ISSUES TO CONSIDER WHEN DECIDING TO SUPPORT THE PROPOSED HOUSE MEDICARE BILL: FEDERAL ACUPUNCTURE COVERAGE ACT OF 2015/16
NGAOM members have been asked to vote to support the House Medicare bill (will get assigned a number once sufficient support is evident) sponsored by California Representative Judy Chu. This bill, known as the Federal Acupuncture Coverage Act, will likely not be introduced without a strong show o
f support from the acupuncture profession. Note that a version of the bill has been introduced in each of the previous eight Congressional sessions. It has never received sufficient support to pass.
The bill will include acupuncturists as licensed providers and acupuncture as a reimbursable procedure under Medicare.
Several issues have been presented weighing the pros and cons for the inclusion of acupuncture and acupuncturists under Medicare. You are strongly encouraged to review the AAAOM document of FAQs on this legislation. There are really only two particular issues that dominate the conversation. These issues have several branches.
ISSUE #1: Inclusion in Medicare will drive down present reimbursement rates.
Branch 1.1 Medicare is used to set reimbursement rates in the private sector.
This is partly true. Medicare is often used to establish reimbursement rates for other public social service programs. There are private insurers that base reimbursements on Medicare rates. However, this is not universally the case nor is it the sum of ways in which insurance reimbursements are set. There are numerous exceptions. Acupuncturists who bill insurance know that rates differ widely according to the carrier and within different plans offered by the carrier. Rates may also be different for capitated plans in which an LAc may be a provider.
Additionally, I know of one state where the reimbursement rate for Work Comp and Auto is set to “Medicare +10%.” However, in this state that reimbursement rate is $75 which was established in 1995, and Medicare does not include acupuncture or acupuncturists.
Conclusion: Reimbursement rates are determined by multiple factors and must be considered on a state to state basis by each specific circumstance. And while Medicare may be one criterion, it is neither the sole nor determining criterion. There is no blanket rule.
Branch 1.2 RBRVS will be impacted negatively by Medicare.
This is not true. The Regional Based Relative Value Scale is a standard used by governmental healthcare reimbursement agencies and private carriers to establish a fair reimbursement rate based on where the provider works. RBRVS is not uniform except in terms of the concept which argues that the Cost of Living (COL) is higher in urban areas than in rural areas. Therefore, reimbursements should be tailored according to whether the provider works in a less costly rural or more costly urban setting.
Again, there are exceptions to the RBRVS “rule.” States that are mostly rural are not necessarily impacted by rural versus urban status. Hawaii has one urban zone. Governmental reimbursement rates are the same for the entire state. I would imagine the same applies to Alaska, Montana and Idaho. RBRVS rates are negotiable by groups which represent stakeholders.
Conclusion: RBRVS is not determined by Medicare. The concept is based on the rural and urban status of any given region. Rates must be considered on a state to state and region by region basis. There is no blanket rule.
Branch 1.3 Medicare will drive down acupuncture fees.
This is not true. Acupuncture reimbursements are being driven down by two factors: (i) the low participation of acupuncturists in mainstream medicine, and (ii) the aggressive discounting of acupuncture services by the limited number of network organizations such as ASH and Align Network that agree to limit fees to $40 and $50 net. Acupuncturists further undermine their own fee standards by relying on cash practices as their principal source of revenue. It is well known that approximately 10% of acupuncturists earn more than $100,000 gross revenue annually; and that the median gross income is closer to $40,000. If acupuncturists are going to improve this situation then acupuncturists must figure out how to work in the mainstream.
ISSUE #2: Inclusion in Medicare will bring acupuncture and acupuncturists closer to the medical mainstream.
Branch 2.1 Inclusion in Medicare is recognized by mainstream payers and other professions as a marker of professional mainstream participation.
This is true. Acupuncture is not recognized as a mainstream healthcare profession. Coverage varies widely form plan to plan in terms of conditions and diagnoses. Very few acupuncturists train alongside physicians, physical therapists, nurses, physician assistants, LVNs or medical assistants. Acupuncturists rarely refer to or receive referrals from physicians or other mainstream providers. Very few acupuncturists bill carriers for their services even though (i) the number of carriers that include acupuncture as an eligible service in health insurance policies has grown tremendously, and (ii) four specific acupuncture CPT codes have existed since 2005.
Conclusion: There is no question that the inclusion of acupuncture within Medicare will bring attention to the profession. Also note that there are other federal health plans for veterans (other than the VA) and government workers which cover acupuncture, selectively. The real question is how many acupuncturists will shy away from participating. If as many acupuncturists fail to participate in Medicare as there are acupuncturists who fail to participate in billing private insurance, then the profession will retain its outsider status.
Branch 2.2 Inclusion in Medicare will give acupuncturists to participate in the burgeoning healthcare boom for aging “baby boomers.”
This is true. The largest segment of the population was born in the 30 years following WWII. These “baby boomers” will receive 100% of their healthcare under Medicare. Mainstream providers have positioned their practices and healthcare payrs have positioned their coverage to minimize catastrophic illness. Prevention care that treats aches and pains is of great interest. An example of how “alternative medicine” is getting on board is the American Specialty Health (ASH) “wellness programs.” ASH covers acupuncture, massage and chiropractic care at greatly reduced reimbursement rates. Carriers pay for these programs because they believe “wellness care” will forestall long and costly end-of-life illness.
Conclusion: Miss out on Medicare and miss out on the greatest opportunity in modern times to build a collaborative practice with mainstream providers and insurance carriers.
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Prepared by Steven H. Stumpf, EdD
VP NGAOM International
 AAAOM Federal Legislation Initiative FAQs updated November 2013https://c.ymcdn.com/sites/www.aaaomonline.org/resource/resmgr/Legislation-2013/aaaom_legislation_faq_2013-1.pdf