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Naturopathic Insurance Leaders on 3rd Party Payment, the CPT, Villani's Views, and CAM-IM Maturation PDF Print E-mail
Written by John Weeks   

Naturopathic Insurance Leaders on 3rd Party Payment, the CPT, Villani's Views, and CAM-IM Maturation

Summary:  What does taking 3rd party payment change in a clinical practice? What role does such payment play in the development of a healthcare profession? Tino Villani, DC, a long-time chiropractic leader and CEO of Integrator sponsor Triad Healthcare, provided a wonderfully frank assessment. Villani focused on some of the corruptive pressures. This article looks at views of two insurance-savvy leaders of the naturopathic medical profession, Kevin Wilson, ND, and Bruce Milliman, ND, who read Villani's comments and reflected on their own views. These are their remarks - plus some responses from Villani. This article is part of a sponsored series on the future of Yoga Therapy from the International Association of Yoga Therapists.

Inclusion in 3rd party payment is often viewed as a sign of arrival by the emerging complementary and alternative health care professions. Insurance coverage is a literal gold ring of inclusion.

Image
This article is part of an Integrator exploration of professional development engaged as part of a series on the Future of Yoga Therapy which is sponsored by the International Association of Yoga Therapists
Yet like so many fabled rewards, there are dark sides. Witness the way conventional primary care has been hammered down by an insurance payment system which tells MDs and their administrators that the most money they can churn is a function of how many short visits they can line up, back-to-back. The end product is a system in which they no longer have the time to engage the responsibilities which are suggested by "primary care."

Tino Villani, DC, a chiropractic leader in his state of Connecticut and CEO of Integrator sponsor Triad Healthcare, provided the Integrator a wonderfully candid, personal view of the impact of insurance coverage on his profession. (See
Insurance Coverage and Development of CAM Professions: Perspective of Agostino Villani, DC, Triad CEO.)

I then turned to naturopathic medical leaders who have had key roles in that profession's more recent engagement with insurance for their reflections on the Villani's piece.

  • Kevin Wilson, ND, has held state and national leadership positions for his profession and is a past-president of the Oregon Association of Naturopathic Physicians and current chair of its legislative committee. He also serves as chair of the Formulary Council of the Oregon Board of Naturopathic Examiners. He has been the principal naturopathic doctor involved with the development of CAM network Complementary Healthcare Plans which manages CAM benefits for employers and insurers including Kaiser Northwest Permanente.

  • Bruce Milliman, ND, negotiated his profession's ground-breaking role as recognized primary care providers (PCP) with Regence Blue Shield, one of Washington State's most significant carriers. Milliman also serves as the representative of the American Association of Naturopathic Physicians on the Health Care Professional Advisory Committee of the American Medical Association on its Current Procedural Terminology (CPT) Editorial Panel, the codes which govern much of insurance reimbursement. He is the acknowledged insurance expert of the Washington Association of Naturopathic Physicians as it has found its way into significant insurance coverage over the past decade of experience with the state's legislation which required all health plans to include "every category of provider."

This article is structured as an interview based on their separate responses to my request. I then circulated it to Villani, who added some additional comments which are added in the comment field, below.


Integrator: What was your initial response to Villani's comments?

Image
CAM network ND lleader Kevin Wilson, ND (photo from the author's file)
Wilson:
The Villani article was impressive and largely accorded with my experience.
I do think that 3rd party payment compromises the practice of healthcare across the board. Practitioners start thinking about reimbursement first, procedures second and healthcare third when they see that the patient is on a particular plan. As another managed care executive, I also agree with Villani that there is hope for the future. But it seems more of an afterthought now than the exciting, early part of my involvement on the management side.

Milliman:  First, I liked the article. It seems that Dr. Villani is a deep thinker with a lot of experience.  Yet his perspective, in contrast to his expressed opinion regarding the effect third party coverage on his profession, to me is 'chiro-centric' rather than 'patient-centered.' I do think it is disingenuous to assert that the reasons for soliciting inclusion are only to share in the apparent economic benefit of that inclusion.

