Some Notes on Subluxations and Medicare

Stephen Barrett, M.D.

In 1972, in response to vigorous lobbying by chiropractors, Congress enacted a law providing for limited coverage of chiropractic services under Medicare. The law, which took effect in 1973, called for payment for the treatment of "subluxations demonstrated by x-rays to exist." [1] A New York Times editorial called the enactment of Medicare coverage "the most shocking victory for special-interest lobbyists" and added that "the scientific basis of the chiropractic cult is highly dubious." [2]

A few weeks after the law was passed, Doyl Taylor, head of the AMA Department of Investigation, told me that when chiropractic inclusion appeared inevitable, the "subluxation" language was inserted with the hope of preventing chiropractors from actually being paid. The idea's originator thought that since chiropractic's traditional "subluxations" were visible only to chiropractors, this provision would sabotage their coverage. After the law was passed, however, two things happened to enable payment. First, chiropractors held a consensus conference that redefined "subluxations" to include common findings that others could see. Second, according to Taylor, the government officials responsible for interpreting the new law "decided that Congress intended chiropractors to be paid for something." The regulators then defined subluxation as "an incomplete dislocation, off-centering, misalignment, fixation, or abnormal spacing of the vertebrae demonstrable . . . to individuals trained in the reading of x-rays." and stipulated that the "primary diagnosis" must be a subluxation.

Subluxation "Defined"

The consensus conference, held in Houston in November 1972, resulted in the following statement:

A subluxation is the alteration of the normal dynamics, anatomical or physiological relationships of contiguous articular structures. In evaluation of this complex phenomenon, we find that it has-or may have-biomechanical, pathophysiological, clinical, radiologic, and other manifestations [3].

The American Chiropractic Association included the Houston "definition" its Basic Chiropractic Procedural Manual, the first edition of which was issued in 1973. The book noted:

Through the years there have been numerous concepts within the chiropractic profession of what constitutes a subluxation. Each of these has had its own rationale and each has had certain validity that has been a contribution to our understanding of this complex phenomenon.

The advent of chiropractic inclusion in Medicare has brought the absolute necessity for a uniform methods of describing, documenting, and reporting spinal subluxations so that those who will administer the law will not be confused by the present lack of uniformity and differences in reporting terminology, to our detriment [4].

The manual also noted that the conferees had assembled to concur upon a definition that would be "agreeable to all chiropractors while understandable to nonchiropractors; would encompass our understanding so that we would not have improper limitations on us, but would be simple enough for lay interpretation."

The resultant "definition, several pages long, described the supposed radiologic manifestations of 18 types of "subluxations," including "flexion malposition," "extension malposition," "lateral flexion malposition," "rotational malposition," "hypomobility" (also called "fixation subluxation"), "hypermobility," "aberrant motion," "altered interosseous spacing," "foraminal occlusion," scoliosis, and several conditions in which "gross displacements" are evident. Some are fancy names for the minor degenerative changes that occur as people age; they often have nothing to do with a patient's symptoms and are not changed by chiropractic treatment. Some, as acknowledged by the Houston conferees, are not even visible on x-ray films. Labeling them "subluxations" was simply a device to get paid.

In the early 1960s, when the National Association of Letter Carriers Health Plan included chiropractic, it received claims for treatment of cancer, heart disease, mumps, mental retardation, and many other questionable conditions. In 1964, chiropractors were asked to justify such claims by sending x-ray evidence of spinal problems. They submitted hundreds, all of which supposedly showed subluxations. When chiropractic officials were assembled to review them, however, they were unable to point out a single subluxation [5]. Following this incident, the plan stopped covering chiropractic services. Referring to these events as an "unfortunate debacle which almost destroyed chiropractic credibility in Washington," the 1973 Basic Chiropractic Procedural Manual cautioned, in italics, "The subluxations must be perfectly obvious and indisputable." [4] These strategic comments were omitted from revised versions of the manual published in 1977, 1980, and 1984.

The Inspector General's Report

A 1986 report from the U.S. Department of Health and Human Services' Office of the Inspector General (OIG) revealed that chiropractic manipulation had been the ninth most frequently billed procedure under Medicare Part B during 1983. The report was based on telephone discussions with 145 out of 200 chiropractors randomly selected from lists provided by insurance carriers. The report noted:

The Medicare Carriers Manual . . . presents a system for classifying subluxations . . . and a system for relating various symptoms to a particular area of the spine. The manual also lists examples of conditions for which manual manipulation of the spine is not an appropriate treatment. Some critics have suggested that this system has provided a blueprint for chiropractors to work backward to identify the appropriate location of a subluxation for billing purposes, as opposed to treating and billing for a subluxation which has been identified on an x-ray [6].

