OIG's chiropractic report should draw more attention

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Elizabeth Newman
Elizabeth Newman

After many years at McKnight's, I'd like to think I'm reasonably well-versed on how long-term care services and reimbursement work, ranging from therapy caps to Medicare Part B to Medicaid funds. While those stories can largely be summed up as “never enough,” fairly often I've also edited or written stories on how providers are prosecuted for fraud, ranging from “worthless services” to rackets involving partial hospitalization programs

But a report last week from the Health and Human Services Office of Inspector General on fraud related to Medicare and chiropractic reimbursement led me to ask aloud the following question: “Wait, Medicare covers chiropractic stuff?”

It does! To the tune of $450 million a year for chiropractic services. To be fair, that's a drop in the bucket related to the $590 billion in Medicare spending in 2017 alone. Even when looking at 13 years of data in which the OIG says Medicare paid “hundreds of millions for chiropractic services that did not meet Medicare requirements,” it's not as if killing off this benefit would save Medicare from ballooning.

And yet.

The struggle is to balance what you may know intellectually about chiropractic services with what you may see or feel via anecdotes. Chiropractic and osteopathic manipulation is, as Forbes contributor Steven Salzberg, a Bloomberg Distinguished Professor of Biomedical Engineering, Computer Science, and Biostatistics at Johns Hopkins University, wrote, “pseudoscientific.” There's little evidence it helps and even some research suggesting it could increase the risk of stroke for seniors. Those of us who want to beat our heads against the wall every time someone talks about beating cancer with a positive attitude or preventing getting the flu through garlic tend to encase ourselves in the warmth of cold, hard data. In that case, chiropractic care falls under the “not good evidence it works” category.

But many of us have also seen our friends or family swear by their chiropractor, and who are we to judge if it helps their hips/back/neck? We may have seen residents benefit related to their back or neck pain, not a small issue for seniors. If it's a difference between one of your residents receiving an opioid for his or her back, or seeing a chiropractor, which would you prefer? The American College of Physicians, after all, recommends non-drug treatments, including spinal manipulative therapy, before drug therapies for long-term care patients with lower back pain.

But at the very least, both sides should be able to agree with many of the OIG's recommendations for better oversight of chiropractic services, if for no other reason than there appear to be more controls for outpatient physical therapy and speech-language pathology services. Even if we can agree that there may be reasons to continue chiropractic services for Medicare patients, it's imperative to crack down on bad policy.

For one, as the report notes, many chiropractors are using an AT modifier to make sure their claims are paid, regardless of whether they were performing corrective treatment for subluxation. CMS agrees with that recommendation and said it has discussed coverage and billing. But those efforts aside, the OIG notes that “many chiropractors have continued to bill for services that are medically unnecessary or not adequately supported.” It points out that CMS has a training video, which has been viewed around 9,000 times over two years, while there are 41,000 chiropractors billing Medicare in calendar year 2016.

As with other services, medical review seems logical. The report notes if the threshold had been 30 services per beneficiary to be unnecessary, Medicare could have potentially saved $95.1 million for 2013-2015. Beneficiaries themselves could have potentially saved $24.3 million during that period by not having to pay co-insurance for medically unnecessary services.

It's the last part that convinces me we need to do better around chiropractic services. It's not just because that $95.1 million could potentially go to reimbursements for long-term care services but because I think beneficiaries need to have the best care possible. Break down that $24 million for seniors on limited incomes. If it's a choice between paying for blood pressure medication or a co-pay on an X-ray, I'm confident we'd all want the senior to choose the service supported by science.

Follow Senior Editor Elizabeth Newman @TigerELN.


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Daily Editors' Notes

McKnight's Daily Editors' Notes features commentary on the latest in long-term care news and issues. Entries are written by Editorial Director John O'Connor, Editor James M. Berklan, Senior Editor Elizabeth Newman and Staff Writer Marty Stempniak.