Approximately 130 million Americans are enrolled in Medicare, Medicaid, or both. (1) In the face of the opioid crisis, an aging population, and poor pain management, it is vitally important that beneficiaries have convenient, affordable access to safe and effective care.
Chiropractic physicians (DCs) and acupuncturists are trained to provide evidence-based, non-pharmacological care to patients suffering from pain. Notably, this includes common spinal conditions like back and neck pain, a leading cause of disability (2) and top healthcare cost driver in the U.S. (3) Spinal manipulation and exercise, commonly delivered by DCs, and acupuncture as delivered by licensed acupuncturists, are recommended in numerous best practice guidelines as first-line treatments for pain. This includes guidelines from the American College of Physicians (4) which recommend these therapies prior to prescription or over the counter drugs, and are based on research from both private (5) and public plans. (6)
Commercially, chiropractic and acupuncture services are increasingly included in health plans. (7) But, currently, their coverage is uneven or altogether absent from Medicare or Medicaid plans. Arbitrary restrictions on these services in Medicare and Medicaid plans can create disruptions in care continuity and increase costs, especially for individuals who age into Medicare. For example, chiropractic coverage in Medicare consists of a single service: spinal manipulation. Examinations, clinically necessary imaging, rehabilitation, and exercise are not covered benefits if delivered by a DC, although covered if delivered by another provider type. This results in disrupted or delayed care, higher out of pocket costs for the beneficiary, and steers back pain patients in particular toward lower value services like advanced imaging and invasive interventions, (8) which increase the risk of an acute problem developing into a chronic one. (9) Like chiropractic, early treatment with acupuncture for spinal pain has been shown to decrease the need for advanced imaging, invasive procedures, and opioid medications. (10)
However, Medicare only covers acupuncture for chronic low back pain, and only when delivered by a very narrow group of providers. This constitutes an illusory benefit for most beneficiaries. Moreover, beneficiaries are unable to receive acupuncture from licensed acupuncturists, arguably the most expert in delivering this service. For both licensed acupuncturists and chiropractic physicians, current coverage gaps inhibit referrals and needlessly complicate care coordination between providers within health systems and other integrative, multidisciplinary settings. Enhancing the chiropractic and acupuncture benefit would both reflect public trends of increasing patient acceptance and private sector utilization of these services, and better align Medicare and Medicaid coverage with evidence-based care.
Policy changes at the state and national level to allow DCs and acupuncturists to practice at the top of their license within the Medicare and Medicaid programs would increase beneficiary access to services, empower patient choice, decrease opioid utilization, (11) and better leverage an underutilized healthcare workforce. (6) The result would be greater utilization of higher value services (12) and relieving the burden of pain management from primary care. Improving access to chiropractic and acupuncture services are two strategies that would not only provide increased options to evidence-aligned benefits, but also likely decrease costs within the system. (13, 14 ,15)