Integrative Health Care: The Implementation of ACA Section 2706

Tuesday, May 27, 2014

Water Work OutThe Integrative Healthcare Policy Consortium (IHPC) was formed in 2001 at the request of several congressional lawmakers, including Sen. Tom Harkin of Iowa, who wanted to be kept apprised of the growth and public use of complementary and alternative medicine, still called CAM, but now known when blended with conventional care as “integrative medicine.”[1]  Largely due to Harkin’s leadership since the 1990’s, many CAM therapies have found places in academic health centers, in military and veterans medicine (acupuncture for pain mitigation and opioid alternatives), in hospital systems (massage therapy in adjunctive cancer treatment), in local physician-led clinics and recently in residency programs (12 preventive medicine residency programs now include integrative medicine training).

The members of the IHPC are the professional organizations representing credentialed and licensed acupuncturists, naturopaths, massage therapists, chiropractors, midwives, homeopaths, and several universities that provide the health and medical education for these disciplines. IHPC reports that its member organizations represent 350,000 providers around the United States. They serve the vast majority of the millions of patients reported to make use of CAM or integrative health services on an annual basis.

Although this now-inexorable advance of unconventional therapeutic traditions and techniques has become a standard part of health care choice for millions of Americans, the discrete disciplines have yet to attain anything close to financial parity in the health care market as part of insurance reimbursement.

To address this imbalance, Harkin worked with IHPC and others during the creation of the Patient Protection and Affordable Care Act (ACA) to include complementary practitioners and integrative health care providers in several sections of the law. The provisions that come with the most teeth, although they are blunted so far, are in Section 2706, “Non-discrimination in Health Care.” This is the section of the ACA that addresses imbalances in the health insurance marketplace, including protections for preexisting conditions. Section 2706(a) states, “Providers: A group health plan and a health insurance issuer offering group of individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care providers who is acting within the scope that that provider’s license of certification under the applicable State law.”

IHPC has made the correct interpretation of these provisions its primary focus in the last 2 years and has worked with congressional offices such as Harkin’s, the U.S. Department of Health and Human Services (HHS), and its regional directors to do so.

IHPC’s April 10 briefings on Capitol Hill for Senate and House member and committee staffs focused some of the real-world reasons why this evolution is reaching a new level of institutional acceptance and inclusion. Speakers focused on the clinical and research outcomes that highlight the value of integrative therapies and the role of integrative providers within conventional health care settings at academic health centers and in innovative health care systems. The briefing also highlighted two important factors that will have a bearing on the continued adoption of integrative therapies and their delivery within a more favorable financial framework:

  • A cohost of the briefings was the Coalition for Academic Health Centers for Integrative Medicine (CAHCIM, formed in 2002), 57 U.S. medical schools and organizations that conduct clinical practice and research around integrative therapies.
  • The briefings took place in the middle of a public comment period for a “Request for Information Regarding Provider Non-Discrimination,” issued by HHS, the U.S. Department of the Treasury, and the U.S. Department of Labor (DOL) at the direction of the Senate Appropriations Committee (see more below).

The repeated theme evident here and elsewhere is the narrowing of the historic gulf between the discrete disciplines represented by the IHPC and conventionally trained physicians educated in the nation’s top medical schools, represented by CAHCIM. The briefing was the first time IHPC and CAHCIM have joined forces to inform policymakers about the progress that integrative practice is making throughout health care and wellness systems.

Margaret Chesney, PhD, chair of CAHCIM and a longtime integrative medicine leader at the University of California, San Francisco Osher Center for Integrative Medicine, described in some detail the differences in outcomes found between usual care and integrative care in the treatment of heart disease.

Courtney Baechler, MD, MS, a cardiologist, chief wellness officer, and vice president at the Penny George Institute for Health and Healing at Allina Health in Minnesota, presented an overview of the institution’s experience with integrative medicine and health practices. The success treating chronic pain, heart disease, cancer, and spinal fusion among other conditions has been so effective that integrative treatments will be implemented throughout the 13-hospital system.

IHPC Chair, Led Wisneski, MD, a faculty member at Georgetown University, The George Washington University, and the University of Colorado, placed the substance of the presentations into a policy framework and noted how proper implementation of Section 2706 will expand the conversation about the health care workforce and establishing additional appropriate places for integrative medicine training in residency programs.[2] (The presentations are available on the IHPC website, http://www.ihpc.org.)

