12/6/03 Chiropractic's Biggest Win Ever on Capitol Hill from the Dynamic Chiropractic online Opponents Told to "Back off" as Congress Approves Plan to Test Expanded Medicare Access to DCs ARLINGTON, Va. - As part of legislation overhauling the 38-year- old Medicare program - passed by the House of Representatives on Nov. 22, 2003, and the Senate on Nov. 24 - Congress has authorized four two-year pilot projects designed to test expanded access to chiropractic services for America's seniors. Senator Charles Grassley (R-IA), the chief sponsor of the "Medicare Chiropractic Demonstration Project," and other pro-chiropractic members of Congress, succeeded in turning back strong opposition from the organized medicine lobby and other special interest groups. As the deadline for consideration of the bill approached, Senator Grassley even contacted one key opponent of the chiropractic provision - Senate Majority Leader Bill Frist, MD - via his electronic pager and sent the message to "Back off!" Also included in the Medicare bill is an ACA-backed provision aimed at ensuring that Medicare beneficiaries will continue to have access to chiropractors and other physicians; it replaces a 4.5 percent physician payment cut due to take effect in January with 1.5 percent payment increases in 2004 and 2005. "This is chiropractic's biggest win ever on Capitol Hill," commented ACA Chairman George B. McClelland, DC. "The Medicare Chiropractic Demonstration Project marks the beginning of the end of three decades of discrimination against doctors of chiropractic and chiropractic patients under Medicare. For the first time, Medicare beneficiaries will have the freedom to choose a doctor of chiropractic to provide a range of the covered services they want and need." ACA's efforts on the Medicare front have been gaining the attention of the national media, with prominently placed articles appearing in the Washington Times, Quad-City Times (Iowa), Chicago Tribune and twice in the Washington Post. Senator Grassley, quoted in the Quad-City Times, states, "This provision is a big step toward Medicare recognizing the comprehensive value of chiropractic services." Meanwhile, in one Washington Post article, Dr. McClelland is quoted as saying, "Every doctor of chiropractic and chiropractic patient in Iowa and across America should know that it was Senator Grassley who took on and defeated organized medicine and other special interest lobbyists seeking to stop this day from happening." A second Washington Post article notes that, "Chiropractors, who are usually at a disadvantage in political contests against physicians, won a rare victory with this legislation, which creates a new chiropractic demonstration project and increases reimbursement for chiropractic services." An ACA-backed demonstration project within the Department of Defense (DoD) health system that was approved by Congress in 1995 led to the enactment of legislation (Public Law 103-337) in 2000 establishing a permanent chiropractic care benefit for America's active-duty military personnel. In 2002, also at the urging of the ACA, Congress approved legislation (Public Law 107-135 and Public Law 107-251) to establish a permanent chiropractic care benefit for America's veterans through the Department of Veterans Affairs health system, and to include doctors of chiropractic in a National Health Service Corps student loan reimbursement pilot program. "This tremendous victory is the result of many years of hard work and commitment," said ACA President Donald Krippendorf, DC. "This did not happen overnight." (Please see the Medicare Timeline for a better understanding of this 30-year battle.) Medicare Timeline * Prior to the 1990s, little had taken place, legislatively or otherwise, to change the core status of how the chiropractic profession fit into the Medicare program. Significant developments begin in 1991, when the ACA's Legislative Commission reviews the Medicare situation and reiterates two long-standing goals: 1) expansion of chiropractic reimbursement to cover diagnostic X-rays and physical exams; 2) as an alternative, getting rid of the mandatory X-ray mandate. As a practical matter, the ACA's lobbying remains focused on trying to expand reimbursement rather than elimination of the X-ray requirement at this time. * By 1992, some progress is achieved on the regulatory front. ACA successfully obtains an increase in the relative value of the A2000 manipulation code