H.R. 2654 forces Medicare to treat chiropractors and MDs as equals
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The “Chiropractic Medicare Coverage Modernization Act of 2021” (H.R. 2654) would force taxpayer-funded Medicare coverage of chiropractors’ services for all Medicare-covered benefits allowable under a chiropractor’s state license. Deceptively promoted by the American Chiropractic Association (ACA) as a means of increasing patient access to a broader range of pain management services and a cure for the opioid epidemic, the bill actually creates parity between medical doctors and chiropractors and requires coverage of a broad range of services going far beyond musculoskeletal issues. It is part and parcel of the ACA’s plan to rebrand chiropractors as “primary care physicians” who, in their own words,

can treat anything a medical doctor can.

Bait and switch

First, the “pain management” bait: H.R. 2654 is a reboot of a 2019 bill that tried, but fortunately failed, to do the same thing. The bill has bipartisan support of over 60 Representatives who have been fooled by the ACA into thinking this bill would simply, as the ACA puts it, expand Medicare to cover chiropractic’s “broad-based, non-drug approach to pain management” including spinal and extremity manipulation, evaluation and management services, diagnostic imaging and “utilization of other non-drug approaches”.

Now for the switch: The bill accomplishes this, per the ACA, by “appropriately defining” a Doctor of Chiropractic as a “physician” (just like an M.D. or D.O.) in the Medicare program and providing patients

access to all Medicare-covered benefits allowable under a chiropractor’s state license.

Unless you are familiar with the broad scope of practice the state legislatures have magnanimously gifted to chiropractors and the ACA’s push to redefine D.C.s as PCPs you might be forgiven for believing the ACA’s song and dance about pain management.

Co-sponsors of H.R. 2654 have apparently swallowed the bait, hook, line, and sinker. Congressional “findings” in the bill state that it would bring Medicare coverage “more in line” with that of the Veteran’s Administration, Department of Defense, federal employee coverage, and private health insurance. This is false: When these cover chiropractic services at all, it is limited to treatment of musculoskeletal issues, primarily pain.

With that introduction (and relying heavily on my post on the earlier bill), we’ll take a look at how chiropractors managed to get limited Medicare coverage in the first place. Then we’ll see just how H.R. 2654 could force taxpayers to fund chiropractors’ efforts toward redefining themselves as primary care physicians and subject seniors to their incompetent diagnosis and treatment of a wide variety of conditions.

Medicare and chiropractors: a contentious history

In the U.S., Medicare (Part B) covers people 65 years and older for “medically necessary” services and “preventive services”. “Medically necessary” services are broadly defined as “services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice”. “Preventive services” are “health care to prevent an illness (like the flu) or detect it at an early stage, when treatment is most likely to work best”. This includes a yearly “wellness visit” to create a “personalized prevention plan” designed to help prevent disease and disability, as well as many other preventive and screening services, such as tobacco and alcohol abuse screening, obesity education, nutritional counseling, colonoscopies, mammograms, bone mass measurements, PAP smears, and so on. (Hospital services are covered under Part A.)

For M.D.s and D.O.s, Medicare will pay for any covered service. Coverage for chiropractic services is limited, however,

to treatment by means of manual manipulation of the spine to correct a subluxation.

As we know, the chiropractic “subluxation” is a fictional condition invented in 1895 by an uneducated self-styled “magnetic healer” and, most unfortunately, incorporated into the legal definition of chiropractic practice in all 50 states. This bit of legislative alchemy has permitted chiropractors, for over 100 years, to falsely claim their physical exams and wholly unnecessary x-rays have revealed “subluxations” in their patients’ spines that, unless “corrected”, can lead to all kinds of maladies. They proceed to treat these fictional subluxations with spinal “adjustments”, a process that must be repeated regularly lest their patients fall victim to the numerous ailments these non-existent subluxations are alleged to engender.

Interestingly, the ACA’s promotion of H.R. 2654 doesn’t mention the whole “subluxation” thing, presumably because they are well aware that subluxations are fictional and don’t want to open that whole can of worms by having to explain why they haven’t fessed up to Congress.

