The Great Insurance Debate
Posted August 18th, 2008 by Justine
I’m a member of the Acupuncture and Oriental Medicine Society of Massachusetts(AOMSM). Recently, a “subcommitteeof insurance” was formed by someone who is very in favor of attempting to getacupuncture covered by insurance. Currently, as some of you may know, Massachusetts requires all residentsto have health insurance – those without face tax penalties. Putting aside the thought that thelikelihood of this is probably quite slim, I think it’s still a valuablediscussion.
The person who started the subcommittee put the following post up in the forum:
Insurance Debate: Arguments For:
1. If acupuncture is to become main-stream medicine, insurance coverage wouldmaterially endorse its legitimacy and recognize its value within our healthcare system.
2. I believe that if acupuncture is to succeed and flourish in the evolution of ourmedical system, then access to acupuncture has to expand beyond those who canafford to pay out of pocket on top of their insurance premiums. Withcredit dwindling and inflation growing, less money is available for healthcosts not covered by one’s insurance policy.
3. Insurance coverage would greatly expand the market for acupuncture, both in terms of the locations in which it can be practiced and the numbers of those whowould utilize acupuncture. People will be far more willing to try acupunctureif their insurance plan covers it; furthermore, they will be more likely to follow through with a treatment plan if the financial restriction is reduced.
4. Greater access will expand the market and better allow us to ‘compete’ and demonstrate to the public what we can do vs. other medical interventions.
5. Insurance reimbursement for Lic Ac’s will expand the job market for acupuncturists. Medium to large clinic settings as well as hospitals will be more inclined to hire acupuncturists if they can make money by integrating our services with the rest of their reimbursable procedures. Consider places like universities or university athletic teams, pain clinics, fertility clinics, rehab centers, GP offices, etc., etc.
6. Mandating that all insurance plans cover acupuncture does not compel any individual acupuncturist to accept insurance. People are more apt to go to someone who accepts insurance—of course, wouldn’t you? But that is the case now anyway.
7. For those with established cash based clinics that are already successful, there is little reason to switch. For those who are starting out or are in need of a more patients, expanding the market with insurance reimbursement provides anopportunity for growth that is currently suppressed.
Upon seeing this, I replied with the following post:
AcupunctureInsurance -Arguments Against:
Interesting discussion. My opinion is that insurance for acupuncture is a bad idea, and here is why:
1. The health care system is already overburdened. We are all mandated in this state to pay for health ins. and it is already very expensive. Health care is a huge expense and it is greedy to ask for them to pay for acupuncture on top of it when it is simple and can be given to people without costing a lot, if the practitioner chooses to practice that way.
2. Insurance companies won't want to make acupuncture available to people unless they charge even more. If they don't charge more, I can't see how they'd make it available. Most people can't afford more than they already pay for health insurance - and if they were to pay more, then it would really be like the same thing as just paying for acu out of pocket - but instead of the extra expense being an option, it would be mandatory.
3. Insurance billing, coding, etc. is a huge pain to have to deal with in a practice, day in and day out. I for one would not want to have to deal with this, and I am willing to bet that the majority of private practitioners won't, either. For the patients I have who can use insurance, I hand them a reimbursement form that they submit and that is simple enough - but it would take an entirely new job of someone to have to work for us in our offices to deal w/ insurance all the time.
Of course, I'm all about making acupuncture affordable and accessible to people...so I chose a business model that does this.
I think many of your reasons are nice, ideally (that it would make
acupuncture more mainstream and "legitimate," etc.) but I still don't
think that's a good reason to have insurance cover it, nor do I think that insurance covering it necessarily makes people think it is more
legitimate (think about chiropractors - many people are still skeptical or don't care for it, even with it being covered - the same would happen for us). I also think it is a nice concept that acupuncture would keep people from getting sicker and thus bring down the cost of health care ultimately - however, I doubt the reality of this would actually happen.
Finally, one last person put in her opinion after I had stated mine,having a bit of a for/against combo
This is a useful discussion and I don't have a solid opinion but here are a few thoughts;
1. Since insurance is mandatory in MA (mine is very very inexpensive) having acupuncture under the plans may be advantageous to our clients as it provides services for folks who otherwise couldn't possibly afford it. For some people there is no premium and those are exactly the clients least likely to have extra funds to pay for treatments. So in a very substantial way, insurance coverage would provide services to the poorest among us.
