Thursday, May 9, 2013

If we can slide our attention away from the question of whether or not the under-35 generation will buy health insurance, we can locate other provisions of the Patient Protection and Affordable Care Act (PPACA) that may actually expand access to effective care options and deliver research that decision-makers, patients, and practitioners can more easily take advantage of.

Photo of two medical professionals conferringThese provisions are designed to ensure: 1) wider access to long-established patient-valued care choices, and 2) patient participation in the formulation of research agendas. 

For purposes of this article, we are talking about a class of care service that fits both: sub-sets of the complementary and integrative medicine disciplines – acupuncture and Chinese medicine, chiropractic, midwifery, and naturopathy.   

All of these disciplines are long established, have  strong records of positive outcomes, repeated patient use, growing licensure and increasing adoption in conventional clinical and educational medical programs (including in military health).  Greater access to them has the potential to address (in the short term at least) two challenges confronting daily health care practice: back pain and the growing shortfall of primary care physicians.

The availability of such contributions, however, rests in part on how state insurance commissioners interpret the provisions of the little known and little understood piece of the PPACA, Section 2706, “Non-discrimination in health care.”  It forbids insurers from discriminating against licensed providers no matter their discipline if their scope-of-work covers their state’s essential benefits standard.  In the case of primary care, compliance with Section 2706 could add several thousand providers to our very serious shortfall of primary doctors.

Back Pain and Patient-centered Research

Integrative therapies like acupuncture have grown more acceptable as pain management tools, driven over the years by patient choice that is finally influencing not only conventional treatment attitudes and services but research as well.  The primary organization investigating public use of acupuncture and other integrative therapies is the National Institutes of Health’s  National Center for Complementary and Alternative Medicine, NCCAM.  Unlike its sister institutions, NCCAM is charged with research on therapies and products in use every day by millions of Americans.  But as with almost all research enterprises NCCAM has had next to no involvement by patients.  This may change with the development of the Patient-Centered Outcomes Research Institute (PCORI).

Last February, PCORI CEO Joe Selby, M.D., visited NCCAM to introduce PCORI to its National Advisory Council: researchers, clinicians and practitioners from medical schools, clinics, and research centers across the U.S. During the presentation, NCCAM Director Josephine Briggs, M.D., noted that by dealing with products and therapies used widely by the public, NCCAM was the NIH center with the closest relationship to the patient experience. 

In the two months since that first connection, several meetings have taken place.  In a March interview, Briggs said that both organizations share an interest in strengthening research around pain, a subject of primary importance in NCCAM’s portfolio and for all of NIH.  Several years ago, the NIH Pain Consortium was established (Briggs sits on its executive committee), to ensure cross-institution collaboration.

While no partnership has been created, PCORI is creating the kinds of protocols that can assist research organizations with no history of patient involvement.  “We have very limited tools and methods to capture the most representative patients,” Briggs noted.  It is important, she said to examine pain “as it exists in the real world,” rather than in academic settings, where most NCCAM research has been conducted.

Another goal for Briggs is to put the proven benefits of integrative therapies, particularly for pain management, into the field sooner rather than later.  “We want to make sure that the evidence is growing,” she said, “so as to become part of the reimbursement system.”[1]

Bolstering Primary Care with Non-MD/DO Providers

As the nation’s cohort of primary care physicians has receded in recent years (bad timing with the prospect of millions of new insured citizens getting ready to enter the system) national policy organizations such as the Institute of Medicine and others have looked closely at expanding primary care responsibility to non-M.D.s.  For example, studies have examined the emerging roles of advanced practice nurses and physicians assistants in primary care.[2], [3]

An interesting expansion on this concept was published in a March 2013 report, Meeting the Nation’s Primary Care Needs, by Michael S. Goldstein, Ph.D., of the UCLA Center for Health Policy Research and John Weeks, executive director of the Academic Consortium for Complementary and Alternative Health Care (AACAHC).  AACAHC is an umbrella group for the associations of colleges and educational institutions serving the complementary and integrative disciplines.

