Beyond spinal manipulation: should Medicare expand coverage for chiropractic services? A review and commentary on the challenges for policy makers

Objectives: Private insurance plans typically reimburse doctors of chiropractic for a range of clinical services, but Medicare reimbursements are restricted to spinal manipulation procedures. Medicare pays for evaluations performed by medical and osteopathic physicians, nurse practitioners, physician assistants, podiatrists, physical therapists, and occupational therapists; however, it does not reimburse the same services provided by chiropractic physicians. Advocates for expanded coverage of chiropractic services under Medicare cite clinical effectiveness and patient satisfaction, whereas critics point to unnecessary services, inadequate clinical documentation, and projected cost increases. To further inform this debate, the purpose of this commentary is to address the following questions: (1) What are the barriers to expand coverage for chiropractic services? (2) What could potentially be done to address these issues? (3) Is there a rationale for Centers for Medicare and Medicaid Services to expand coverage for chiropractic services? Methods: A literature search was conducted of Google and PubMed for peer-reviewed articles and US government reports relevant to the provision of chiropractic care under Medicare. We reviewed relevant articles and reports to identify key issues concerning the expansion of coverage for chiropractic under Medicare, including identification of barriers and rationale for expanded coverage. Results: The literature search yielded 29 peer-reviewed articles and 7 federal government reports. Our review of these documents revealed 3 key barriers to full coverage of chiropractic services under Medicare: inadequate documentation of chiropractic claims, possible provision of unnecessary preventive care services, and the uncertain costs of expanded coverage. Our recommendations to address these barriers include the following: individual chiropractic physicians, as well as state and national chiropractic organizations, should continue to strengthen efforts to improve claims and documentation practices; and additional rigorous efficacy/effectiveness research and clinical studies for chiropractic services need to be performed. Research of chiropractic services should target the triple aim of high-quality care, affordability, and improved health. Conclusions: The barriers that were identified in this study can be addressed. To overcome these barriers, the chiropractic profession and individual physicians must assume responsibility for correcting deficiencies in compliance and documentation; further research needs to be done to evaluate chiropractic services; and effectiveness of extended episodes of preventive chiropractic care should be rigorously evaluated. Centers for Medicare and Medicaid Services policies related to chiropractic reimbursement should be reexamined using the same standards applicable to other health care providers. The integration of chiropractic physicians as fully engaged Medicare providers has the potential to enhance the capacity of the Medicare workforce to care for the growing population. We recommend that Medicare policy makers consider limited expansion of Medicare coverage to include, at a minimum, reimbursement for evaluation and management services by chiropractic physicians

Note and Comment

The Basis of Relief from Penalties and Forfeitures - The equitable principle of relief from penalties and forfeitures is so far elementary as almost to defy analysis. Many, perhaps most, of the judicial explanations of the principle have based it upon interpretation or construction, appealing to the doctrine that equity regards intent rather than form. Yet a logical application of this doctrine would lead to results very different from those which have actually been arrived at in the decisions. Thus, a stipulation in a mortgage that the mortgagor waives his equity of redemption can hardly be interpreted as meaning that he does not waive it, yet all such stipulations are ignored and redemption granted, nevertheless. Again, a penalty for breach of contract cannot be saved by the most solemn declaration that it is intended as liquidated damages. It must be conceded that many cases have actually been, decided on the interpretation theory, producing such enormities as Iowa Land Co. v. Mickel, 41 Ia. 4o2 (sale of land, $15a out of$6oo paid, $4ooo in improvements, second instalment of$150 one day late due to a misunderstanding; held forfeited), and Doctornan v. Schroeder, 114 AUt. 8io (N. J., 1921; sale of land, $IOOO paid, last instalment of$iooo thirty minutes late; held forfeited). But such cases represent the minority view, and one applicable only to instalment sales, no court pursuing this course in mortgage or liquidated damage cases

The effectiveness and costs of continuous ambulatory peritoneal dialysis (CAPD) /

Item 1070-MS/N 052-003-01002-0"OTA-HCS-35"--P. [4] of cover."September 1985."Shipping list no.: 85-846-P."Performed as part of OTA's assessment of medical technology and costs of the Medicare program."Bibliography: p. 73-75.Mode of access: Internet

Do medical devices have enhanced placebo effects?

Abstract Although the placebo in a clinical trial is often considered simply a baseline against which to evaluate the efficacy of a clinical intervention, there is evidence that the magnitude of placebo effect may be a critical factor in determining the results of a trial. This article examines the question of whether devices have enhanced placebo effects and, if so, what the implications may be. While the evidence of an enhanced placebo effect remains rudimentary, it is provocative and therefore worthy of further study. Suggestions are made, therefore, for how such an effect can be investigated without violating the principles of informed consent

Cardiac rehabilitation enrollment among referred patients: patient and organizational factors