2. As for increases in insurance premiums, those in higher income brackets may feel the pinch but those in the lower brackets are not likely to incur any changes in rates so again, this is a means of serving the most under-served and likely the most needy members of our community.
3. A modest increase in monthly premiums is unlikely to be anywhere close to thecost of weekly treatments ($200-$300 a month).
4. Making acupuncture inexpensive is a luxury best reserved for practitioners who don't have a great deal of debt, children or overhead expenses. There are ways to make it more affordable but not everyone is in the same economic situationfor a variety of reasons. I also think that giving a really good acupuncture treatment with thorough intake and differential diagnosis is work. It is lovely and rewarding work but nonetheless, it takes time and energy and it's ok to becompensated for this.
5. There is no doubt that insurance coverage increase work load and paper work enormously. It also means thatinsurance companies get some power in dictating length of treatment, numbers oftreatment etc... It isn't a simple issue, but it may be that to survive in thecurrent environment, we either need to acclimate or change the system. Thesecond is a much greater challenge and may occur more effectively by doing thefirst.
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Now I’m curious to hear a little more from you CAN readers…I know many of you have strong opinions on this topic and I'd like tosee more thoughts that lie outside my head to bring into the discussion –whether for or against. Thanks! (and sorry for the typos... I had some issues w/ the cutting and pasting...)
No more regular/frequent txs
Let's not forget that insurers limit the no. of treatments within a certain period, so that for a patient who needs daily txs for 5 days, or 3x/week txs for 2 weeks, not all the visits will be covered.
On number 4 and 5
4. This a huge misunderstanding about community acupuncture. I have debt and I'm no martyr. I have every intention of making as much or more money charging lower fees because so many more people can afford it. I understand that CAN usually focuses on social justice and making acupuncture accessible, but we really need to let people know we are making money, some of us are making a lot more money than most private treatment acupuncturists.
5. I don't think this person has ever dealt with insurance companies. The amount of hassle is INSANE and we would have to hire another person to handle it, and that person will spend hours on the phone just trying to get any payment at all. Many patients will be denied acupuncture treatment, it will likely be limited to a small number of conditions and denials after the fact will be rampant. Be prepared to have zero money coming in on a regular basis. Insurance is a nightmare! Does anyone really want to acclimate to that? No bleeping thanks!
HA! HAHAHAHAHA! (#4)
I guess this means someone else must be waiting to pay our mortgage, our student loans, that pesky tuition bill from Haverford College for Lucas, as well as WCA's 4,000 foot plus rent bill and payroll for eleven people and payroll taxes and workers' comp insurance and malpractice insurance for six acupuncturists and... where oh where is this person? Apparently I have been making my life unnecessarily difficult. Why didn't somebody tell me?
Also, I confess that I have trouble taking this whole "subcommittee of insurance" seriously. Oh please! Insurance companies are huge, for-profit companies. Newsflash: they do not care about acupuncturists or acupuncture. They don't have to. None of us have the kind of power it would take to make them care, or respond, or do anything differently. Remember that the Clintons lost when they tangled with them.
I really don't get it; why do we want to introduce a middle man
into the the equation? It makes absolutely no sense to me regardless of how much you charge per treatment. Here is a case where I think the market can take care of the problem itself. CA practices will fill the need of people who can't afford acupuncture at BA prices.
I think many in the profession are lured into the fantasy that they are or should be considered equals to MDs, and getting insurance companies to cover acupuncture will somehow "prove" this to the world.
Darlene Berger
Community Health Acupuncture Center
801 Livernois, Ferndale, MI 48220
248.246.7289
I think Darlene has nailed it.
It's about self-esteem.
