Senate Bill 590 does not call for a new benefit. It would not require health insurance policies to cover acupuncture services, but, rather, it would require that licensed non-physician acupuncturists be reimbursed for these services when they are covered, and at the same rate as licensed physician acupuncturists.
At issue, here, is whether there is a need to require coverage of acupuncture applied by non-physicians. In response to this point, the American Academy of Medical Acupuncture stated, "The number and availability of physician acupuncturists is more than adequate." The submission from the Insurance Federation also states, "In the instances where it [acupuncture] is appropriate, adequate numbers of licensed physicians are available to administer it." Figures submitted by Highmark suggest that there are 260 acupuncturists practicing in Pennsylvania. Approximately 200 of these are classified as non-physician acupuncturists, who would be required to perform only under a physician's supervision.
With regard to the proposed benefit being "needed by" the residents of Pennsylvania, Highmark finds, "minimal interest among group accounts specifically requesting acupuncture services."
From the information received, a specific need to cover acupuncture applied by non-physicians was not proven to the Council.
The Highmark submission stated, "The availability of acupuncture practitioners does not appear to be an issue for those having coverage in the Commonwealth. Few benefit programs incorporate acupuncture as a basic benefit in either traditional indemnity (fee-for-service) or managed care plans." Highmark continued, "Market demand for acupuncture services is minimal, as reflected in group benefit designs administered through Highmark Blue Cross Blue Shield. Of those few employers specifically electing such coverage, most are large national corporations. Little in the way of such coverage is demanded by small and medium-sized businesses." They noted that Pennsylvania's Medical Assistance program does not reimburse for acupuncture services under the traditional fee-for-service coverage.
Highmark also noted, "Since the legislation does not seek to mandate an additional benefit, no issues arise with regard to inadequate health care or financial hardship. The prevailing licensure and physician oversight in administering acupuncture services has not created any apparent service inadequacies or financial hardship."
In their submission, the Insurance Federation agreed that neither inadequate health care nor financial hardship have occurred by failing to cover services of non-physician acupuncturists.
The Council did not receive sufficient information to describe the coverage of acupuncture services (either by physicians or non-physicians). Further, no information was submitted to suggest that inadequate health care or financial hardship have resulted from not covering services of non-physician acupuncturists.
The Council received no information in support of this measure, only in opposition to it. Opposition was expressed both to Senate Bill 590 in particular and to mandates in general.
Highmark suggests that, "no evidence can be found that acupuncture services are in demand in Pennsylvania among individual participants enrolled in programs of health care coverage." They note a "minimal interest among group accounts specifically requesting acupuncture services."
Strong opposition to this mandate was expressed by the American Academy of Medical Acupuncture (AAMA). In their submission, they stated, "the AAMA strongly opposes payment for physician acupuncturists and non-physician acupuncturists at the same rate. The services provided are not identical." While the services provided by these different practitioners may overlap, the American Academy of Medical Acupuncture argues that physicians are trained to differentiate between a problem most effectively treated with Western medical techniques from one best treated with acupuncture, which provides a valuable cost containing service. They provide the following example: . . . "a persistent groin pain could easily be mistaken for an inguinal strain by a non-physician acupuncturist. If the pain problem were actually caused by an inguinal hernia, as properly diagnosed by a physician, the appropriate medical treatment of surgical repair would have provided a more efficient and less costly resolution of the problem. In addition, prompt surgery would have saved the patient and the insurance provider from enduring and paying for a services of ineffective, unnecessary, inappropriate and costly acupuncture treatment by the non-physician.
The Insurance Federation notes that "acupuncture remains an experimental technology." As such, they argue that it is logical and "very sensible" that the insurer be allowed to limit coverage of acupuncture services to those applied by physicians. They argue that this step is especially important for insurers beginning to offer this coverage in the marketplace. They note, that it is "conservative in terms of the treatment by ensuring conventional medical oversight and financially conservative because it subjects utilization to that approved by a conventionally trained physician."
The Insurance Federation continued, "There is always great concern by both insurers and employers about creating additional input points to the health care system. Certainly, broadening the insurance for acupuncturists beyond physicians has the potential to induce a lot more of this type of service. If the bill were to have this effect, the additional health care costs and the corresponding increase in insurance premiums for policies covering them might be fairly significant."
Highmark notes, too, that there could be significant cost implications resulting from a proliferation of additional providers. For example, in this particular instance, the numbers of non-physician acupuncturists might increase dramatically if reimbursement options are available. Further, opposition to mandates, in general, is often expressed because they tend to disproportionately advantage particular provider groups.