Sections III and IV of the OIG report were especially critical:

III. Chiropractic Today: A Continuing Paradox

Because heated controversy regarding chiropractic theory and practice continues to exist, it was decided early in the study to examine Medicare issues in the context of how the profession views itself and is viewed by others. Onsite and telephone discussions with chiropractors, and their schools and associations, coupled with a review of background materials (many of which were provided by respondents) result in a picture of a profession in transition and containing a number of contradictions.

Professional Organization and Practice

Chiropractors have organized their professional and educational structure into a format which to some extent mirrors mainstream medicine. There are two major (and competing national organizations, the American Chiropractic Association and the International Chiropractors Association, state and local societies, specialty boards, a national Board of Chiropractic Examiners and a Council on Chiropractic Education which recommends policy and sets accreditation standards for chiropractic colleges across the United States.

Within the profession, there continues to be a debate between "straight" chiropractors who limit their activity to spinal manipulation therapy and "mixers" who use a variety of therapeutic techniques, most often different forms of physical therapy. It is recognized by many chiropractors that elaborate claims for universal efficacy of chiropractic care have been greatly overstated in the past, but there continues to be some disagreement within the profession regarding which conditions are appropriate for chiropractic care and regarding appropriate parameters for treatment.

During the field visits, chiropractors were asked how they viewed their position within the larger health care delivery system, and their relationship with orthodox medicine. The respondents maintained that, for many patients, the chiropractor can and should serve as a sort of gatekeeper, doing an initial diagnostic work up on patients, referring those for which chiropractic care is inappropriate. It is for this purpose that many chiropractors are seeking greater access to hospital diagnostic resources and physical therapy facilities, and expansion of their scope of practice in states where their activity is limited. However, many also conceded that most patients at an initial visit present such complaints as headaches or lower back pain, and view the chiropractor as a specialist dealing with a limited set of conditions.

Many of the respondents stressed the value of expanded scientific inquiry into the efficacy of chiropractic, and welcomed the continued upgrading of curriculum and admission standards at the colleges. They were eager to point out the increased time the colleges have allocated to teaching the basic sciences and stressed the increased numbers of PhDs on their faculties from such disciplines as chemistry, physiology, nutrition, etc.

The Problem Side of Chiropractic

Despite the evidence which was presented during the study regarding the increased emphasis on science and professionalism in the training and practice of chiropractors, there also exist patterns of activity and practice which at best appear as overly-aggressive marketing -- and, in some cases, seem deliberately aimed at misleading patients and the public regarding the efficacy of chiropractic care. Teaching materials provided by one chiropractic college warn students of "cultists" within the profession which on one side are "anti-diagnosis, antitherapeutics, pseudo-religious and stress one cause/one cure"; and, on the other extreme, use a "plethora of questionable elixirs, pseudo-medical concepts regarding treatment of specific disorders, and practice a variety of (questionable) healing philosophies."

During the study, discussions were held with reform-minded chiropractors who are in the process of forming a separate professional group of practitioners, the National Association of Chiropractic Medicine, that would set strict standards of ethical conduct and practice, and would actively work in cooperation with consumer groups and others to expose and rid the profession of questionable activities. To date, this group appears to have attracted only a small proportion of the profession. During the discussions, some representatives of schools and associations recognized that there continue to be problems with some of the chiropractors, but emphasized their minority status within the profession.

Examples of problem situations gathered during field visits included:

  • Practice-building courses, popular with many chiropractors, advocate advertising techniques which suggest the universal efficacy of chiropractic treatment for every ailment known to humans. The chiropractor's staff is encouraged to reinforce this message even in regard to a patient's questioning the continued use of medication and other therapies prescribed by other physicians for life-threatening conditions and venereal disease.
  • A newspaper in Iowa published a multi-part story on chiropractic where a reporter visited many chiropractors and got many different conflicting diagnoses and proposed treatment plans.
  • There was testimony regarding patients who, on the basis of a limited examination, had been encouraged to sign contracts for a multi-year course of chiropractic therapy (payable in advance by Mastercharge, Visa or in easy installments).
  • A major television station in Chicago did an expose of cancer scams which heavily involved chiropractors in Illinois.