     
"Insurance has
boxed
NDs in just
as chiropractors

have been to certain
codes
and procedures
and
spending caps
that patients
and
Docs seem to bang

their heads against.

"We love our
cash-paying patients."

Kevin Wilson, ND

I believe those other reasons include but are not necessarily limited to an almost congenital provider concern to assure universal patient access to their services. We want to be able to serve both those patients wealthy enough to pay out of pocket, and for those who cannot afford both the cost of monthly health insurance premiums, co-payments, deductibles, etc. and the cost of health care services as an additional expense. 

I think physicians, whatever their letters (DO, MD, ND), and other types of healthcare providers too, want and deserve to make a fair living and compete in the health care marketplace on a level playing field, but I doubt that the profit motive is the prime driver for any of the health care professions.


Wilson:  Third party payment seems to hurt chiropractic more than others for some reason. They just keep getting chipped away at and they seem to be forced to work for less and less. That said, I can see some similarities. I had hoped that by including naturopathic medicine in managed care that we could extract some data about us and our practice that would be helpful in advancing the profession. But it has not really worked. Insurance has boxed us in just as chiropractors have been to certain codes and procedures and certain spending caps that patients and docs seem to bang their heads against.

Image
CPT advisor Bruce Milliman, ND
Integrator
:  I do know from talking with other naturopathic doctors in Washington that some time-intensive 'procedures' are not as likely to be offered. Examples are services which do not pay very well, or are not covered, like craniosacral therapy, massage and hydrotherapy. True, some are now referring to massage therapists for some of this care rather than delivering it themselves. We don't know what this kind of limiting of a practice, or external referral, may be doing to the doctor-patient experience.

Milliman: If the chiropractic community, or the naturopathic community, has been wrongly limited, this is a scope issue, not a reimbursement issue. As I understand the CPT [Current Procedural Terminology] codes, they are intended to be 'provider type blind.' They describe a service or a procedure.  Whether that service or procedure constitutes a covered benefit is one question, and whether a particular provider is authorized to deliver or perform that service or procedure is a totally separate question. 


"If the current code
set does not adequately
describe the services
delivered by any
provider group, that
group should join
together and propose
additional codes ... by
an eminently democratic
process, through the
CPT Editorial Panel."

Bruce Milliman, ND


The former point speaks to the nature of the health care coverage of the patient in question. The latter point speaks to the licensed scope of practice of the provider in question. If the current code set does not adequately describe the services delivered by any provider group, that group should join together and propose additional codes for consideration by what seems to me to be an eminently democratic process, through the CPT Editorial Panel.  That provider group may want to join together with other provider groups who also perform that or a similar service, as consensus presents a powerful force with which to contend.

Integrator: I am surprised that you view the CPT, which is controlled by the American Medical Association, as an "eminently democratic process." I would venture that a group dominated by MDs is hardly a jury of one's peers, for either chiropractors or your own profession.

Milliman: True enough. But the Editorial Panel is the current custodian with the responsibility for guiding the form our system takes. So why not engage in the process rather than complain that it is not perfect?

Wilson: My exprience tells me that insurance companies will not pay for some procedures that are in our ND scope of practice, yet they will pay for them when performed by an MD. One example is injections that are in our scope in Oregon. I've seen rampant discrimination in managed dcare with the insurance company deciding what they will and will not cover, and by them.

Integrator: I know that this has been an issue with chiropractic because in some cases "manipulation" or manual therapy may be covered, but only when performed by an osteopath, or in some cases, a physical therapist.

Milliman:
When such and issue has been perceived to be discriminatory by our professional association's Insurance Committee in our state (Washington) we have successfully worked through the state OIC's (Office of the Insurance Commissioner) grievance process.  Other concerns have required legislative change.  Medicine is one third art, one third science and one third politics.

Integrator:  Well, you both have mentioned to me in the past that you believe there are positive impacts and benefits from participating in managed care, whatever the imperfections.

 
"Managed care has
improved some aspects
of naturopathic medicine.
It helped tighten up
the practice by enforcing
some time constraints
on practitioners.