service for the 1992 update of the RBRVS (resource-based relative value system) fee schedule. In April 1992, the ACA secures the appointment of Dr. Jerilynn Kaibel to serve on the Practicing Physicians Advisory Council (PPAC). The knowledge base obtained via this appointment and the internal networking by Dr. Kaibel within PPAC and HHS builds credibility for chiropractic, identifies some sympathetic players in the Health Care Financing Administration (HCFA) and plays a critical role in the process that ultimately results in the replacement of the single A2000 code by a series of chiropractic manipulation codes. (The process that allows this is finalized in late 1996 with the publication of the 1997 version of the CPT codes by the American Medical Association). * On Feb. 24, 1993, Sen. Tom Daschle (D-S.D.) introduces S. 421, a bill to reimburse chiropractic X-rays and physical exams in Medicare. The bill is identical to legislation (S.614) introduced by Daschle in the previous Congress. Nine cosponsors are obtained for the measure. The small number of cosponsors reflects a shift in priorities and grassroots activities to larger health care reform issues. The ACA succeeds in winning the appointment of Dr. Kaibel to the Clinton administration's Health Care Reform Task Force. National health reform dominates through 1993, with no legislative action taking place regarding Medicare. However, the 1994 Medicare update contains an increase for chiropractic supported by the ACA. * In 1994, national health reform proposals continue to advance in Congress. The ACA proposes inclusion of a "full scope" provision in the proposed national health reform plan and Medicare. This is the first time a full scope Medicare provision has been "in play" on Capitol Hill, with a potentially available legislative vehicle that could move the provision. ACA's full scope Medicare expansion plans are championed by Rep. Harold Ford (D-Tenn.), member of the House Ways & Means Committee that has jurisdiction over Medicare. Congressional Budget Office estimates block acceptance of the ACA's full scope plan; however, Ways & Means Committee Chairman Sam Gibbons (D-Fla.) agrees to the inclusion of chiropractic X-rays in the reform bill approved by the committee in June. The ACA is the only group to win a specified expansion of Medicare provider services in the Ways & Means Committee bill. * ACA Chair Dr. Lowry Morton and other senior ACA officials meet with HHS Secretary Donna Shalala Apr. 7, 1995 in Washington, D.C. as part of a campaign of intensified lobbying of the Clinton administration aimed at improving the status of chiropractic inclusion in Medicare. In response, Secretary Shalala appoints a senior HHS official to serve as a "liaison" to work with the ACA to resolve Medicare issues. ACA works with Secretary Shalala's office and the liaison to convince HHS to take favorable action regarding ACA Medicare concerns. * In August 1995, Dr. Kaibel is appointed to the American Medical Association's RUC Health Care Professionals Advisory Committee (HCPAC). ACA works with the Lewin Group to expand the process of assembling needed data to win expansion of the A2000 code. * March-April 1996 - At the ACA's urging, the HCFA issues a memo to regional Medicare administrators stating that standards for chiropractic X-ray referral must be no more or less demanding than those applied to other physicians in Medicare. * In November 1996, new codes are finalized and published by the American Medical Association in the 1997 edition of the Current Procedural Terminology codes, and HCFA publishes new fee schedule reflecting new chiropractic codes and work values. Chiropractors receive a 15.5 percent increase, compared to a reduction of 4.6 percent that would have taken place under the old A2000 code. * In August 1997, Congress approves the Balanced Budget Act of 1997, which is signed into law by President Clinton. The law cuts approximately $115 billion in Medicare expenditures, but a chiropractic provision to abolish X-rays is included at a projected cost of $1.9 billion over a 10-year period. The cost of the provision is the highest for any single provider group in the bill; most providers face cuts in reimbursement. The provision to abolish X-rays becomes effective Jan. 1, 2000. * March 2001 - Representative Wes Watkins (D-Okla.) reintroduces ACA's full scope Medicare bill in the new Congress. In June of that year, the ACA's study of the cost