Congress must close Medicare gaps in access to non-drug pain management

As our population ages and the opioid crisis continues to ravage our communities, increasing access to high-value, non-pharmacologic options for managing pain and chronic disease must be a top priority for Congress. Current Medicare coverage does not reflect the current guidelines for treatment of pain, and a straight-forward first step is to improve coverage for the 64 million Americans enrolled to better include chiropractic and acupuncture. 

Bipartisan solutions have already been introduced, but with the midterm elections approaching, the window for Congress to address current limitations within the Medicare program through reconciliation is closing. 

Chiropractic care and acupuncture are recommended in numerous best practice guidelines as first-line treatments for pain. Both are increasingly covered in commercial health plans, and patients are seeking non-drug approaches to managing their pain and chronic diseases.  

However, arbitrary limits on Medicare coverage mean that seniors — arguably one of the most important groups to consider when thinking about pain and chronic disease — don’t have access to the evidence-based, recommended care they deserve. The time is now for Congress to pass bipartisan legislation to create greater choice and better outcomes for patients, as well as projected cost savings to the system. 

Current Limitations  

The American College of Physicians (along with other reputable organizations) recommends both spinal manipulation and exercise (commonly delivered by chiropractic physicians) and acupuncture for common back pain, prior to prescription or over the counter drugs. One would expect Medicare coverage to reflect the current guidelines, ensuring our seniors have convenient, affordable access to the safest and most effective care. Unfortunately, that is not the case: arbitrary limits on interventions and visits restrict access for beneficiaries.  

For example, chiropractic coverage in Medicare consists of a single service: spinal manipulation. Examinations, clinically necessary imaging, rehabilitation, and exercise are not covered benefits if delivered by a chiropractic physician, although they are covered if delivered by another provider type. This results in disrupted or delayed care, and higher out of pocket costs for the beneficiary.  

Like chiropractic, early treatment with acupuncture for spinal pain has been shown to decrease the need for advanced imaging, invasive procedures, and opioid medications. However, beneficiaries are unable to receive acupuncture from most licensed acupuncturists, arguably the most expert in delivering this service. (CMS limits authorized providers to physicians or “auxiliary personnel” who must be supervised by a physician, physician assistant or nurse practitioner.) 

Lack of access to these safe, recommended interventions steers back pain patients in particular toward lower value services like advanced imaging and invasive interventions including surgery, and increases the risk of an acute problem developing into a chronic one. 

Closing these gaps would address a discrepancy between the current Medicare program and the Affordable Care Act, which stipulates that group health plans and health insurance issuers may not discriminate against a health care provider acting within the scope of their license under state law. Congress has a responsibility to update and reform these programs to align with the intention of this non-discrimination provision, especially as they seek to extend the sunsetting subsidies to keep costs low. 

Legislative Proposals to Expand Medicare Coverage 

Greater access to chiropractic and acupuncture services can lead to a reduction in visits to primary care providers, resulting in substantial savings in annual costs in the Medicare program, lower per beneficiary costs among patients within Medicare, and projected cost savings to the system.  

Bipartisan legislative measures at the federal level have already been introduced and are viable options for closing existing coverage gaps within Medicare: 

• S. 4042 / H.R. 2654, the Chiropractic Medicare Coverage Modernization Act – this bill would expand Medicare coverage to include more chiropractic care options, which will lead to improved spine care among older adults, increased access to non-opioid pain management, and overall cost savings in the Medicare system. This bill does not expand benefits within Medicare; rather, it allows beneficiaries to seek care from chiropractic physicians for covered services that fall within their scope of practice, expanding patient choice and the health care provider workforce.  
• H.R. 4803, the Acupuncture for Our Seniors Act – this bill will allow the Centers for Medicare & Medicaid Services (CMS) to recognize licensed acupuncturists as Medicare providers, resulting in increased and expanded access to acupuncture services for the treatment of chronic back pain. This will make it possible for beneficiaries to see a licensed acupuncturist for care, rectifying current coverage that discriminates against a licensed class of providers and significantly limits access, essentially constituting a shadow benefit. 

Expanding coverage of chiropractic and acupuncture services are simple yet necessary policy solutions to increase access to care, decrease opioid utilization and make healthcare more affordable. It would be shortsighted of Congress to debate ways to reform Medicare and expand coverage options without addressing these coverage gaps. Our seniors deserve access to the safest, most effective care for pain and chronic diseases. Chiropractic care and acupuncture are sought-after and recommended; Congress must make them accessible.  

Michele Maiers, DC, MPH, PhD, is executive director of Research and Innovation at Northwestern Health Science University