By Kristen E. Porter, PhD, MS, MAc, Lac and Elizabeth Sommers, PhD, MPH, LAc
Improving access to acupuncture care is a fundamental public health goal. This can be achieved through a variety of mechanisms, including legislative processes that mandate reimbursement by health insurance.
While federal efforts, namely the Hinchey Bill, are not currently active, lawmakers in Massachusetts are considering legislation to cover acupuncture reimbursement. Insurance parity, requiring that any insurer that covered acupuncture provided by a physician would also cover all licensed acupuncture providers, is currently held in states such as California, Florida, Maine and Maryland.
Reimbursement parity would require that all service providers are reimbursed at the same rate. Workers' compensation, for example, has one fee schedule that is used across the board for all providers who perform acupuncture. New Mexico has reimbursement parity for providers. Other insurers pay at a higher rate if the provider is a physician.
There are four major stakeholders on this issue: health insurance providers, acupuncturists, physicians, and consumers with health care needs. Acupuncturists have differed in their attitudes about insurance reimbursement. Supporters value improving patient access and treating patients who are on disability or have limited incomes. Additionally, reimbursement may boost business revenues, which is a major issue for many acupuncturists in private practice. Opponents view insurance payors as gatekeepers who have caused considerable challenges for other medical providers and may not be worth the additional complications such as administrative burden and potential scope of service limitations.
The dichotomy of acupuncturists' opinions about the value of insurance coverage was described by Hudson Doyle LAc, president of the Acupuncture and Oriental Medicine Society of Massachusetts (AOMSM): "...getting involved with insurance opens a real possibility of bureaucracy that can hamper the practice and put practitioners at risk for a lot of paperwork. I've spoken with chiropractors who wish that insurance reimbursement never came into being." He further explained that "a disadvantage of the bill is that it will become a constant struggle for our organization to keep any gains we have made. Washington State has had to keep fighting every year, which may be an unanticipated consequence that might come to pass."
More allopathic providers are accepting and even embracing integrative approaches that promote collaboration with acupuncturists (Chen et al. 2010). Chen's survey reported that 73 percent of the physician respondents agree that insurance should at least partially cover the cost of acupuncture, and 30 percent thought that insurance should fully cover treatment. Nearly half the responders indicated that they would continue to refer to acupuncture at the same rate, with 34 percent planning to increase acupuncture referrals.
Initiatives – old and new
Proposed legislation in Massachusetts is being supported by AOMSM. In 2008, Richard Ruth LAc spoke with his state representative, Rep. William Pignatelli (D), about sponsoring a bill that would mandate insurance coverage for the services of licensed acupuncturists. As a result, H4111 was drafted and two other state legislators added their support. This bill was supported by NCCAOM, AAAOM, New England School of Acupuncture as well as acupuncture patients and practitioners. The review committee in 2010, however, decided that the bill required further study.
Rep. Pignatelli offered his explanation that "it was a late file bill and the committee did not understand the concept of acupuncture. However, the opposition was primarily from the acupuncture world itself. The legislature is tough enough, so the acupuncture industry needed to get along with one another, with respect to the bill, which was not true at that time."
James Moran LAc, explained that "House Bill 4111 died in committee – a failed home-run. However, acupuncture supporters got to play some 'legislative ball' that may make future attempts a bit easier."
The revised bill currently being reviewed, HR 1593, is "more comprehensive and provides an understanding of what acupuncturists do" explained Pignatelli. He elaborated that "many legislators have been contacted by acupuncturists and patients who has raised a lot of awareness." The biggest challenge to the bill is creating another mandated benefit, because it raises concerns about who pays for it and how insurance rates will be affected. Pignatelli stated that "... health and wellness are more front and center than ever, so I am hopeful." He believes that passing this bill should be part of overall healthcare reform.
Acupuncturists in support of the bill weighed in on their perspectives. Ellen Silver Highfield LAc, Director of Acupuncture Programs at Boston Medical Center, stated that "If we can form an alliance with physicians, the mandate is going to be a true step forward. The MDs' pulses that I've taken indicate that this is the right time to join forces; maybe, this time, we can actually get a bill passed!"
Carol Krieger RN BSN LAc Dipl.OM, a student in the Pain Research, Education and Policy program at Tufts University, feels that acupuncture reimbursement will be an "advantage to patients with chronic pain issues in terms of potential reduction in medications, which could reduce overall costs and minimize negative impact of adverse effects related to medications.
Demie Stathoplos MBA MSW, executive director of Pathways to Wellness in Boston, said that Pathways has seen its revenue from health insurance coverage increase a hundred fold in the past four years, indicating that insurance companies themselves realize that acupuncture can be clinically and cost-effective in treating a myriad of health conditions – especially for patients who are homebound and those with severe chronic illness.
"Without widespread health insurance coverage of acupuncture, safe and effective treatment is out of financial reach for a majority of people. It's rare that we have the opportunity to support an action that can improve quality, access and cost of care simultaneously. This is one of those opportunities," Stathoplos said.
Massachusetts acupuncturist Naomi Alson MAc LAc vividly describes her experience treating "a young girl who has had severe back pain for seven years. After her first treatment she walked out pain free. She is a good candidate for regular acupuncture care. At 25, she doesn't want to take strong pain medications and she can't maintain employment as a practical nurse due to chronic back pain.
"HR 1593 will insure that acupuncture is accessible to most people in Massachusetts, rather than being a medicine for the well-to-do," said Alson. "It will change acupuncture from being a "fringe" treatment, to becoming a more acceptable mainstream treatment. Often my patients have to receive fewer treatments than they ideally need, because the cost of treatment is unaffordable. This is frustrating for me as a practitioner because I see clients begin to improve and then discontinue appointments because of financial constraints."
Alson noted that nearly every day she has patients call to see if insurance covers acupuncture.
"My patients are waiting for this law," she said.
The new bill, HD1593 includes legislation for both insurance reimbursement and parity, defined as "insurance equality." Nineteen co-sponsors are currently signed onto the bill, which exceeds what was required to move forward. The next step for the bill is to go before the Joint Financial Committee.
Clearly, the yin and yang of this issue are not resolved in our acupuncture community. Nuanced discussion and the commitment to working with our peers are in order to ensure that steps forward – in the direction of fairness and increasing access to acupuncture care – will be needed as discussion continues.
Laws and governing regulations like Massachusetts' HR 1593 may help to ensure that health care that includes wellness is a right, not a privilege.
Chen L, Houghton M, Seefield L, Malarick C, Mao J. A survey of selected physicians' views on acupuncture in pain management. Pain Medicine 2010;11:530-534
Click here for more information about Kristen E. Porter, PhD, MS, MAc, Lac.
Click here for more information about Elizabeth Sommers, PhD, MPH, LAc.
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