PURPOSE: Cardiac rehabilitation (CR) is underutilized despite well-documented benefits for patients with coronary heart disease. The purpose of this study was to identify organizational and patient factors associated with CR enrollment. METHODS: Facilities of the Wisconsin Cardiac Rehabilitation Outcomes Registry (N = 38) were surveyed, and the records of referred patients were analyzed. Generalized estimating equations were used to account for clustering of patients within facilities. RESULTS: Of the 6874 patients referred to the 38 facilities, 67.6% (n = 4,644) enrolled in CR. Patients receiving coronary artery bypass grafting (adjusted odds ratio [OR], 1.72; 95% CI: 1.36-2.19) and those who possessed health insurance (OR, 3.04; 95% CI: 2.00-4.63) were more likely to enroll. Enrollment was also positively impacted by organizational factors, including promotion of CR program (OR, 2.35; 95% CI: 1.39-4.00), certification by the American Association of Cardiovascular Pulmonary Rehabilitation (OR, 2.63; 95% CI: 1.32-5.35), and a rural location (OR, 3.30; 95% CI: 2.35-4.64). Patients aged ≥65 years (OR, 0.81; 95% CI: 0.74-0.90) and patients with heart failure (OR, 0.40; 95% CI: 0.22-0.72), diabetes (OR, 0.58; 95% CI: 0.37-0.89), myocardial infarction without a cardiac procedure (OR, 0.78; 95% CI: 0.67-0.90), previous coronary artery bypass grafting (OR, 0.72; 95% CI: 0.56-0.92), depression (OR, 0.56; 95% CI: 0.36-0.88), or current smoking (OR, 0.59; 95% CI: 0.44-0.78) were less likely to enroll. CONCLUSIONS: Predictors of patient enrollment in CR following referral included both organizational and personal factors. Modifiable organizational factors that were associated either positively or negatively with enrollment in CR may help directors of CR programs improve enrollment

Postoperative <i>Staphylococcus aureus</i> Infections in Medicare Beneficiaries

<div><p><i>Staphylococcus aureus (S. aureus)</i> infections are important because of their increasing frequency, resistance to antibiotics, and high associated rates of disabilities and deaths. We examined the incidence and correlates of <i>S. aureus</i> infections following 219,958 major surgical procedures in a 5% random sample of fee-for-service Medicare beneficiaries from 2004–2007. Of these surgical patients, 0.3% had <i>S. aureus</i> infections during the hospitalizations when index surgical procedures were performed; and 1.7% and 2.3%, respectively, were hospitalized with infections within 60 days or 180 days following admissions for index surgeries. <i>S. aureus</i> infections occurred within 180 days in 1.9% of patients following coronary artery bypass graft surgery, 2.3% following hip surgery, and 5.9% following gastric or esophageal surgery. Of patients first hospitalized with any major infection reported during the first 180 days after index surgery, 15% of infections were due to <i>S. aureus</i>, 18% to other documented organisms, and no specific organism was reported on claim forms in 67%. Patient-level predictors of <i>S. aureus</i> infections included transfer from skilled nursing facilities or chronic hospitals and comorbid conditions (e.g., diabetes, congestive heart failure, chronic obstructive pulmonary disease, and chronic renal disease). In a logarithmic regression, elective index admissions with <i>S. aureus</i> infection stayed 130% longer than comparable patients without that infection. Within 180 days of the index surgery, 23.9% of patients with <i>S. aureus</i> infection and 10.6% of patients without this infection had died. In a multivariate logistic regression of death within 180 days of admission for the index surgery with adjustment for demographics, co-morbidities, and other risks, <i>S. aureus</i> was associated with a 42% excess risk of death. Due to incomplete documentation of organisms in Medicare claims, these statistics may underestimate the magnitude of <i>S. aureus</i> infection. Nevertheless, this study generated a higher rate of <i>S. aureus</i> infections than previous studies.</p></div

Note and Comment

The Basis of Relief from Penalties and Forfeitures - The equitable principle of relief from penalties and forfeitures is so far elementary as almost to defy analysis. Many, perhaps most, of the judicial explanations of the principle have based it upon interpretation or construction, appealing to the doctrine that equity regards intent rather than form. Yet a logical application of this doctrine would lead to results very different from those which have actually been arrived at in the decisions. Thus, a stipulation in a mortgage that the mortgagor waives his equity of redemption can hardly be interpreted as meaning that he does not waive it, yet all such stipulations are ignored and redemption granted, nevertheless. Again, a penalty for breach of contract cannot be saved by the most solemn declaration that it is intended as liquidated damages. It must be conceded that many cases have actually been, decided on the interpretation theory, producing such enormities as Iowa Land Co. v. Mickel, 41 Ia. 4o2 (sale of land, $15a out of$6oo paid, $4ooo in improvements, second instalment of$150 one day late due to a misunderstanding; held forfeited), and Doctornan v. Schroeder, 114 AUt. 8io (N. J., 1921; sale of land, $IOOO paid, last instalment of$iooo thirty minutes late; held forfeited). But such cases represent the minority view, and one applicable only to instalment sales, no court pursuing this course in mortgage or liquidated damage cases

Adjusted predictors of <i>S. aureus</i> infection within 180-days following surgery by type of index surgery based on incidence rate ratio (IRR).

<p>Note: <i>S. aureus</i> denotes <i>Staphylococcus aureus</i>. <i>S. aureus</i> infection refers to first hospitalization coinciding or following surgery of interest with discharge diagnoses including any ICD-9 code specific for infection due to <i>S. aureus</i>. Rehab denotes rehabilitation; SNF denotes skilled nursing facility; ESRD denotes end-stage renal disease; NEast denotes northeast; MidAtlan denotes mid-Atlantic; COPD denotes chronic obstructive pulmonary disease; n.a. denotes not applicable, vs. denotes versus. IRR>1 denotes factor associated with higher risk; IRR<1 denotes lower risk. Each IRR regression was based on all cross-tabulated non-zero cells. Based on log likelihood ratio Chi-squared, the overall regression tests for all six procedures plus the pooled group were highly significant (p<0.0001). *denotes p<0.05.</p><p>Adjusted predictors of <i>S. aureus</i> infection within 180-days following surgery by type of index surgery based on incidence rate ratio (IRR).</p