It's about sustainability
In the nineties acupuncture
In the nineties acupuncture was covered by medi-cal and paid a reasonable amount of money in a timely fashion. Many folks who would not have had access to care were able to enjoy the benefits of acupuncture. I feel that we saved the system a LOT of money, and for the conditions we are able to treat, I think that acupuncture is MUCH MORE cost effective than allopathic medicine. Locally, teachers, as well as workers at the local supermarket and the largest building supply store are well covered by their insurance to receive acupuncture. In our present economy, a lot of these folks do not have an extra $20 for acupuncture, and they are happy to be covered, and not have ANY additional expense for acupuncture. While I certainly would not want to trust the well being of my body or my practice to the insurance companies, I also am reluctant to walk away from serving others who might need and benefit from my services, especially on a point of ideology that may not be important to a person who is suffering. To a person already paying for health insurance, even the most affordable acupuncture represents additional money that they must cough up for healthcare. Perhaps another element of lacking self esteem is not believing that we can save healthcare systems a lot of money; anecdotally I believe that we can, and refuse to assume that the opposite is true, especially with no proof either way.Happy Stickin'
I used to have acupuncture
I used to have acupuncture coverage, but the co-pay was $25 and any coverage at all was after a large deductable. If I were struggling financially paying $15 or $20 at the CA clinic makes more sense.
People who are fortunate enough to have acupuncture coverage can take a receipt and request reimbursement from their insurance company. CA clinics support that, we aren't telling people they can't use their coverage. The number of people who have acupuncture coverage is very small, and to try and fight for more coverage in the age of constant benefit cuts just doesn't make sense. The simple logic that acupuncture costs less in the long run falls on deaf ears at the insurance companies. We can't even convince them any preventative care saves money.
Live by insurance, die by insurance
Comment #4...
"Making
acupuncture inexpensive is a luxury best reserved for practitioners who
don't have a great deal of debt, children or overhead expenses."
Now who doesn't have overhead and debt these days? Though certainly a weak arguement, I find this is a common narrative among many of our colleagues who own a narrow view of how 'making acupuncture inexpensive' can take shape, while making a good living as a practitioner. I'm hopeful the continued proliferation of successful CA clinics will help to change this perspective of the average acupuncturist/student of CM. In fact, I'm betting on it.
"I also think that giving a
really good acupuncture treatment with thorough intake and differential
diagnosis is work. It is lovely and rewarding work but nonetheless, it
takes time and energy and it's ok to becompensated for this."
Agreed. Which is why I, and my CA colleagues charge a rate that fairly compensates for the time it takes to determine a pattern differentiation, create treament plan and impliment that plan - primarily as acupuncturists (read: not herbalists). With a schedule set up to treat 5-6 people each hour @ $15-30 each treatment, we are earning anywhere from $75-180/hour during a busy shift. And for many of us, shifts are busy very often.
There's something else that insurance coverage can bring.
In my 9-plus years of dealing with insurance companies, I noticed that covered patients who made appointments with me sometimes made it harder for me to make a person-to-person connection with them. I was a faceless name on a list of providers from the insurance company. These patients didn't feel that they were being treated by a person, but by a generic acupuncturist, almost like being a representative of the insurance company! What was even worse was when insurance companies gave Affinity coverage. This means that (by contract) if you are on the provider list, the patient can go to you and get a discount off your regular prices. This makes less paperwork for everyone, win-win for all, right? I didn't like it. These patients shopped on the phone for all these providers, comparing our regular fees and opting for the lowest-priced providers. In my old practice, it felt cheap to me. I felt like an item on the K Mart shelves. It didn't matter what training I had, what I'd poured into my practice for years.
(Now that I'm CA, I'm proud of being inexpensive, but not cheap!)
But another thing wrong with this insurance picture is that Healthcare companies are moving toward more Affinity, and less full coverage, in order to cut costs. I think the insurance system is broken. That's another reason to avoid getting involved with them, because you'll be in for a roller coaster ride once you sign up with them. Even in the good days, they were always changing policy. What that means is that you had to always be on the phone and fax with them, always changing the paperwork required, dealing with changing allowances and eligibility requirements. If you like doing this kind of bookkeeping work, then that's fine. It drove me crazy.
Oh yes, and the co-payments were usually $15-40.
What do other Mass. acupuncturists think?
A little off the topic of this site, but I don't know anyone in Massachusetts who is glad they were forced to sign up for the mandatory health insurance. In fact, I met an acupuncturist at the Boston WCA training who, after many sucessful years in practice, finds herself having to get a second job to cover health insurance costs.
