2.1 INTRODUCTION
In America, the general public now consider the chiropractic profession as a primary agent of health care management. In 1990 the New England Journal of Medicine carried a report on the number of visits to non-medical health care providers. In that year it was totalled as 425 million, which equated to 9.5% more than the total number of visits to all family physicians. In a follow-up study it was reported that in 1997, total visits to non-medical providers amounted to 629 million. That exceeded the total projected visits to all primary care physicians by 63%. Moreover, a 1998 study, also published in the New England Journal of Medicine reported chiropractic as the most used non-medical treatment (15.7%) [1].
In 1999, Landmark 1999 found that coverage of chiropractic care is offered by nearly two-thirds of all HMOs (65%) This reflected a changed preference on behalf of all consumers with regard to health Insurance. Just under half of the surveyed Health Maintenance Organistions view chiropractic as mainstream health care. [5] By 2004, employees in the USA had the insurance coverage for chiropractic depending on their type of plan, at the following rates: conventional plans (90%), HMOs (78%), PPOs (92%) and POS plans (82%). [2]
2.2 UNITED STATES OF AMERICA
According to Tindle et al in their interesting article ‘Trends in use of complementary and alternative medicine by US adults: 1997-2002’, the use of chiropractic declined from 9.9% of U.S. adults in 1997 to 7.4% in 2002; this was the largest relative decrease among CAM professions, which overall had a stable use rate.[3] ‘Dynamic Chiropractic’ carried an article titled ’The Sustainability of Chiropractic’ in its September 2007 edition, wherein the author also stated that at that time the chiropractic profession in the USA was only reaching 7 percent of the health care market. [4]The author rang alarm bells about the increasing number of chiropractors in the USA, at twice the rate of ‘average overall DC market revenue.’ This comes down to the income of the average chiropractor decreasing substantially and making many practices unviable. In the USA, most states require insurers to cover chiropractic care, and most Health Maintenance Organizations (HMOs) cover these services. [5]
Chiropractic has government recognition in a number of programs including Medicare, Medicaid, Federal Employees Health Care Benefits Programs, Federal and state Workers’ Compensation. [6]
The Public Law, passed by Congress in 1972, and signed into Law by President Richard Nixon on October 30 of that year, therefore amended sections of the Social Security Act (the Act) defining chiropractors as physicians who are eligible for Medicare reimbursement, but only for manual manipulation of the spine to correct a subluxation, or malfunction of the spine [7].
Federal regulations further limit Medicare payment to treatment of subluxations that result in a neuromusculoskeletal condition for which manual manipulation is appropriate treatment. The International Chiropractors Association points out that since that time[7]:
‘ . . . the profession has waged a continuous struggle with a government bureaucracy that has projected a distinct medical prejudice, unfairly targeting chiropractors with exceptionally stringent documentation demands, made numerous attempts to impose finite limits to care, sought to isolate chiropractors from other providers by denying payment for needed services if referred by a doctor of chiropractic, and sought to drive beneficiaries away from seeking chiropractic care through such devices as letters to beneficiaries stating that services provided by their doctor of chiropractic have been determined “…to be medically unnecessary, and therefore will not be reimbursed,” when all that had happened was that Medicare had decided not to pay because an arbitrary, non-statutory 12-visit screen had been reached. Such policies are demonstrably counter-productive on cost-effectiveness grounds and offensive to beneficiary and provider alike because of the agency’s presumption to impose extra-legal pressures on what should be independent beneficiary decision-making.
The chiropractic profession in the United States of America is well and truly aware of the well engrained prejudices which must be overcome in the interests of the patients who wish to exercise their rights under Medicare. The call for chiropractic care is not going to abate. The profession has experienced considerable growth in Medicare, from 11.2 million services and $255 million allowed in 1994 to 21 million services and $683 million allowed in 2004. The ICA revealed its position and expectations in its 2007 document [7].
‘In spite of the program’s imposition of significant barriers, chiropractic utilization continues to grow among Medicare’s 44 million eligible beneficiaries, representing a resounding vote of confidence on the part of program participants in the safe, effective, drugless and natural choice chiropractic represents. ICA is aware, however, that in the public policy debates to come on the future of Medicare, the Centers for Medicare and Medicaid Services (CMS) and the Department of Health and Human Services (HHS) biases and prejudices and the historic negative issues utilized in the past by chiropractic’s critics and competitors, will once again take center stage. In the debate to reshape Medicare that lies ahead, ICA understands that billions of dollars will be in play from competing directions, but that it will be grass-roots constituent action that will, ultimately, make the difference for chiropractic.’
The November, 2007 ‘White Paper on the Future of Chiropractic In Medicare’ [7] was widely circulated within the chiropractic profession. More than 4,000 printed copies were disseminated and over 12,000 electronic copies either distributed or downloaded from ICA’s website. That draft paper stimulated over 1,200 individual comments offering a wide range of recommendations and requests for additional data [7]. Much of the substance of such comments was incorporated into a further White-Paper titled ‘Chiropractic and Medicare In the 2008 Elections and Beyond’, dated August 19, 2008. [8] The preface to that document sums up the major concerns of the chiropractic profession in America quite succinctly. [7]:
Those concerns are that the people of the USA (‘Medicare beneficiaries) need to have access to a full range of chiropractic services to assist with health care costs and with the aging population issues.