effectiveness of chiropractic care in the Medicare program (the Muse study) is released and used to bolster efforts to include the Watkins bill (or provision based on it) into the next Medicare reform vehicle to be considered by Congress. The ACA continues to generate grassroots support for the Watkins bill through 2001. * In 2002, Congress begins to debate details of a Medicare reform and prescription drug bill. The ACA seeks inclusion of some form of the Watkins bill into this vehicle, but Congress is unable to agree on details of the reform proposal. After a year of heavy lobbying, Congress shelves any Medicare proposal until calendar year 2003. * On Nov. 21, 2003, after difficult and contentious negotiations, Senate and House negotiators hammer out final version of Medicare prescription drug bill. The final provision contains a Senate chiropractic pilot program, despite the opposition of AMA and Senate Majority Leader Dr. Bill Frist. The ACA endorses the bill. On Nov. 22, the House narrowly passes the prescription drug bill after a historic "delayed" roll call vote and personal lobbying efforts by President Bush. Efforts to filibuster the bill fail, and on Nov. 24, the Senate passes the measure and sends it to President Bush for his signature. The current Medicare program imposes an arbitrary limit on the covered services that can be offered by America's 60,000-plus doctors of chiropractic and are sought by millions of older chiropractic patients. Under current law, a chiropractor may only provide Medicare beneficiaries with a single covered service (manual manipulation of the spine to correct a subluxation), despite the fact that they are licensed in all 50 states to provide additional services currently covered under Medicare, including X-rays and other diagnostic tests and physiotherapy services. The ACA has long contended that Medicare's arbitrary limit on chiropractic services is harmful to patients and costly to taxpayers. The chiropractic demonstration project, as sponsored by Senator Grassley and to be administered by the U.S. Department of Health and Human Services, will assess how greater freedom of choice for consumers and additional competition among care providers, including doctors of chiropractic, will benefit the health of Medicare beneficiaries and provide for more efficient use of Medicare resources. The four- site, two-year demonstration will likely have a profound impact in rural and medically underserved areas, where beneficiaries will no longer be forced to visit a second or third provider to receive the full range of necessary services. In addition to Senator Grassley, the ACA recognized the support of the following lawmakers for the Medicare Chiropractic Demonstration Project: Orrin Hatch (Utah); Max Baucus (Mont.); Tom Daschle (S.D.); Kent Conrad (N.D.); Ben Nelson (Neb.); Chuck Hagel (Neb.); Norm Colemen (Minn.); and George Allen (Va.). Also noted were Representatives Jim Ramstad (Minn.); Earl Pomeroy (N.D.); Jim Nussle (Iowa); Clay Shaw (Fla.); Phil English (Pa.); J.D. Hayworth (Ariz.); Billy Tauzin (La.); Mike Bilirakis (Fla.); Nancy Johnson (Conn.); Leonard Boswell (Iowa); Collin Peterson (Calif.); Ken Lucas (Ky.); Rodney Alexander (La.); Steve Israel (N.Y.); Virgil Goode (Va.); Bob Filner (Calif.); Paul Gilmore (Ohio); Rob Portman (Ohio); Sam Graves (Mo.); Ed Royce (Calif.); Chris Shays (Conn.); Lloyd Doggett (Texas); Bill Janklow (S.D.); Bob Goodlatte (Va.); and Sherwood Boehlert (N.Y.). ACA leaders also recognized the active involvement of thousands of ACA members and other DCs around the country who participated in a months-long grassroots lobbying effort beginning with ACA's National Chiropractic Legislative Conference in March 2003, as well as the efforts of individual friends of the chiropractic profession, like Mr. Kent Greenawalt, president and CEO of Foot Levelers, Inc. Also, a number of national and state chiropractic organizations played an important role in this Capitol Hill victory, including the Association of Chiropractic Colleges; the Student American Chiropractic Association; the National Association of Chiropractic Attorneys; the Iowa Chiropractic Society; the Connecticut Chiropractic Association; the Chiropractic Association of Louisiana; the Florida Chiropractic Association; the Utah Chiropractic Physicians Association; the Tennessee Chiropractic Association; and other member organizations of the Congress of Chiropractic State Associations.