I also fear that the mandatory coverage is likely to hurt Massachusetts acupuncturists, since people may feel that they need to justify the money they are spending on health insurance by using Western health care instead of thinking of holistic medicine.
I used to think that getting insurance coverage for acupuncture was the answer. But just the small amount of energy I've devoted to helping patients get reimbursement has changed my mind.
*Update* I just found this article on Reuters, criticizing the MA system. I wonder if these critiques might be enough to get the law repealed:
http://www.reuters.com/article/healthNews/idUSPAT17312720080821
Report from the Commonwealth Fund
An interesting article here.
"Two-thirds of the working-age population was uninsured, underinsured, reported a medical bill problem or did not get needed health care because of cost in 2007.
More than two in five adults in the 19-to-64 age group reported problems paying medical bills or had accumulated medical debt in 2007, up from one in three in 2005. Their difficulties included not being able to afford medical attention when needed, running up medical debts, dealing with collection agencies about unpaid bills, or having to change their lifestyle to repay medical debts."
I would not call this a good time to jump on the insurance ship. And Lumiel is absolutely right about the affinity model; insurance companies who do any kind of alt med "coverage" are mostly very open about saying that the trend is toward the affinity model, because that is what works best for the insurance companies.Thank You All!
Wow - thank you all for your insights and thoughts! I knew you'd be a thoughtful bunch.
I'm going to ask my insurance-pondering colleagues to read this discussion... maybe they'll re-think their thoughts.
You all should move to my state
In my state, acupuncture is completely covered by the insurance companies. Everyone is covered for free, so acupuncture is widely available. There is a five dollar co-pay for the patient, and the acupuncturist is reimbursed $80 dollars a treatment. The insurance companies are required to have a team of personel trained in the many different schools of acupuncture. This expedites reimbursement. Once, a claims specialist even gave me advice on a tough case I had been struggling with. All conditions are covered indefinitely, as long as they are described in Chinese medical terms.
All these great changes came after all the acupuncturists in my state marched on to the state capital building. We sang songs about change, held hands, burned candles and cried. The staffers inside the capital building were so moved that they refused to go to work until we got our demands. A few insurance lobbyists even joined our ranks. One of them quit and is now going to PCOM. We brought the state legislative process to its knees and a secessionist movement was narrowly averted in the 11th hour when every one of our demands was met and the general public was satisfied.
So, yes, you should all just move to my state. It is acupuncture heaven.
Did I mention I live in a state of delusion?
From one who knows
I have been practicing in Seattle since 2004; first as a massage therapist covered by health insurance and now as an acupuncturist, also covered by insurance. I used to believe the "Every Catagory of Provider" law that Washington state has in place, (meaning if an insurance company originates in the state they must provide coverage to every catagory of health care provider,) was a good one--allowing people to see ND's, DC's, LAc's, LMP's. But after four years of accepting and billing insurance companies, I have really changed my tune. I was supporting a way to make alt med available to everyone, and CA has shown me a way.
To add to the list of reasons insurance coverage stinks for acupuncture:
Most allow a max of 12 visits per YEAR
Most reimburse around $80 for the first visit, but after that it's more like $40-50
The charting that is required to CYA (cover your a*s) is ridiculous--a good 10-15 minutes of charting per patient
All dictate WHAT ailments can be treated and it is limited to musculoskeletal pain conditions--so I go fishing with my infertility/anxiety/depression/GI/diabetic/smoking cessation patients for a sore neck/back/elbow that I can chart so they'll be covered and I won't be audited for coding for their real complaint
Many audit and many more have announced they will audit L.Ac.'s much more--meaning an insurance auditor can show up in your office and demand your charts with little or no warning. If you mistakenly wrote the wrong date down or have not signed your chart notes, they take those payments back and assess a fine, AND can kick you off their plan. If they find a diagnosis that doesn't exactly match what you coded on the bill, that is considered fraud, and that is a criminal offense. Forget TCM or Zang Fu diagnosis; they want the western diagnosis.
Frankly, I've been living in fear of an audit and feel like a creep for coding "Lumbago" for my infertility folks. It's a game you have to play, and I hate the rules and hate the lying and fear. I'm also currently waiting for a total of $2,000 in payments dating back to last November from the insurance companies.
It's a bad, bad deal. I can't wait to be a CA provider.