"It's has taught them
that simply spending
lots of time with a
patient is not necessarily
good medicine or in
anyone's best interest."

Kevin Wilson, ND
 
Wilson:  Managed care has improved some aspects of naturopathic medicine. It helped tighten up the practice by enforcing some time constraints on practitioners and taught them that simply spending lots of time with a patient is not necessarily good medicine or in anyone's best interest. We ND's pride ourselves on taking enough time with our patients to get the whole story and for the patient to feel heard. This is often remarkably helpful. But that had the tendency to become self indulgent for the doc and the patient. Managed care helped moderate that phenomenon.

Milliman: It is my contention that this is 'welcome to the club.' The problems encountered by any one health profession are experienced by all health professions - electronic, cyberspaced, bureaucratized, regulated and scrutinized to the Nth degree. This has some good consequences, some bad. One good consequence of having some ground rules via evaluation and management guidelines is that quality of documentation improves. I would assert that the quality of care, too, improves commensurately.

Wilson:
It is interesting what the coverage can do to our relationships with our patients. I have seen patients which I had for a long-time as cash-paying patients get insurance coverage which is nominal at best. They then become lousy insurance patients who balk at spending anything beyond their "benefit." They subsequently truncate their care, abandoning a program before you could really get it going.

Having practiced a long time now and having billed insurance companies for years, I have seen three significant changers.
Initially, we just bundled everything in our treatment of the whole person that we did together, and for a very modest price. Then low and behold, insurers told us to put a code and price on all we did. Because naturopathic doctors are very eclectic, we did a lot with patients and had a lot of codes to mark. Suddenly, we were getting paid a lot. I'll be honest - I loved it. But as one can imagine the insurers did not. They forced bundling back, with a vengeance

 
"One good
consequence

of having some
ground
rules via
evaluation
and
management
guidelines
is that quality
of
documentation
improves."


Bruce Milliman, ND
 
 
But I still think that I learned something valuable. Doing everything that you can fit into a patient's visit is foolish, confusing and unnecessary. Insurance coverage and more so, managed care has forced a focusing of practice to that which works best. It has forced time efficiency. Good coverage should not rule out the exotic or rare treatment but direct the doc to do their best and have a discriminating mind for not only what they are best at, but what works best for the patient{s}.
                
Integrator: Any additional comments?

Wilson:
I wish insurance would go away in its present form. It has damaged the practice of all kinds of medicine. And yet, I believe that it has had beneficial effects on naturopathic medicine. Helping it to grow up, but as I have grown up in this way, I have gotten stiffer. I hope that a more mature form of naturopathic medicine is not a stiff one.

I am proud of my colleagues who have jumped off the cliff, going on a cash-only practice basis. Many have found that they can fly and have done exceedingly well both financially and clinically. But I am also proud to have helped my patients afford my care by billing their insurance all these years. It is a Faustian deal though, letting an entity get between you and your patient.
So, as you know, we love our cash paying patients. It's a clean and unencumbered relationship that is all the better now for what I have learned from my ventures into managed care.

   
"It is a Faustian deal,
letting an entity
get between you
and your patient."

Kevin Wilson, ND

Integrator: Bruce, your perspective is quite unusual because you have the rare - and historic role - inside your profession of being inside the inner sanctum of payment and coverage in actually advising the AMA's coding process. It seems to have bred a kind of optimism in you. Any other comments?

Milliman
Modern naturopathic medicine cares for people who have evaluation and management needs, preventive needs and health promotion needs. The profession, in other words, is 'needs driven' and not modality driven. These needs can be addressed for a larger number of people by participation in third party reimbursement. The problems with the health plans are more attributable, in my view, to the emergence of third party administrators, or middle men like networks which basically drive down reimbursements for all types of participating providers. The provider's defense against this potentially adverse effect is to contract exclusively with health plans - or with networks, where unavoidable - which have coverage plans and fee schedules they feel they can live with.