Prior to the start of this program inspection, OIG regional studies had uncovered problems with chiropractors vis a vis federal programs. Independent studies of chiropractic services conducted by the Chicago, Philadelphia and New York regional offices found serious recordkeeping problems. The office records did not support diagnostic information submitted with the claim; frequently, little else was documented beyond the patient's payment record (i.e. no complaint, no examination notes, no treatment notes or progress notes, no documentation for the taking of or evaluation of x-rays, etc.) Treatments billed for spinal ailments were in fact treatments for sinus problems, bed wetting, crossed eyes, sprained wrist. A review of office records showed patients receiving regular treatment, with little or no change, over long periods of time, some going as far back as late 1960s and early 1970s. In addition:

  • For a sample of 21 patients, one New York chiropractor was unable to furnish treatment records for 19 patients, or x-rays for 16 patients.
  • A Pennsylvania chiropractor billed Medicaid for the same-day treatment of a nine-member family, with no documentation of such in the office records.
  • The Atlanta Regional Office has investigated a chiropractor who, using a medical doctor's provider number and signature stamp, billed Medicare for the x-rays and office visits, and also for physical therapy which was provided (if provided at all) by the chiropractor.

Some of these problems are not unique to chiropractors. But, at a time when chiropractors are pursuing greater legitimacy in the competition for limited health care dollars, caution should be exercised before any changes in coverage are considered.

Chiropractic Under Medicare

The Social Security Act limits Medicare coverage for chiropractic services to "treatment by means of manual manipulation of the spine to correct a subluxation demonstrated by x-ray to exist." Because chiropractic theory regarding illness differed so greatly from mainstream medicine, the x-ray requirement was written into the benefit as an attempt to "control program costs by insuring that a subluxation actually exists." The consensus, from the chiropractic community as well as representatives of the health care field, is that the x-ray requirement has not served this purpose. . . . Medicare expenditures for chiropractic services have increased at an annual rate of 18.7% between 1975 and 1984.

The responses in the telephone survey (supported by information gathered during the field visits) brought into question some of the other basic assumptions inherent in the coverage. There was no clear consensus as to what a subluxation is; furthermore, in the telephone survey:

  • The majority (81%) stated that, on an older person's x-ray, more "wear and tear," osteoarthritis and osteoporosis will show up, and not subluxations per se.
  • The majority of respondents (84%) said that there are subluxations that do not show up on x-rays.
  • Nearly half stated that, when billing Medicare, they "could always find something" (by x-ray or physical examination) to justify the diagnosis, or actually "tailored" the diagnosis to obtain reimbursement.
  • Many respondents in the telephone survey, in advocating a change in the benefit, volunteered that the majority of their Medicare patients had chronic conditions that would never be corrected, and were receiving what was essentially palliative or maintenance care for those conditions.

These responses raise serious questions as to the extent that Medicare is paying for conditions that do not meet the original intent of the law.

Subluxations and the X-ray Questions

Previous regional studies of selected chiropractors raised serious questions as to whether chiropractors were billing only for treatment of subluxations visible on x-rays, as specified by the Medicare benefit. The 1974 ACA guidelines for Medicare claims review (later withdrawn) stated:

Subluxations . . . demonstrable by x-ray represent only a relatively small portion of spinal subluxations treated by Chiropractic Physicians. Clinical subluxations not necessarily demonstrable by x-ray, constitute the majority of spinal subluxations successfully treated by Chiropractic Physicians.

In our current study, the on-site discussions with chiropractic schools and associations went even further. As was summarized at one school: subluxations are a minor part of chiropractic practice, the term itself is out-of-date, and the x-ray requirement is a distortion of chiropractic which forces chiropractors to state a subluxation is present on an x-ray even when it is not.

Based on a 1979 New Zealand study of chiropractic praised by chiropractors in its fairness to their profession, chiropractors in the telephone survey were asked whether there were different categories of subluxations (such as "structural" and "functional") and whether there are subluxations that do not show up on x-rays. According to the New Zealand report, "structural" subluxations are generally visible on x-rays; "functional" subluxations may not be evident on x-rays because they relate to the functioning of a joint, as in impaired range of motion. While no clear consensus emerged around the structural/functional distinction itself, 84% of the respondents in this current study said that there are subluxations that are not visible on a standard x-ray, and their descriptions generally related to function (fixations, hyper/hypo-mobility).

Having gotten a consensus that some subluxations are not visible on x-rays, respondents gave a very different set of answers when asked whether chiropractors do anything different in treatment or billing when a Medicare patient's x-ray does not show a subluxation:

  • 29% stated that one could "always find something" on the x-ray to justify the billing, but there was wide divergence as to whether this "something" correlated to the patient's complaint or treatment.
  • 10% indicated that if they determined the subluxation by other means (i.e. physical examination and palpation) they billed it as though it appeared on the x-ray;
  • 6% actually said they "adapted" their diagnosis to "what Medicare wants to hear." As one chiropractor said "Do we change the diagnosis? I'll find a millimeter out of alignment or rotated on any x-ray. . . It's called 'the insurance game'... I don't consider it lying -- it's just learning how to function within the system ... [for example,] when you get to the allowed number of treatments, change the subluxation up or down one and give a new date of onset."

