Kaiser Permanente Mid Atlantic States and Mid-Atlantic Permanente Group recently announced the elimination of neck manipulation from their chiropractic coverage. The revised policy states,
Given the paucity of data related to beneficial effects of chiropractic manipulation of the cervical spine and the real potential for catastrophic adverse events, it was decided to exclude chiropractic manipulation of the cervical spine from coverage.
Their decision was applauded by some but was predictably attacked by chiropractors.
The American Chiropractic Association (ACA) promptly responded with a letter to Kaiser outlining “the extensive data that supports cervical spinal manipulation as both beneficial and safe.” I have not yet been able to find a copy of that letter online. I don’t doubt that they presented data to support their beliefs. I do doubt that they presented a balanced view of the entire body of published evidence, the body of evidence that Kaiser relied on in making its decision. When the BCA (British Chiropractic Association) tried to defend itself against Simon Singh’s criticism, it provided a list of allegedly supporting studies but these were readily demolished in the blogosphere. Several previous posts on SBM including this one by a chiropractor have examined the evidence for neck manipulation and concurred with Kaiser that there is a “paucity of data related to beneficial effects of chiropractic manipulation of the cervical spine” and a “real potential for catastrophic adverse events.” That’s what the science says. It is encouraging that Kaiser followed the science.
The ACA also released the following statement, signed by ACA President, Dr. Rick McMichael :
The American Chiropractic Association is aware that Kaiser Permanente Mid Atlantic States and Mid-Atlantic Permanente Medical Group have revised their Chiropractic Manipulation Medical Coverage Policy to exclude cervical Chiropractic Manipulative Treatment (CMT) from coverage. This restriction, if allowed to stand, will be harmful to chiropractic patients and doctors. We have contacted Kaiser to express our grave concern over this change, and we await its reply. ACA will expend every effort to encourage Kaiser to reverse this new restriction, and we will keep our members and the profession informed along the way.
Chiropractors are not doing well. 20-25% of chiropractors leave the field within 10 years of graduation. Their average income has dropped from $97,892 annually in 1992-1993 to only $48,900 in 2002-2003.
The new Kaiser policy threatens their livelihood, especially the livelihood of the many practitioners who use neck manipulation on virtually all patients regardless of the presenting complaints. So of course they will protest and will try everything possible to convince Kaiser to change its mind. Such lobbying has been effective in previous cases.
In 2007, United Healthcare decided to stop reimbursing chiropractic care for children and for headaches. A joint letter from various chiropractic organizations chastised them:
Attached is an analysis which demonstrates that the above policy is not only flawed but more importantly, poses a threat to the health of children, adolescents and those individuals suffering with headache pain who may be insured or otherwise covered under United Healthcare programs and policies. We view your recent policy determination to be a material denial of essential benefits and coverage paid for by employers and other insureds. The broad stroke elimination of these important benefits is, in our view, not only unconscionable but is an abrogation of the promises made to cover chiropractic services to employees, individuals and their dependants.
The chiropractors contended that they are “uniquely qualified to address all types of childhood and adolescent ailments [not true].” They provided their evidence that chiropractic treatment was effective for headache [not convincing]. They said a number of other things that those of us on SBM would disagree with. United Healthcare backed down and rescinded the policy.
Kaiser made a good, science-based decision that will protect patients and also save money. They are to be commended. I hope they will stick to their guns and withstand the pressure that will be exerted against them by non-science-based chiropractors and health consumers. I hope other insurance and health care organizations will follow suit. In another action earlier this year, Saskatchewan deleted chiropractic subsidies from its health budget to save $10 million.
Note: this policy change does not restrict patients’ rights to choose any treatment they want. It does not prevent chiropractors from doing neck manipulation; it only means that patients will have to pay for it out of pocket. Their approach seems entirely reasonable for a large organization that is trying to reduce costs for everyone by refusing to pay for treatments of questionable efficacy and safety.
This article was originally published in the Science-Based Medicine Blog.