Advancing Complementary and Alternative Medicine Professions

Complementary and alternative medicine (CAM) practitioners such as chiropractors and acupuncturists are almost unique among health professionals in that, although they are legally recognized as members of professions, and some can provide primary care, Medicare and most private insurers treat them primarily as purveyors of a limited set of procedures.

While conventional doctors belong to health care systems, CAM practitioners usually do not, and their services are treated as "add-on" or second-tier services that conventional doctors could also offer their patients. As a result, integrating CAM practitioners into primary care — which has a shortage of providers — is rarely considered in health policy or research. Furthermore, CAM practitioners cannot seek reimbursement from insurers for many services they are trained to perform and so cannot practice to the full extent of their capabilities, which for chiropractors might include giving full physical examinations or writing prescriptions.

In addition to undermining the intent of various states' laws that establish CAM practitioners as licensed health professionals, limiting CAM professionals' scope of practice has significant policy implications for patients, the CAM professions, and health care in general. Complementary and Alternative Medicines: Professions or Modalities? examines the landscape for four types of CAM practitioners with the strongest claim on established professional status: chiropractic, acupuncture and Oriental medicine, naturopathic medicine, and massage therapy. The study examines various policies that apply to CAM, the research literature, and the results from two panel discussions — one of CAM experts and the other of health care decisionmakers.

Policies Where Profession Versus Procedure Makes a Difference

There are a number of health-related policies where designation as a profession versus a procedure or modality has an impact. Often, these policies prevent patients from accessing CAM practitioners, even when the treatment they provide may promise the best outcomes. These include:

1. Licensure. Individual states set the scope of practice for the health care professions practicing in that state. The scope for the CAM professions varies widely across states and may not reflect their full capabilities.
2. Health plan coverage. The determination of who and what is covered is defined by the profession/license of the practitioner (and whether that individual is part of the health plan's network), the procedure being offered (and procedures for which the practitioner is allowed to bill), and the condition for which the treatment is given. Different health plans cover different combinations of these three characteristics. Many types of CAM professionals are not approved for health plan reimbursement or are not members of a health plan's network, and even if they are, they can only bill for particular procedures for particular conditions. No codes exist for many, if not most, CAM procedures, let alone for their full scope of practice.
3. Workforce. Medicare is allowed to reimburse care for only a physician's services as defined in the Social Security Act (Section 1861); chiropractors are included in the definition of a physician, but no other CAM profession is. For other provider types to be covered by Medicare, Congress would have to include them. Many other health-related policies are also tied to Medicare's coverage, including the provider types covered by state Medicaid systems, the Department of Veteran Affairs' reimbursement for outside care, the policies of private insurers, and an individual's eligibility for some education loan repayment programs and residency funding. The Veterans Health Administration and the medical health system of the Department of Defense hire doctors and other health care providers using the Office of Personnel Management job code lists, which do not include specific categories for most CAM providers. Finally, the Affordable Care Act is inconsistent on who is a primary care provider.
4. Regulatory Practice Constraints. Under the laws in most states, CAM practitioners and regular physicians are prohibited from practicing together.
5. Research. Most medical research is focused on the efficacy of a treatment, such as acupuncture or spinal manipulation. What is needed are comparative effectiveness studies of patient management by a chiropractic or naturopathic doctor versus a traditionally trained medical doctor, and studies that examine the effects and optimal mix of multidisciplinary care teams.

The Future of Health Care — and CAM?

One key solution to helping CAM professionals practice to the full extent of their training and capabilities involves integrative care — that is, including, as appropriate, practitioners of CAM on the team of doctors, nurse practitioners, and physician's assistants that has traditionally been responsible for a patient's care. Because CAM and non-CAM providers often perform in siloes, care does not necessarily address conditions in an integrative or coordinated manner. Integrative teams would provide not just medical care, or care for a particular episode, but also wellness care, prevention, and support for lifetime health. Integrative care may be the future of health care, so advancing CAM in this way addresses the rapidly emerging future rather than the present state of the industry.

Policy Considerations from Expert Panelists

A number of specific regulations and coding issues act as obstacles and may even preclude integrative care teams that include CAM in mainstream settings. During the panel discussions, the experts considered the following:

• creating new OPM occupation codes so that CAM professions can be hired into more health care systems and practice at the full scope of their license
• changing the Social Security Act to allow CAM providers into Medicare
• correcting the inconsistency in the Affordable Care Act regarding who is considered a primary care provider
• identifying and addressing regulatory practice constraints.

A number of issues for the CAM professions also need to be addressed to move the health care system to successful integrative care. These recommendations include the following:

• conducting prospective comparative studies and/or demonstration projects to generate evidence that CAM and integrative health care can be effective
• making a case that highlights the improved outcomes associated with integrative teams to convince policymakers, insurers, and even influential large employers of the value of expanding the role of CAM practitioners
• educating conventional practitioners, CAM practitioners, and patients. Conventional practitioners often do not know when they should refer a patient to a CAM provider, or to whom. CAM practitioners may not know how to navigate the larger health care system, and patients do not always know when they would benefit from CAM treatment.
• working together across CAM professions to strive collaboratively toward mutual goals.