covered. In the 1970s, chiropractic and organized medicine were in a battle. 
However, since that time, interprofessional collaboration
and integrative care have changed the health care landscape
considerably, with a nationally representative sample of
physicians reporting that among complementary health
approaches, referrals to chiropractic account for 27%, second
only to massage.  Professional medical guidelines for back pain encourage physicians to refer for spinal mobilization, yoga, and other complementary and alternative medicine therapies before considering opioid prescription for back pain.  It appears that there is a support for eliminating the inequities currently faced by Medicare beneficiaries seeking chiropractic care. The provision of full coverage for chiropractic services may improve access to Medicare for the vulnerable populations for whom it is most needed, helping to reduce disparities in access to health care. [3, 67]
CALL TO ACTION
The House of Representatives is considering a resolution
from Representatives Brian Higgins (NY-D) and Tom
Reed (NY-R), who introduced HR 3654 on July 9, 2019, in
the 116th Congress, aiming to rectify the nearly 5–decade
issue of unequal coverage for Medicare beneficiaries with
back pain who seek chiropractic care.  As of this writing
in September 2020, the bill has 82 cosponsors (43 Republican,
39 Democratic), and summarizes its purpose as
“[amending] amend Title XVIII of the Social Security Act
to provide Medicare coverage for all physicians’ services
furnished by doctors of chiropractic within the scope of
their license, and for other purposes.” 
Enactment of this bill into law would have the immediate
effect of relieving the inequities and their manifestations
as briefly explored in this article. To support passage
of this legislation, the chiropractic community — including
patients who benefit from the care — should engage all
stakeholders in academia, the press, legislatures, and regulatory bodies. Advocacy and messaging should include discussions of less opioid use, reduced back surgeries and
costs, and greater patient satisfaction associated with chiropractic.
Publications should also advocate for research on full
integration of chiropractors within the health care community.
Research is needed to determine those who serve as
point of entry for most Medicare patients with back pain
(eg, physicians, physician assistants, nurse practitioners,
physical therapists, osteopaths, chiropractors). Research is
also needed to determine the relative costs to the Centers
for Medicare and Medicaid Services of the back pain
treated by various provider types—and not merely the
immediate costs associated with various providers, but
global costs including subsequent radiographs, therapies,
and referrals for advanced imaging, injections, and surgeries
over time, balanced against long-term outcomes. Until
such questions are investigated, full inclusion of inexpensive
conservative chiropractic care within Medicare would
seem to be a pragmatic first step for our government, especially
given the Centers for Disease Control and Prevention’s
national goals of reducing health disparities.
I argue that there is room for all treatments for back pain,
especially because there is not at present any single universal
cure, whether manual, pharmaceutical, surgical, psychosocial,
or behavioral. In this view, practitioners should
work together to solve what the World Health Organization
has termed the leading cause of musculoskeletal disability,
which is also the largest single category of disability worldwide. [67, 69] For integrative and collaborative care to work
effectively, all players should be able to refer, interact, follow
evidence-based guidelines, and consider patient preferences
and viewpoints. When patients are artificially
constrained from receiving treatment for back pain that
they themselves highly rate as effective, no one benefits:
not government or payors, not practitioners who would otherwise
collaborate on case management, and certainly not
patients with back pain, who, owing to lack of full coverage
at the chiropractor’s office, are financially incentivized to
seek care elsewhere that may not be evidence-based.
Vulnerable patients who most need chiropractic services,
such as those who are older, poor, female, and/or
members of racial or ethnic minorities—who often are
involved in physical and manual labor—should not be the
citizens least likely to receive what scientists have concluded
is a safe, inexpensive, and effective single treatment
for back pain beyond self-care and exercise. It is time to
end discrimination against Medicare beneficiaries who
seek chiropractic care. It is time for Medicare to pay for the
required screening exams, radiographs when indicated,
guidance and tips for healthy eating and lifestyle choices,
help with activities of daily living, and exercise counseling
and instruction—the full range of services at a chiropractor’s
office—so that our senior citizens and vulnerable populations
can experience enhanced clinical outcomes
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