Others raised concerns about both the impact of this particular measure (i.e. mandating reimbursement for a new class of practitioners) and the possibility that Senate Bill 590 would open the door to future bills mandating coverage for all acupuncture services. Highmark cautions that such action would have "serious implications for. . . the overall cost of health care."
The American Family Life Assurance Company suggests that supplemental health insurance policies be excluded from the bill (accident-only, specified disease, hospital indemnity, Medicare supplement, long-term care, disability income or other limited benefit health insurance). They argue that these policies are of limited nature and fill the gaps "between what is covered by comprehensive insurance and the total financial impact of an illness or injury." They state, "Not only is there no need for this type of mandate to include supplemental insurance, there is also no public demand for it."
Both the purchaser and insurer communities expressed strong opposition to the general idea of legislatively imposed health care mandates. In general, submissions contend that mandates result in rising health insurance costs, which cause employers and individuals to drop coverage, and thereby contribute to the increasing number of uninsured. The following are some of the arguments made by opponents of mandates:
Reimbursement at different rates for physician and non-physician, licensed acupuncturists cannot be said to have a social impact. Because submissions received by the Council suggest that the number of physician acupuncturists is adequate, it would appear that there is no social impact resulting from the lack of this measure.
Senate Bill 590 does not mandate coverage of a new therapy. While studies were submitted that address the proliferation, efficacy, and acceptance of acupuncture services, Senate Bill 590 does not address the general issue of acupuncture but instead deals with the reimbursement policies for practitioners.
The Council did not receive any studies comparing the results of acupuncture treatment by those who are physicians as opposed to those who are not. Council staff were unable to identify any such studies through independent research.
Although their submission did not provide studies comparing treatment results for physician and non-physician acupuncturists, the American Academy of Medical Acupuncture discussed the difference between the two practitioners and rationale for reimbursement at different rates. In their letter, "The American Academy of Medical Acupuncture (AAMA) strongly and most emphatically opposes the current version of Pennsylvania Senate Bill 590 because it is contrary to well-established principles of medical reimbursement and not cost effective." In discussing physician acupuncturists and non-physician acupuncturists the Academy continues, "The use of the word, 'discrimination' [in Senate Bill 590] is offensive to physicians. Discrimination occurs when two entities of equal status are treated differently. In the instant case, the two entities clearly are not of equal status. One group is comprised of physicians who have added the specialty of Medical Acupuncture to their Western medicine training and are licensed by the Commonwealth to practice both medicine and acupuncture. The other group is comprised of non-physicians who are licensed to practice only acupuncture. Reimbursement at different levels for services by providers of unequal status is not discrimination. It is correct."
The position of the American Academy of Medical Acupuncture stated that, "Legal precedent, logic and well-established principles of medical reimbursement require physicians and non-physicians to be compensated at different levels. To reimburse physician acupuncturists and non-physician acupuncturists at the same level is analogous to paying psychiatrists and psychologists or ophthalmologists and optometrists at the same rate." The letter continued, "Like ophthalmologists or psychiatrists, physician acupuncturists have the knowledge and ability to determine which treatment(s) will be most effective for a particular patient. Like ophthalmologists or psychiatrists, physicians are ethically and legally bound to factor in their Western medical diagnostic and therapeutic acumen and expertise when examining and treating a patient. A physician acupuncturist can select drug therapy, acupuncture, surgery, or osteopathic manipulation. His/her services are not limited to one medical modality. And as physicians, the highest standards of safety, cleanliness and patient care are insured. In other words, a physician acupuncturist offers patients the best of both worlds. And in doing so, a physician acupuncturist is able to offer the fastest, most efficient, and cost effective therapeutic treatment(s)."
The second point made by the American Academy of Medical Acupuncture is that Pennsylvania already recognizes physician acupuncturists and non-physicians acupuncturists to have a difference in status. They stated, "because safety and sanitary conditions are an issue, a non-physician acupuncturist cannot practice acupuncture in Pennsylvania without being under the supervision of a physician. The Commonwealth, therefore, has already recognized the difference in status between physician acupuncturists and non-physician acupuncturists."
The American Academy for Medical Acupuncture concluded, "What we strongly oppose is payment for physician acupuncturists and non-physician acupuncturists at the same rate. The services provided are not identical."
It should be noted that the position of the American Academy of Medical Acupuncture is consistent with that of the Insurance Federation. In their submission, the Insurance Federation noted that, "The effect of this bill would be to preclude an insurer wishing to offer this benefit [acupuncture services] from (a) limiting its coverage to services provided by the most highly trained practitioners; and (b) distinguishing the level of compensation for their service between those who meet a stricter standard of educational accomplishment.