Examining the responses about the appropriateness of x-rays in relation to the age of patients helps provide at least an internal logic to the apparent contradictions in these responses. Eighty-one percent of the respondents indicated that the older a person, the greater the likelihood of conditions showing up on x-rays; however 87% of this subgroup specified general degeneration of the spine, osteoarthritis, osteoporosis, and not subluxations per se, as the kinds of things that would show up. The implication is that although there are subluxations that do not show up on x-rays, a chiropractor "can always find something" on an older person's x-ray that for Medicare purposes can be related to, or reinterpreted as, a subluxation.

The cost of an x-ray to justify Medicare reimbursement can often exceed the total reimbursement for the treatments themselves. Almost every chiropractor interviewed complained that this high initial expense was unfair to a patient already on a limited income. However, a great many chiropractors, including those who disagreed with the x-ray requirement, admitted that they would x-ray the Medicare age group anyway, either to rule out inappropriate conditions (e.g., cancer) or to protect themselves from malpractice suits. This becomes an important consideration when looking at the requested coverage changes below.

Desire for Expansion of Medicare Coverage.

At the beginning of each telephone interview and again at the end, chiropractors were queried about changes they would like made in the Medicare benefit. Par and away, the biggest response (68%) was for coverage/reimbursement of x-rays. Thirty-one percent felt the x-ray requirement should be changed or eliminated, but many felt the x-ray should be reimbursed even if the requirement were dropped. From the discussion in the previous paragraph, it is unclear whether dropping the x-ray requirement will result in significantly fewer x-rays. Any shifting of x-ray costs from the patient to the program could mean substantial increases in Medicare expenditures. Thirty-seven percent of the respondents felt that Medicare should expand coverage to include more or all of the chiropractors' scope of practice (i.e. what they had been taught and are licensed to perform). Linked with this group were 17% who specifically wanted coverage for physical therapy by chiropractors, 8% who wanted coverage for the initial examination, and 13% who wanted parity in coverage and/or reimbursement with mainstream medical practitioners. 18% recommended the liberalization or elimination of the limits on the number of allowable visits. The implementation of any of these recommendations would result in significant increases in Medicare payments, with no new effective control over quality or quantity of services.

The chiropractic schools and professional associations voiced support for all of these changes. In addition, many school representatives spoke of the need for federal funding for research, comparable to the research money available to medical schools.

As noted previously, it is unclear to what extent Medicare now pays for treatment of conditions that do not meet the original intent of the law. The chiropractic community seems to sidestep rather than clarify the ambiguities involved in the current program while requesting a major increase in coverage and costs for the Medicare program.

A Conspiracy of Silence?

The OIG investigators concluded that the Medicare x-ray requirement "is not corrently well enforced, may be unenforceable, and is highly conducive to abuse." Noting that chiropractors were lobbying to remove the x-ray requirement for justifying their services, the report warned that the financial impact of such a law would be great. Chiropractors finally got their wish in 1997, when Congress quietly amended the law to permit payment for subluxations diagnosed by other means -- a policy scheduled to take effect on January 1, 2000.

Chiropractors responding to a 1995 American Chiropractic Association Survey reported an average gross 1996 income of $228,236, with 8% from Medicare Part B and 1% from Medicare HMOs, which would add up to about $20,500 per chiropractor [7]. Since 1973, Medicare has paid billions of dollars for treating chiropractic "subluxations." Yet, as far as I can tell, neither Congress nor the American media have investigated what these dollars have bought.

References

  1. Social Security Amendments of 1972 (Public Law 92-603), October 30, 1972, pp. 123-134.
  2. Health policy paradox (editorial). The New York Times, November 18, 1972.
  3. Schafer RC, editor. Basic Chiropractic Procedural Manual, Fourth Edition. Arlington, VA: American Chiropractic Association, 1984.
  4. Schafer RC, editor. Basic Chiropractic Procedural Manual, First Edition. Arlington, VA: American Chiropractic Association, 1973.
  5. Deely JP. Report of director, health insurance, to the officers and delegates of the forty-fifth national convention of the National Association of Letter Carriers. August 1966, p. 53A.
  6. Moran WC and others. Inspection of Chiropractic Services Under Medicare. Chicago: OIG Office of Analysis and Inspections, 1986.
  7. Goertz C. Summary of the 1997 ACA annual statistical survey on chiropractic practice. Journal of the American Chiropractic Association 35(11):30-34, 1998.

This article was posted on November 22, 1998.