Holistic Medicine in the New Affordable Care Act Era



The Affordable Care Act offers the opportunity to shift American health care from disease treatment to prevention. Practitioners of complementary, alternative and integrative medicine (CAM) see new entry points for bringing their healing practices to the public. Hospitals are waiting for the insurance companies to approve CAM providers.

However, the top priorities of ACA— covering the uninsured, making treatment more effective and controlling runaway costs—don’t include promoting natural medicine. In short, while broadly prohibiting discrimination, there are two important limitations. The ACA is not an “any willing provider” law, requiring insurance companies to contract with any provider agreeing to the insurers’ contract. And insurers can pay different rates to different providers as long as these rates are based on quality or performance measures.

Each discipline has the opportunity to deepen their modality’s professionalism and assure that the state does not discriminate against them as legislation is passed approving the ACA. Health disciplines that prove their ability to deliver a desired result and can regulate their professions quality can succeed in participating in the insurance system.

Even though the law allows for alternative medicine, it is unspecific about reimbursing practitioners. The burden rests on disciplines to show value and costeffectiveness of their work and to sustain improved health benefits. Licensing and regulation are key components for insurance providers. Those that have professionalized their modalities will have the easiest time. Those that have not will still have to rely on continuing in the self-pay model.

CAM policy-watchers rejoiced when Senator Tom Harkin, D-Iowa, inserted into the law a section stating that insurers “shall not discriminate” against care providers acting “within the scope of that provider’s license.” The action emboldened several CAMs to move on the challenge; educating state directors, writing letters and addressing lawmakers. On the forefront are national organizations representing naturopaths, acupuncturists, nutritionists, midwives and chiropractors.

“In 16 states, naturopath doctors will be able to bill insurance,” says Lorilee Schoenbeck, ND, a Vermont practitioner and board member of the American Association of Naturopathic Physicians “That will be the largest single event to impact our profession in years. And it’s a change our nation needs. Our health care system needs prevention-oriented, low-cost primary care that’s effective for chronic illness.”

There is no guarantee, however, how state and federal regulators will interpret the nondiscrimination clause as they implement the complex law. Some states have indicated they are not aware of the nondiscrimination language or do not believe it mandates equal coverage. The nondiscrimination language resembles Washington State’s 1995 “every category provider” law, which requires private commercial insurers to cover licensed CAM providers. The naturopathic doctors association hired former Washington State insurance commissioner, Deborah Senn, to make a case to federal regulators. “The change has been very popular in Washington because it’s about good consumer choice. Implementation was very successful here,” says Senn, “And we expect it to be successful nationwide.”

The American Association of Acupuncture and Oriental Medicine (AAOM) conducted a national letter-writing campaign, attracting more than 20,000 signatures in support of expanded access to acupuncture. “We looked into hiring a lobbyist to get the attention of government officials,” says Jeannie Kang, LAc, a Los Angeles acupuncturist and past AAOM president. “But it was going to cost $10,000 a month. We don’t have that kind of money.”

“The support came from our patients. It’s very consumer-driven medicine.” Several states have included acupuncture for treating pain, nausea and other ailments in their essential-health benefit plans. Millions of Americans will be eligible for acupuncture under their insurance plans. “It’s a very big deal for our profession,” says King. “Our medicine is still quite young in this country. But we have been quickly recognized as effective.”

Few professions fit the health care law’s prevention focus as well as nutritionists, which understand that helping patients with diet changes can save them heart surgeries or cholesterol medications with unpleasant side effects.

The law specifically says nutritionists and registered dietitians (RD) may be included in patient-centered medical homes, an arrangement designed to coordinate a multidisciplinary team. Again, the limita-tion of the law regarding reimbursement places the burden to show value and costeffectiveness on practitioners.

“Health care reform has the potential to increase demand for RDs, but this outcome is not a given, “ writes P. A. Tuma, director of regulatory affairs for the Academy of Nutrition and Dietetics, in a policy brief. “The RDs can be assured of far greater benefits by advocating for state and federal regulations that specifically identify dietitians as capable providers of particular services.”

Certified professional midwives (CPM) secured a partial victory in the law, according to Mary Lawlor, MA, CPM, LM, executive director of National Association of Certified Professional Midwives (NACPM) The provision doesn’t mention CPM specifically, making it challenging to ensure states understand the value of access to midwifery. “The gap between passing a law and implementation is enormous,” Lawlor says. “The provider and facility fee structure implementation is missing or incomplete.”

She continues, “The high cost of conventional birth procedures and shortage of obstetricians, especially in rural areas, will help midwives prove their worth. We’ve been able to make the case that maternity care is in terrible shape. We spend more money on it than any other country, and yet our outcomes are getting worse. Physicians tend to give everyone medical care that’s appropriate for only the most highrisk births. We’ve been able to show clearly that midwives can provide better care.”

Chiropractic care is included in most health insurance plans, including major medical plans, Workers’ Compensation, Medicare, some Medicaid plans and Blue Cross Blue Shield plans for federal employees, among others. Chiropractic care is also available to active-duty members of the armed forces at more than 60 military bases and is available to veterans at 36 major veterans’ medical facilities.

The American Chiropractic Association has a daily Capitol Hill presence representing doctors of chiropractic. Of all the CAM modalities, the chiropractic organization is the most active. Lobbyists participate in stakeholder roundtables, submit potential legislative language and press lawmakers for clarifications to current or proposed legislation. By far, the most sophisticated of the CAM modalities in lobbying, chiropractors are a model for preparing and presenting resource information, statistics and talking points regarding their role in the new healthcare delivery system.

Besides licensing and regulations, scientific assessments of alternative therapy are required to demonstrate efficacy. For providers that have anecdotal evidence of effectiveness, this is putting the cart before the horse. Until then, recipients will pay 100 percent of alternative therapy expenses.

Although the Affordable Care Act doesn’t include promoting natural medicine, it could indirectly support an array of professions based more on relationships and behavior changes rather than on medical technology. With a shift in payment models from “fee for service” to “fee for results”, health providers will be looking to practitioners to make Americans healthier without hospitalization and surgery. “Getting involved soon after the bulk of the law takes effect is key,” says Michael Cronin, ND, a board member of the American Association of Naturopathic Physicians. “The better we do early on, the more opportunities will open up.”

The benefits of integrating with insurance companies are significant, including reams of new data to study and demonstrate the efficacy of natural therapies. “That data will be useful in the future for getting wider acceptance and recognition,“ says Kang. “So there’s a ripple effect that will go wide and deep.”

Dale Bruder is a regular contributor to Natural Awakenings.  

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