In any event, current coverage translates into just a handful of the 15,000 procedure codes used to bill Medicare. Chiropractors don’t like this, hence they want “parity” with M.D .and D.O. physicians and the ability to bill Medicare for any service that is within their expansive scope of practice, whether they are competent to perform that service or not.

Congress authorized limited Medicare coverage of chiropractic services in the early 1970s over objections of the Department of Health, Education and Welfare, as it was then called. Regulations further limit coverage to neuromusculoskeletal conditions for which manipulation is an appropriate treatment. Since inception, chiropractors and the Department of Health and Human Services (HHS), whose Centers for Medicare and Medicaid Services (CMS) administers the Medicare program, have been locked in a near-continuous battle over claims submitted for so-called “maintenance care (sometimes called “wellness care”) which basically consists of regular “spinal checkups” for the detection and correction of (fictional) “subluxations”, advertised by chiropractors as necessary to prevent health problems. There is no evidence that maintenance care is effective for this or anything else and it is not covered by Medicare, which hasn’t stopped chiropractors from submitting hundreds of millions of dollars in unauthorized claims. They are also notorious, as detailed in several HHS Office of the Inspector General reports, for failing to adequately document their Medicare claims.

This ongoing conflict is the reason H.R. 2654 contains a provision requiring chiropractors to take a course on documentation. [The ACA also conveniently omits the substantial history behind the documentation requirement in its discussion of the bill.] Oddly, the documentation requirement does not apply if the chiropractor is seeking Medicare payment for “manual manipulation of the spine to correct a subluxation”, the very portal through which they are being paid millions of dollars for unauthorized treatment. I have no idea why.

As the ACA explains, H.R. 2654 won’t add new services, “it only allows access to all Medicare-covered services that DCs are licensed to provide”. Of course, the unspoken corollary here is that each dollar that goes into a chiropractor’s pocket is a dollar of Medicare’s $731 billion in benefit payments (2018) that is not going into an M.D.’s, D.O.’s, or allied health professional’s pocket for the same service. Hopefully, this means they’ll fight this bill tooth and nail.

The DC as PCP

With this in mind, let’s take a look at what chiropractors claim they are capable of, and authorized to do, under state law. This is what chiropractic organizations had to say on the subject in “The Chiropractic Profession and Primary Care”, part of a white paper put out by a group of alternative medicine practitioners touting “the potential contributions of chiropractors . . . as providers of primary care”. Here’s how I summarized their position in a previous post:

The chiropractors claim, right off the bat, that they are primary care physicians. This is based on the Council on Chiropractic Education, the American Chiropractic Association, International Chiropractors’ Association and other chiropractic organizations saying that they are. The authors say that chiropractors can practice as a first-contact provider for patients of all ages and genders, assess a patient’s health status, formulate a clinical diagnosis, develop a case management plan that includes treatment, prognosis, and any necessary referrals. They can (according to the ACA) address “a large majority of personal health care needs.” The ICA says that the chiropractor can “provide all three levels of primary care interventions and therefore is a primary care provider, as are MDs and DOs.” The authors further claim that chiropractors “are trained to appropriately diagnose and manage the majority of healthcare issues that may present to their offices.”

The ACA has gone so far as to establish the ersatz specialty of “chiropractic internist“, billing it as “the only natural primary care doctors that are licensed in all 50 states”. One can become a “chiropractic internist” after a series of weekend classes in hotel conference rooms, taught by other chiropractors and containing little to no clinical training, and taking a test that, as far as I can tell, no one but chiropractors has evaluated or even seen. Perhaps realizing the obviously oxymoronic character of the term “chiropractic internist”, the ACA is now pushing the more nebulous term “ACA internist“.

According to the ACA Council on Diagnosis and Internal Disorders, in answer to its rhetorical question: “Can a Chiropractic Internist treat anything a medical doctor can?”