Traditionally, many of the practitioners of these disciplines have considered themselves in the primary care business as a simple matter of how they serve their patients.  As a way to create something more substantial than anecdotal assertions, AACAHC asked four of its member organizations – representing some 107,000 practitioners -- to create a self-assessment describing their capabilities and shortcomings as providers of primary care medicine.[4]   The report’s primary findings:

  • The disciplines strongly self-identify as primary care providers.
  • Most of their clinical work is with patients who choose them as the first choice for care.
  • The accreditation standards for the disciplines recognize a broad scope of practice with educational requirements closely aligned with traditional primary care.
  • Some states legally define some of these disciplines as primary care providers.
  • Some disciplines are part of patient-centered medical home planning as primary care resources in underserved areas.

The report also noted, “These disciplines are generally unrecognized by the conventional medical community and workforce planners.”  Although chiropractic, acupuncture and naturopathic medicine have attained varying degrees of licensure among the states, participation in reimbursement has been slow to come by.  The AACAHC report argues that the practitioners of these disciplines “represent a hidden dimension of primary care in the United States.”

Where the ACA Opens the Door to Expanded Therapy Options. Or Maybe Not

Of course the historical relationship of these disciplines with the broad health care system has been to be apart from it.  Despite a $30-plus billion market and annual service to 30 million citizens, including increasingly children, the services are paid for out-of-pocket, with few exceptions.[5]

Several components of the PPACA acknowledge the depth and historic reality of these citizen-selected therapies and contain language meant to bring them into the care system.[6]  Section 2706 is the directive meant to make that happen.  As the text reads:

“(a) Providers. A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider's license or certification under applicable State law.”

Section 2706 falls in with other provisions under “Health Insurance Market Reforms:” fair insurance premiums; guaranteed availability and renewability of coverage; prohibiting preexisting condition exclusion; prohibiting discrimination based on health status; ensuring comprehensive insurance coverage; and prohibiting excessive coverage waiting periods.

Each of these clearly is intended to create wider, more affordable, equitable and simpler patient access to a full measure of proven, available care options than is presently available within the reimbursement-based care system.  For practitioners in the integrative disciplines – whether delivering back pain therapy or augmenting the nation’s primary care system – such inclusion would be a sea change, elevating their work to parity with other licensed disciplines. 

In a letter to HHS Secretary Kathleen Sebelius asking for diligent enforcement of the states’ interpretation of Section 2706, Keith Overland, DC, president of the American Chiropractic Association, wrote: “Discrimination against providers is also discrimination against patients…(it) unlawfully restricts the patient’s ability to select the provider, and the service, of his or her choice.”

Although Section 2706 may not receive the interpretation at the state level that integrative practitioners want, patient choice is clearly re-aligning basic components of the nation’s care system.  The conversations about how far it might advance between now and October when the insurance exchanges open should be interesting to witness.


[1] Interview with author, April 16, 2013

[2] Petterson, SM, et al. Projecting US Primary Care Physician Workforce Needs: 2010-2025. Ann Fam Med. 2012;10:503-509. doi:10.1370/afm.1431

[3] Frame PS, Wetterau NW, Parey B. A model for the use of physician’s assistants in primary care. J Fam Pract. 1978:Dec;7(6):1195-201

[4] Association of Accredited Naturopathic Medical Colleges, Association of Chiropractic Colleges, Council of Colleges of Acupuncture and Oriental Medicine, Midwifery Education Accreditation Council

[5] Complementary and alternative medicine use among adults and children: United States, 2007. Barnes PM, Bloom B, Nahin RL.  Natl Health Stat Report. 2008 Dec 10;(12):1-23.

[6] Reference Guide: Language & Sections on CAM and Integrative Practice in HR 3590/Healthcare Overhaul.

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