ALTERNATIVE MEDICINE: NOT SO ALTERNATIVE ANYMORE
After her Saab got rear-ended last December, Elizabeth Forster was diagnosed with whiplash. Although her father and brother are medical doctors, the 33-year-old San Francisco caterer decided to go to a chiropractor, who adjusted her spine and recommended massage to prevent scar-tissue buildup. Forster also went to an orthopedist, ''but he wasn't able to provide the instant relief of chiropractic and massage,'' she says. She still hopes to be reimbursed by the other driver's insurance but says the $4,000 she paid for nontraditional therapy was worth it.
Forster isn't alone. More than one-third of Americans use alternative therapies such as chiropractic, acupuncture, and massage. Traditionally, consumers were forced to foot the bill for such services, but that is changing. Landmark Healthcare, a Sacramento managed-care company, recently surveyed 80 national health maintenance organizations and found that 58% intend to offer alternative-care therapies to members by 1998.
BIG BUSINESS. In January, Oxford Health Plans in Norwalk, Conn., announced it would cover some alternative therapies--when used with conventional medicine, they are known as complementary therapies--and Blue Cross provides coverage in some states. Some other providers with alternative-care packages are Health Partners of Arizona, American Medical Security in Green Bay, Wis., WellCare Management Group in Kingston, N.Y., and Alignis in Atlanta.
They are tapping into a big business. The only comprehensive study of alternative therapies to date was published in the New England Journal of Medicine in 1993. It found that 34% of adults had used some type of unconventional therapy in the previous year and spent approximately $13.7 billion on therapy and medication, 75% of it out-of-pocket. ''For HMOs and insurance companies that are looking for ways to differentiate themselves, alternative-care coverage makes good sense,'' says Barry Scheur, president of Scheur Management Group, a Boston managed-care consulting firm.
After reading the study, Seattle family physician Laura Patton started asking her patients whether they used alternative care. ''I was astonished by how many said yes,'' she recalls. The profile of her patients who also used alternative therapies mirrors that of the study: educated, upper-income adults under the age of 40 seeking relief for a chronic condition.
Indeed, the HMO network with which Patton was affiliated, Seattle's Group Health Cooperative in Puget Sound, has for years offered some coverage for chiropractic, naturopathy, acupuncture, and massage--but only through special riders. Last year, Group Health Cooperative expanded the number of therapies it covers and established broader eligibility guidelines.
Little is known about the efficacy and cost benefits of alternative medicine, however, and many insurers remain cautious. ''They don't want to jump in and offer the same levels of coverage that they have for conventional medicine,'' says Robert Hunter, director of insurance for the Consumer Federation of America in Washington.
Indeed, coverage differs dramatically. Blue Cross of California has been reimbursing patients for chiropractic since 1984, and some acupuncture and biofeedback since the early 1990s. But because there is little scientific study of the outcomes of such treatments, Blue Cross does not have blanket standards for the use of most alternative treatments. ''We review on a case-by-case basis,'' says Lee A. Hartman, medical director of medical policy and review for Blue Cross of California.
Oxford's policy for alternative-care is likely to become a prototype for health plans that offer coverage. Members must visit a primary-care physician, who then refers them to a preferred alternative provider. After the initial visit, the alternative provider will send the HMO a care plan, which is reviewed by a panel of Oxford medical doctors and alternative specialists. The panel determines whether the plan makes sense, whether it's medically necessary, and whether doctors need to be involved. ''The goal is to integrate the best combination of traditional and complementary medicine,'' says Hassan S. Rifaat, director of alternative medicine and an M.D. at Oxford.
COMP POLICY. Oxford members also receive a negotiated rate with preferred providers of massage and yoga. The patient pays the fee, which is typically $50 for a one-hour massage, directly to the provider and there is no reimbursement. It isn't much of a discount--massages start at $60 per hour in the New York metropolitan area--but no referral is required.
If you are considering alternative therapy, make sure you consult your health-care provider first. Find out which treatments are eligible and what the reimbursement policy is. Ask whether a primary-care physician's referral is necessary and how many visits are covered. If you need treatment for an injury sustained on the job, your workers' compensation policy also may provide coverage. Indeed, these policies may be more accepting of alternative therapies than traditional plans, since companies usually will pay for treatments that might bring disabled employees back to work sooner. ''If a patient believes very strongly in this type of care, you might be more inclined to authorize it even if it's not documented as effective,'' says Gideon A. Letz, medical director of the State Compensation Insurance Fund, which handles 40% of California workers' comp claims.
Next, learn more about the credentials and background of the practitioners. Your health maintenance organization or insurance company may have a list of prescreened providers. If there are no preferred providers, be prepared to do a little research on your own. They should be licensed by a state or national board and belong to professional organizations.
To ensure that there's a good fit between the treatment you want and what the practitioner provides, set up a pre-appointment meeting and ask a lot of questions. Any competent therapist will have gone through a lot of training and should be able to answer questions to your satisfaction. For example, one chiropractor might only treat your back, while others might ask general questions and try to treat the underlying causes of the stress that leads to chronic back pain. ''Some might incorporate nutrition therapy in addition to doing spinal manipulations,'' says Raymond A. Priesler, a Manhattan chiropractor.
Naturally, it doesn't hurt to talk to people who have undergone the treatment you're considering. Your local hospital or medical school may have references. Another good source of information is Dr. Rosenfeld's Guide to Alternative Medicine by Isadore Rosenfeld (Random House, 1996, $25.95).
It is also important to bring your primary-care physician into the discussion. ''There needs to be a lot more conversation between conventional doctors and patients about what the patients are seeking in alternative therapy,'' says Patton, the Seattle doctor. If your physician seems judgmental about alternative therapies, consult another doctor.
There will be more information on alternative care soon. The National Institutes of Health more than doubled the Office of Alternative Medicine's budget in 1995 to fund eight research centers. And several insurers that offer coverage have begun their own studies.
Meanwhile, mainstream medicine is becoming more open to alternatives. More than 30 well-known medical schools offer courses in alternative medicine, including Columbia, Emory, Georgetown, Harvard, Indiana, Johns Hopkins and the University of California at Los Angeles.
''I've gained a greater appreciation for the psychological issues of recovery,'' says Letz of his 10 years at the California workers' comp fund. ''There's often a fine line between mainline medicine and the alternative.'' And 10 years from now, alternative therapies just might be standard practice.
Updated June 15, 1997 by bwwebmaster
Copyright 1997, Bloomberg L.P.