Recognizing Complementary and Integrative Providers in the Healthcare Workforce

Doctors of Chiropractic

The training of chiropractic doctors (DCs) is most like that of primary care medical physicians, especially with regard to the basic and clinical sciences and their ability to perform general and focused examinations of patients. The depth of their professional education with regard to the musculoskeletal system – and the spine in particular – provides them with a high level of competence when providing conservative, non-pharmacologic care for patients with back pain.

Chiropractors are licensed in all 50 states as portal-of-entry or first contact providers whose scope of practice allows them to provide a broad range of diagnostic and treatment services. In addition to their training, this level of licensure positions them to fulfil many primary care roles by diagnosing and managing common health problems or referring patients to specialists when needed.

However, while chiropractic services are generally covered by most commercial health insurance plans, there is benefit set variation and, more importantly, barriers to patient access including visit limits, requirements for prior authorization of services and high out-of-pocket expenses. (6)

Coverage for chiropractic services in Medicare and Medicaid programs is even more limited and does not currently reflect the scope of practice of DCs – even when care is provided to patients with low back pain. These arbitrary limits often result in unnecessary referrals or out-of-pocket expenses, adding waste to the total cost of care.

Acupuncture and Chinese Medicine Providers

During their training, acupuncture and Chinese medicine providers focus on the theories, science and use of acupuncture and herbal therapies while also studying bioscience principles that are directly related to clinical practice.

Chinese medicine is a complete medical system that addresses the patient’s whole health through the use of acupuncture – the most commonly utilized treatment approach – along with dietary and lifestyle recommendations, herbal products and movement therapies.

Acupuncture is licensed in all but three states in the U.S. (i.e., South Dakota, Oklahoma and Alabama) and the majority either require examination or certification by the National Certification Commission for Acupuncture and Oriental Medicine. In Minnesota, the profession is regulated by the Board of Medical Practice.

Insurance coverage for acupuncture services in commercial health plans is gradually expanding and the Centers for Medicare and Medicaid Services recently announced that acupuncture for chronic low back pain will be covered under section 1862(a)(1)(A) of the Social Security Act.

The complexity of pain, and the challenge of addressing it without the risk of addictive medications like narcotics, is now bringing the value of complementary and integrative healthcare providers into sharper focus. The burden of low back pain merits particular consideration due to the frequency with which it is ineffectively managed with pharmacological and surgical treatments in lieu of more conservative and noninvasive approaches recommended in recent clinical practice guidelines. (11)

A 2017 guideline report from the American College of Physicians is of particular importance. (12) In it, the authors provide a detailed summary of high quality evidence supporting the use of nonpharmacologic and non-invasive treatments for low back pain. Importantly, recommendations suggest using non-pharmacologic treatments like acupuncture, therapeutic massage, and spinal manipulation, before considering medications or more invasive procedures.

Recent research has clarified the clinical value of chiropractic and acupuncture relative to the opioid abuse epidemic. In a large retrospective analysis of administrative claims data from OptumLabs, investigators found that patients receiving initial treatment for low back pain from a chiropractor or acupuncturist were about 90% less likely to use opioids in the short term, as compared to those who received initial treatment from a primary care physician. Patients who saw a chiropractor or acupuncturist were also less likely to use opioids in the long-term compared to those who saw a primary care physician (78% and 93%, respectively). (13)

A second systematic review and meta-analysis found that chiropractic users were 64% less likely to receive an opioid prescription, providing further evidence that chiropractic care can help in diminishing the rate of opioid use. (14)

These and other studies demonstrate an important primary prevention strategy for opioids, namely, present pain patients with viable alternatives to opioids, eliminating the risk of addiction altogether. Moreover, this strong data speaks to the need to engineer systems to triage access to conservative care providers, like doctors of chiropractic and licensed acupuncturists, for back pain complaints. And it is worth noting that, in addition to pain, the utilization rate of a wide-range of CIH therapies is high among American adults who have two or more chronic health conditions. (15) When patients seek care from CIH providers – especially early during an episode of pain – the encounter is typically more personal, patient-centered and lowers the risk of opioid use. (16, 17)

Early access to safe and effective non-pharmacologic therapies provided by acupuncturists, chiropractic doctors and massage therapists can replace more costly and potentially harmful treatment.

We believe that the challenge of effectively addressing acute and chronic pain – without the use of opioid medication – reinforces the need for new and novel approaches care delivery approaches. This perspective is reflected in the comprehensive 2019 Pain Management Best Practices Report from the Department of Health and Human Services. In the report, the authors emphasize the importance of an “individualized, patient-centered approach for the diagnosis and treatment of pain” and a multidisciplinary approach “using one or more treatment modalities” for chronic pain. (18)

But there are several factors and barriers that continue to inhibit broader patient access and utilization, including the following:

• Patients seeking complementary and integrative care are often reluctant to inform their primary care medical providers.
• Medical physicians and other conventional health professionals are often hesitant to refer patients to CIH clinicians due to a lack of knowledge regarding the training and services they are capable and licensed to provide.
• Health insurance benefit design can adversely influence patient decisions to seek care from CIH providers in ways that are inconsistent with clinical guidelines for the non-pharmacologic treatment of low back pain. (19)

While there is variation in their training and scopes-of-practice, we maintain that the roles CIH providers play in the healthcare workforce contribute to the goals of the Triple Aim.

However, we also recommend that public policy and other decision-makers consider the following:

• In those state agencies that engage in healthcare workforce planning – including the Minnesota Department of Health – data on CIH professionals should collected, analyzed and reported.
• Health systems, Federally Qualified Community Health Centers and other organizations should incorporate CIH providers into care pathways, optimizing collaboration and care coordination with other members of the patient’s healthcare team.
• Educational institutions training healthcare providers should give consideration to competencies that enhance collaborative and integrative healthcare across a range of disciplines and settings.
• Health insurers and third-party administrators should modify benefit designs by eliminating co-payments for multiple visits and arbitrary limits on care, and create incentives that direct patients toward high-value services.
• Legislation should be advanced that expands reimbursement to reflect the full scope of services provided by doctors of chiropractic and acupuncturists in Minnesota’s publicly funded insurance programs, to improve care and reduce the out-of-pocket costs incurred by low-income patients.