Not all chiropractors practice according to the same philosophy. This is leading some in the benefits industry to believe more scrutiny is necessary when it comes to paramedical expenses and determining whether they’re being used for evidence-based treatments.
A recent article in the Globe and Mail highlighted a divide within the chiropractic profession between those who practice evidence-based treatments and those who believe removing subluxations or nerve impingements in the spine can treat conditions that don’t appear spinal-related, such as asthma, attention deficit hyperactivity disorder and autism.
The latter group, called vitalist practitioners, believe eliminating spinal blockages allows a healing force called ‘innate energy’ to flow through the body, thereby addressing several disorders, according to the article. It noted many vitalists advocate against vaccination.
“This is where we’re highly critical,” says Ned Pojskic, leader of pharmacy and health provider relations at Green Shield Canada. “We’re questioning whether the profession needs to take a closer look at itself and separate those types of practitioners.”
For instance, a mother from Innisfil, Ont., took her nine-year old autistic son to a chiropractor who claimed he could mitigate the boy’s symptoms by making him more verbal, according to the Globe article. The family spent $5,000 for six months of treatments and stopped therapy after their son refused to return. According to the mother, she felt duped by the practitioner.
Dubious practices like this lead people astray, says Pojskic. “It provides false hope and it may, indeed, delay access to actual treatments that do improve outcomes. There’s evidence-based treatments for autism that can help improve communications and social functions. . . . That’s where the effort needs to be focused. That’s where our challenge is and why we’re highly critical, because it’s not just innocuous; in some cases, [it] could be dangerous.”
According to the College of Chiropractors of Ontario, which regulates the profession in the province, chiropractors are allowed to assess, diagnose, prevent and treat conditions related to the spine, nervous system and joints.
In a published statement on its website responding to the issue, the college said its role “is not to endorse any specific style of practice, but rather to require that all members practice within the chiropractic scope outlined in the legislation and respect all CCO standards of practice, policies and guidelines.”
The college has also published clear standards for chiropractors to respond to health-related questions that fall outside the scope of practice, it noted, such as those relating to vaccination, surgery or medication.
For private plans, these specifics carry weight. According to the Canadian Chiropractic Association, the majority of chiropractic expenses are covered by private insurance plans.
On a broader level, paramedical expenses have steadily increased in recent years, according to Joseph Chan, senior benefits consultant at Stem Capital Inc., noting they generally account for 10 to 15 per cent of health-care spending in private plans. In some, that share rises to 20 or 30 per cent.
Chiropractic services closely follow massage services in terms of popularity among employees, says Chan. “When I look at plan experience and use, the ones that attract the most attention when it comes to [paramedical services] would be massage, chiropractor and physiotherapy. It’s almost, in some ways, interchangeable. There will be clinics or providers out there that can do all. In some cases, what we’ve seen is that once you’ve exhausted one, the use would start hitting the other two potentially.”
Private plan sponsors should consider reevaluating their paramedical coverage, says Pojskic. “We pay for these treatments across the board and we need to move away from that broad approach into a more targeted approach that looks at, ‘Are we producing outcomes? Is there evidence based on it?’ And if so, let’s focus on those components or treatments that are evidence-based and not just looking at the global sum.”
Besides being a significant expense for plan sponsors, paramedical services are vulnerable to abuse or fraud because members often don’t need to supply medical proof to access them, says Chan. On the other hand, drugs are prescribed by doctors and employees are reimbursed directly at pharmacies. But with paramedical services, employees have more control over their spending, he adds.
“You [could] have a provider that has a registered massage therapist willing to sign off the receipt. You’ve probably seen some of these fraudulent cases . . . the service wasn’t actually provided,” says Chan. “It was a collusion between the provider and, in some cases, the employees.”
While employees, in the past, were required to provide a doctor’s note for certain therapies like massages, that practice has dissipated over the years because it’s seen as a burden on the health-care system, says Bernard Potvin, senior benefits consultant at Mercer. He notes the only real safeguard in insured benefits plans are contracts that state treatments should be medically necessary and that insurers can, at any time, ask for medical proof from plan members.
In recent years, benefits providers have started using technology to make the claims and reimbursement process more efficient, says Potvin. “Technology is wonderful and it’s easier to submit claims rapidly, but it’s also increasing the opportunity for fraud.”
Reviving the practice of asking plan members for medical evidence before allowing them access to treatments could prevent misuse of the system, he adds. As well, employers can take a proactive stance by working with insurers to look at unusual patterns among the top claimants for paramedical services.
For instance, a family that uses up their entire paramedical budget for a year would warrant investigation, says Potvin. “Those are situations where there should be a red flag. It’s fairly rare for every single member of the family to have a medical requirement to use these benefits.”
Also, Potvin suggests employers explain the issue to members. ”A lot of employees don’t realize that submitting a fraudulent claim can lead to termination of employment,” he says. “It’s a concern [with] any service or treatment under a health-care plan, [so] we always want to ensure they’re medically necessary.”
Should private benefits plans require members to provide medical evidence before allowing them to access chiropractic treatments and other paramedical services? Share your view in our weekly online poll here.
Considering the news that the B.C. Nurses’ Union’s massage costs increased from $3 million in 2008 to $31 million in 2018, last week’s poll asked whether plan sponsors should be offering unlimited coverage for paramedical benefits. A significant majority (89 per cent) of respondents said no, a reasonable cap on these benefits makes the most sense, while 11 per cent said yes, their plan members are responsible and won’t abuse the offering.