The Request for Information from HHS this past March is intended to correct the substance of a frequently asked questions sheet (FAQ) on Section 2706 that the agencies issued in April 2013. Shortly thereafter, the Senate Appropriations Committee effectively rebuked the agencies for missing the intent of the provisions of the section. The RFI noted the following:

“The goal of this provision (2706) is to ensure that patients have the right to access covered health services from the full range of providers licensed and certified in their State. The Committee is therefore concerned that the FAQ document issued by HHS, DOL, and the Department of Treasury on April 29, 2013, advises insurers that this nondiscrimination provision allows them to exclude from participation whole categories of providers operating under a State license or certification. In addition, the FAQ advises insurers that section 2706 allows discrimination in the reimbursement rates based on broad `market considerations’ rather than the more limited exception cited in the law for performance and quality measures. Section 2706 was intended to prohibit exactly these types of discrimination.”[3]

In May, IHPC organized a survey that was distributed through its member organizations to collect data about the status of Section 2706-directed insurance reimbursement, including the provision or denial of reimbursement to practitioners and to patients. The public comment period closes June 10. IHPC survey results will be available later in June.

IHPC has also expanded its public education and information programs, including its first initiative to engage consumers directly:

  • A booklet on the cost-effectiveness of integrative treatments such as those described by Chesney and Baechler. Although many economic studies exist, their results have not been well compiled or presented in a style useful to decisionmakers.[4]
  • A consumer-facing website and program called CoverMyCare, designed to stimulate CAM consumer and practitioner advocacy to press state officials to ensure insurance company compliance with Section 2706.[5]

These and other initiatives in the integrative field are designed to keep open the door to that health care market created by Section 2706. Even with the promise of reimbursement that matches the reality of public use of integrative therapies, however, there are enough potholes in the implementation to project a long road to national adherence.

A thorough and quite helpful examination of these factors was written by John Blum of Loyola University in Chicago for BNA’s Health Law Reporter: “Non-Discrimination and the Role of Complementary and Alternative Medicine.” Blum, a volunteer member of IHPC’s non-discrimination committee, notes the inconsistencies and misinterpretations bobbing in the wake of 2706’s activation on January 1, such as the FAQ that the Senate Appropriated Committee has directed HHS to correct.

One “striking” inconsistency he writes is how different states treat services providers of the same disciplines in determining Essential Health Benefits: The California benchmark plan includes limited coverage of acupuncture but does not cover chiropractic. New York State covers chiropractic in its Oxford Health Plan-based benchmark plan, but not acupuncture.[6]

Universal state compliance will no doubt take a long time to come to fruition, but there exists already one model of broad adoption that may be influential: the Federal Employee Health Benefits (FEHB) plan. In February, the FEHB Blue Cross Blue Shield Benefit Plan, which covers more than 8 million people, announced that in compliance with Section 2706(a), it would “cover any licensed medical practitioner for offered services within the scope of the provider’s license.”[7]

Blum suggests that eliminating profession-directed discrimination, the primary goal of IHPC and professional organizations, may not be the most compelling argument to make. “The larger issue underlying Section 2706(a),” he writes, “goes beyond questions of non-discrimination and rests with broader considerations about the adequacy of the health care workforce.” Many leaders in complementary and integrative care would agree with this and possibly with his recommendation: “Major areas of population health needs, such as those in the area of pain management, offer opportunities to develop avenues to better utilize (integrative) practitioners, not as reinvented primary care doctors but as licensed professionals within their current scopes of practice…. Those who provide CAM services, particularly in areas such as pain management, should be judged on the present value they bring to the health system and not on their potential to assume roles that will put them into perennial battles with organized medicine.”

In the meantime, the policy paladin of the earliest battles leading integrative medicine and CAM into U.S. health policy, Sen. Harkin, is retiring at the end of this term. This fall, integrative medicine and health advocates from all points on the health care landscape will stop to honor him. It is hard to overstate the importance of the role that he assumed in the CAM and integrative fields in the early 1990s or its impact in the two decades since. The program that will accompany the acknowledgment of his contribution will be a good place to see how the health and wellness landscapes have changed because of his leadership.

 


[1] In May, the research center at NIH dedicated to CAM, the National Center for Complementary and Alternative Medicine, NCCAM, opened a public comment period on the question of changing its name to the National Center for Research on Complementary and Integrative Health, NCRCI.  http://nccam.nih.gov/news/press/05152014?nav=spl

[2] The National Coordinating Center for Integrative Medicine was formed by Health Resources Services Administration in 2012 and is now the Integrative Medicine in Preventive Medicine Education: http://www.imprime.org/about-us.html.

[4] In May, IHPC was awarded a grant from Emerson Ecologics, LLC to support creation of the booklet: http://www.prnewswire.com/news-releases/emerson-ecologics-announces-the-award-recipients-of-the-emerson-grant-257091251.html.

[5]Note: author has been been a volunteer advisor to IHPC and proposed the CoverMyCare project.”

[6] BNA’s Health Law Reporter, 23 HLR 574, 4/24/14. http://www.bna.com

[7] BNA’s Health Law Reporter, 23 HLR 574, 4/24/14. http://www.bna.com. Pg 5

 


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