The Council did not receive any research comparing the services provided by non-physician, licensed acupuncturists to those of physician acupuncturists. Studies on acupuncture services, in general, were received from Highmark. Findings include: (1) In looking at reliance on unconventional therapies (such as acupuncture), researchers found that "roughly one in four Americans who receive treatment from a medical doctor for a serous health problem may also be relying on unconventional medicine." (2) One study reported that evidence for the efficacy of using acupuncture as treatment for addictive diseases was "very encouraging." (3) On this topic, another study notes that "resistance to accept acupuncture therapy is based, not on medicine, but on cultural bias." (4) One study found that a combination of treatments (including acupuncture) may decrease the risk of dying and/or heart attack in patients with severe angina pectoris.
Senate Bill 590 has the potential to increase the cost for acupuncture treatment. If non-physician, licensed acupuncturists are currently paid less than physician acupuncturists, reimbursing both providers at the same rate (assumedly the higher of the two rates) would increase the cost for services provided by non-physician acupuncturists. Further, Highmark argues that health care costs will increase because utilization will likely increase as a result of a proliferation of new providers [non-physician acupuncturists].
The American Academy of Medical Acupuncture argues that the proposed benefit would increase the cost of medical treatment, not only because of the reimbursement to non-physician acupuncturists, but because "patients may be misdiagnosed and, therefore, inappropriately or ineffectively treated with acupuncture by a non-physician when pharmaceuticals or surgery might be faster, more effective and less costly."
The submission from Highmark stated, "In discussions with Blue Cross Blue Shield Plans in Florida, Oregon, and New Mexico where mandated reimbursement to providers is in place (as opposed to an actual benefit mandate), no appreciable increase in costs or premiums was noted." They note that acupuncture is not widely utilized unless coverage is mandated. Council staff were unable to locate any additional information in this area.
The submission from Highmark stated, "This legislation should have no bearing on the 'appropriate use of the treatment or service.' . . . Medical necessity will continue to be the standard by which treatment is determined eligible and treatable under the terms of an insured's coverage."
The Insurance Federation stated, "Certainly, broadening the insurance for acupuncturists beyond physicians has the potential to induce a lot more of this type of service. If the bill were to have this effect, the additional health care costs and the corresponding increase in insurance premiums for policies covering them might be fairly significant."
The only submission which addressed this issue was from Highmark. Their submission suggested that the proposed measure would have a minimal impact on administrative expenses
The only dollar figures provided to the council were supplied by Highmark. In their submission, Highmark stated, "If direct reimbursement were to be legislatively mandated for this additional provider group [non-physician licensed acupuncturists], Highmark Blue Cross Blue Shield and Pennsylvania Blue Shield ... projected the cost at approximately $55,000 annually. This assumption is based on a minimal number of group accounts electing acupuncture coverage with only minimal utilization."
As previously noted, Highmark is concerned that passage of Senate Bill 590 may lead to a mandate to cover acupuncture services in the future. Therefore, Highmark also noted that, "In an alternative scenario involving a more comprehensive benefit mandate being enacted, requiring universal and comprehensive coverage of acupuncture services, costs could conceivably rise to $10,233,000 annually." These cost projections are solely for Highmark members, and do not take into consideration the possible increase in costs other insurers in Pennsylvania may experience.
The Pennsylvania Business Roundtable writes that, "The greatest concern is that such mandates [as proposed in Senate Bill 590] will impose additional financial burdens on the payers of health insurance, whether they be private or public.
While submissions provided interesting information, they did not contain specific information on the amount of increase on the benefit costs of purchasers. One may assume, however, that if insurers costs go up due to enactment of Senate Bill 590, these costs will be passed along to the purchasers. No estimation of the increase in the costs to purchasers was provided to the Council, nor were Council staff able to determine such an estimate.
Insufficient information was received to identify precisely how this measure would impact the total cost of health care in Pennsylvania. In response to this requirement, Highmark stated, "Based on conservative assumptions applicable to our own members and accounts, including the three Blue Cross Plans and applying this to programs offered by commercial insurers offering both indemnity and managed care products, Highmark projects the cost of mandated reimbursement to non-physician licensed acupuncturists at $105,000 [annually]." Highmark continues, "Using the alternative scenario of a comprehensive benefit mandate being enacted ... costs could conceivably rise to $19,670,000 annually."
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