The simple answer is YES! Chiropractic Internists use the same diagnostic tests commonly utilized by other medical professionals. . . . While it is true that the scope of practice varies from state to state, Chiropractic Internists practice in most states of the US as primary care practitioners helping people with a wide breadth of conditions and diseases.

Such as?

The list might include things like eczema, thyroid problems, diabetes, parasitic infections, cold sores, Irritable Bowel Syndrome, heartburn/reflux, autoimmune diseases (like lupus, or rheumatoid arthritis, or Crohn’s Disease), infertility, constipation, and vast amount [sic] of other diseases.

And,

Many illnesses that modern medicine has no cure for can be treated by ACA Internists with much success. Illnesses such as fibromyalgia, Crohn’s disease, IBS, migraine headaches, Lyme disease, heart disease, thyroid disease, infertility, low testosterone and diabetes can be greatly improved and often completely resolved with natural therapies offered by these natural physicians.

Of course, there is no proof whatsoever offered for these expansive claims.

In addition, according to the ACA, chiropractic/ACA internists are also

trained and licensed to draw blood, . . . [and] order saliva, urine, and stool tests . . . And since Chiropractic Internists are the natural version of a Medical General Practitioner, you’ll find they are trained to order and read a wide variety of tests (e.g., abdominal ultrasound, EKG, breathing tests, MRIs, CT scans, etc.)

As well, some chiropractors claim they are neurologists, practicing so-called “functional neurology”, about which a recent review concluded there is

no acceptable evidence on the effect or benefit of functional neurology in relation to various conditions and purported indications for intervention.

The American Chiropractic Neurology Board bestows the honorific “Diplomate” on chiropractors who have a whopping 300 hours of post-grad training in “functional neurology” and pass an exam. (An M.D. neurologist must complete four years of medical school and an additional four years of clinical training.) A current ACA continuing education course on “functional neurology” is taught by a chiropractor who co-founded “Plasticity Brain Centers”, which claim, among other things, the ability to treat

everything from Adult ADHD, Adult Autism Spectrum Disorders, early Alzheimer’s/dementia and other forms of cognitive decline, to brain injuries/concussions, dysautonomia, movement disorders, headaches/migraines, Parkinson’s disease, and even those with rare, unknown or un-diagnosable neurological challenges.

The breadth of state chiropractic scope of practice was exposed in a 2014 chiropractic journal article based on a survey of chiropractic regulatory officials. The survey reported that chiropractors are authorized by state law and regulations to order or perform a stunning variety of diagnostic and therapeutic procedures. Here’s a partial list, with the percentage of states including the listed practice in parentheses:

Barium studies (74), cholecystography (X-ray visualization of gallbladder after administration of radiopaque substance) (80), thermography (95), electrocardiography (88), venipuncture (98), blood analysis (100), urinalysis (98), sputum analysis (95), fecal analysis (95), semen analysis (84), throat swab (92), skin scrape (92), school physicals (86), US DOT physicals (98), pre-employment physicals (95), pre-marital physicals (77), sign birth certificates (38), sign death certificates (50), EENT exam (90), abdominal exam (95), stethoscopic exam (98), sphygmomanometry (blood pressure) (95), bi-manual pelvic exam (73), speculum exam (72), recto-vaginal exam (72), Pap smears (79), female breast exam (80), rectal exam (85), male genital exam (85), prostatic exam (digital) (85), hernia exam (85), ultrasound (treatment) (100), IFC (interferential therapy) (100), microcurrent therapy (100), iontophoresis (not with prescription medication) (100), Russian stimulation (100), non-ablative laser therapy, nonadjustive treatment of female pelvic conditions (72), ear irrigation (83), TMJ (100), oral chelation therapy (76), IV chelation therapy (39), vitamin injection (43), limited prescription privileges (7), oxygen therapy (57), dry needling of trigger points (64), minor surgery (9), obstetrics (22), extremity casting sprains (71), extremity casting uncomplicated fractures (58), hypnosis (66), electrolysis (44), hyperbaric chamber (62), manipulation under anesthesia (71).