Finally, I have a point to make which is philosophical or organizational, perhaps more than immediately practical.
If a patient suffers from a condition, there is a way of expressing that condition, however imperfectly, in the form of an existing ICD-9 [International Classification of Disease] word and number. It's called ICD-9 because it's the 9th edition and number 10 is rolling down the tracks. This is an obscure way to point out that change is possible. So, again, why not engage in the process rather than bemoan the fact that the billing system, like our own form of government, is not perfect or does not perfectly represent our perceived needs as a profession.

Integrator: Well, the chiropractors have been pretty significantly included in 3rd party payment for 20-30 years, a significantly longer period than the NDs. This will be an interesting conversation in 2015, to see what changes may have taken place in the interlude.


Image
Agostina Villani, DC, CEO, Triad Healthcare
Comments in response from Tino Villani, DC
:

Regarding Milliman's comments on patient-centric vs provider centric:
"I do not remember where I suggested that the chiropractic profession has responded to 3rd party reimbursement in a patient-centric way, but nonetheless, Dr. Milliman is correct is observing that I am of the opinion that my profession has responded in a provider-centric way. This generalized behavior on the part of chiropractic as a profession occurred gradually over the course of two or three decades.

"Possibly, in the hindsight of thirty years, my perspective on why chiropractic pursued 3rd party reimbursement may seem cynical. But I am not being disingenuous when asserting that the move to insurance was wholly provider-centric in intent.


"Over time, insurance
becomes the prevailing
professional discussion.

"Energy, resources, influence
are directed at this negotiation
for codes and the reimbursement
associated with those codes.

"These issues eclipse the
patient as a focus on
the profession’s agenda."

Tino Villani, DC

 
"My profession’s history is rich with accounts of a time when this was not so - a time when anyone who sought chiropractic care received it, regardless of their ability to pay, and without a thought for insurance. Patients paid with promises, services and apple pies when necessary. Chiropractors accepted these forms of reimbursement, forged strong, meaningful relationships and (as the story goes) had fulfilling careers as healthcare providers to the public. It was a two party transaction in which both parties appeared highly satisfied (as individuals) with the mutual exchange of value. It suggests that chiropractic was a very patient-centered profession.

"I question the decision to pursue 3rd party reimbursement from this perspective. To me, it represented a less personal, more institutional perspective that the dollar was more valuable than the pie. We began a move towards a less patient-centric path."

Regarding Milliman's comments on the role of the CPT
"It’s a nice theory, but practical experience suggests otherwise. Scope is defined by regulatory language. When this language is compromised as part of contract language and financial policy within a 3rd party system, I think there can be little argument that the basis for this is reimbursement."
Regarding the recommendation that a profession work in the CPT system to change codes.
"My point exactly. Over time, this becomes the prevailing professional discussion, as it has with chiropractic. Energy, resources, influence have been directed at this negotiation for codes and the reimbursement associated with those codes. These issues have eclipsed the patient as a focus on the profession’s agenda."
Regarding Milliman's final comments on the ND's being "needs driven" organizing to make changes
"The conflict is, as you suggest, good healthcare professionals are 'needs driven' and patient-centric. 3rd party systems, including their coding and standardization methods, are 'modality driven.' Promoting a patient-centered CAM agenda in a modality-driven industry is difficult and requires so much compromise from the provider that I question its true value.

"If this conflict was between parties of equal size, organizational integrity and political influence, compromise might lead to mutual benefit. But in the current environment this is impossible. We have yet to find a way to balance this environment and my fear is that we have stopped trying and have resigned ourselves to short-term benefit and fighting battles for their own sake."

Send your comments to for inclusion in a future Your Comments article.

Note:  To read the other articles in the IAYT series on the Future of Yoga Therapy go to:

IAYT Sponsors Series on the Future of Yoga Therapy: Context and Current Initiatives

Insurance Coverage and Development of the CAM Professions: Perspective of Agostino Villani, DC, Triad CEO

(Another Kind of) Integration in Georgia - Yoga, TCM, Mindfulness Plus at Athens Regional Medical

Harvard Researcher Sat Bir Khalsa on Hygiene for the Body-Mind and Yoga's Emergence


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