Lest you be misled into thinking chiropractic scope of practice indicates actual competency in this expansive array of diagnostic methods and treatments, it does not. While the scope of this article does not permit a deep dive into the murky waters of chiropractic education and training, suffice it to say that the whole business is controlled by the chiropractors themselves and they alone decide what they are sufficiently educated and trained to do, something they are known to vastly overstate. For example, a real primary care doctor, SBM’s Harriet Hall, M.D., has ably dissected their claim that they can competently practice primary care. (For one thing, many are anti-vaccination, a position that defies good primary care. For another, chiropractic clinical training is grossly inadequate for primary care and consists almost exclusively of seeing patients with musculoskeletal issues, like back pain.) A recent cross-sectional analysis of marketing claims made by chiropractor and other alternative practitioner websites found that a substantial number of chiropractors claim to treat allergies and asthma, despite the fact that there are no chiropractic treatments shown to offer meaningful objective benefits for these conditions. Nonetheless, efficacy claims were common.

Which brings us to their latest perfidy. During the pandemic, chiropractors falsely advertised the “immune boosting” powers of “spinal adjustments” to ward off COVID-19. They shilled for “immune boosting” dietary supplements as well.

Even as they tout themselves as primary care physicians under current state law, chiropractors, with the support of the ACA, are vigorously lobbying for the expansion of chiropractic scope of practice, a campaign we’ve covered extensively here on SBM. They’ve lobbied for expanding chiropractic scope of practice to include diagnosis and treatment of all human ailments and removal of restrictions on treating infectious diseases, endocrine disorders, and abnormal histology. They’ve lobbied, with some success, to add diagnosis and treatment of student athlete concussions, performing school physicals and unnecessary scoliosis exams, prescription privileges, and nutritional counseling.

The latter is a favorite – coupled with the authority to order or perform diagnostic testing, chiropractors can fashion themselves into “functional medicine” practitioners, a lucrative alternative medicine “specialty” comprised of massive over-testing and prescription of dietary supplements, which they can turn around and sell to patients for a tidy profit. In fact, a 2017 review of studies of chiropractic practice revealed that almost a third of chiropractic patients are treated with nutritional supplements, an extraordinary number given the lack of evidence of effectiveness for supplements. But what a great sales opportunity, with taxpayers potentially picking up the tab under Medicare’s “nutritional counseling” coverage.

In several states, chiropractors have successfully included themselves in laws that allow direct primary care agreements with patients, which one lobbyist frankly admitted was aimed at positioning chiropractors as PCPs. Or they want to tack on anything they are taught in chiropractic school as a catch-all category to their scope of practice, leaving it to themselves to add whatever they wish.

Given their sweeping claims of competence and aggressive push for an ever-expanding scope of practice, one thing is certain: Despite giving lip service to pain treatment and alternatives to opioids, if H.R. 2654 passes, chiropractors are going to go full bore in forcing CMS to cover much more than musculoskeletal problems. If they had merely wanted more expansive coverage for the diagnosis and treatment of musculoskeletal conditions, including pain, it would have been easy enough to draft language to that effect, but they didn’t.

While agencies have some wiggle room in interpreting what Congress tells them to do, HHS and CMS will be hard pressed to regulate around the plain language of the bill should it become law. “Any function or action . . . legally authorized by the State” is fairly unambiguous. Based on their history of unauthorized claims under a fairly simple, albeit scientifically deficient, coverage mandate from Congress, just imagine what they could do with “parity” and the authority to bill Medicare for the entire panoply of diagnoses and treatments bestowed upon them by credulous state legislators. Think of the possibilities for colossal battles between chiropractors and CMS over whether a treatment is “medically necessary” or just whose standard should apply when making that determination: evidence-based “conventional” medicine or “chiropractic medicine”?

Don’t let chiropractors deceptively sell H.R. 2654 as an expansion of pain management services and a solution to the opioid epidemic. Let your Representative in Congress know what this bill really does.

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