In this 28 page document the International Chiropractors Association has drawn together facts relating to the present services provided through Medicare, drawing upon information coming from Washington DC and relating this information to the services provided under Medicare by the chiropractic profession. Here the details summarized by the ICA give a clear picture of the fragility of this so called “Health Insurance” monster that is predicted to eventually self destruct.
NOTE: We have added some more recent details.
2.2.1 THE BASIC FACTS OF MEDICARE [WITH OUR COMPARATIVE UPDATES TO 2008]
Medicare is the second-largest social insurance program in the US, with 48.7 million beneficiaries and total expenditure of $549 billion in 2011 (a jump up from total expenditures of $468 billion in 2008 possibly caused by the addition of the prescription drug benefit and the creation of Medicare Part D, from January 2006. [9]Medicare expenditures represent approximately 20 percent of all health care spending in the United States, a figure which reached the $1.66 trillion mark in calendar 2005, [10] with a strong upward trend certain to continue as health care costs increase and large numbers of new beneficiaries becoming eligible for coverage.
Administered by the Centers for Medicare and Medicaid Services (CMS) Medicare covers approximately 46 million people,[CMS puts this figure at 45.2 million beneficiaries in 2008] 44 percent of which are male and 56 percent of which are female, and of which 76 percent are living in urban settings, and 24 percent in rural areas [10].
The most immediate and compelling reality of the Medicare program is the pending funding crisis that is projected to reach monumental proportions. Every estimate reflects a powerful consensus that Medicare will be out of money in the next 10 to 15 years, the ultimate projected ballooned by another $8 trillion by the addition of the Part D drug benefit. The most current projection estimates a 75-year funding shortfall of $33.9 trillion. Medicare contributions by working people will not even come close to funding the guaranteed benefits of the program. According to the April, 2007 report issued by the Trustees of the Social Security and Medicare Trust Funds, Medicare has already begun paying out more than it receives in payroll taxes and the Trustees now forecast that the trust fund will be depleted by 2019 [7].
Medicare payment programs are divided into a hospital segment, Part A, a private physicians segment, Part B, in which chiropractic providers are included, a managed care segment, Part C, and a prescription drug benefit, Part D. All parts are funded from trust funds, all of which are on track to be exhausted just as the numbers of beneficiaries claiming participation will spike [7].
Over a decade ago, the Office of the Inspector General of the Department of Health and Human Services issued a report on chiropractic care covering ’Controls used by Medicare, Medicaid, and Other Payers’essentially ‘to describe how Medicare, Medicaid and private insurers control chiropractic benefits.’ The need to examine the mechanisms used came from requirements spelt out in ‘The Balanced Budget Act of 1997’ which required the health Care financing Administration (HCFA) to establish guidelines for Medicare chiropractic by January 1, 2000. Around that time the State of New York had enacted legislation which required private insurers to include chiropractic coverage in their benefits packages [11].
The task of preparing the report was assigned to the office of Evaluation and Inspections of the Atlanta Regional Office under the direction of Jesse J. Flowers, the Regional Inspector General.
In the report it is explained how they initiated two inspections to better understand the impact of these changes on the Medicare and Medicaid programs and to learn more about utilization controls. This report, describes Medicare, Medicaid, and private insurers’ mechanisms for controlling expenditures and protecting the chiropractic benefit from potential waste and abuse.
A companion report, ’Chiropractic Care: Medicaid Coverage, (OEI-06-97-00480)’ describes current and expected chiropractic care benefits under State Medicaid programs. In the report it is mentioned that controlling expenditure for costly benefits rather than for chiropractic benefits is a priority of Medicare, Medicaid, and private insurers. [12]
The major recommendation made in this report was that the Health Care Financing Administration (HCFA) develops system edits to detect and prevent unauthorized payments for chiropractic maintenance treatments.
It was stated that HCFA may do so by
- Requiring chiropractic physicians to use modifiers to distinguish the categories of the spinal joint problems (i.e. acute, exacerbation, recurrence, and chronic)
- Requiring all Medicare contractors to implement system utilization frequency edits to identify beneficiaries receiving consecutive months of minimal therapy.
The HCFA concurred with the recommendations made. The Balanced Budget Act of 1997 did require that HCFA develop utilization guidelines for chiropractic care. In developing such guidelines, HCFA was to develop modifiers to distinguish categories of spinal joint problems, and utilization frequency edits as the Regional Inspector General and staff assigned to this task recommended [11].
2.2.2 CHIROPRACTIC CARE: MEDICAID COVERAGE
The second report, [as mentioned above] was also conducted over a decade ago. [Note: More recent investigation relating to Government supported health care insurance in the United States of America with comparison to that of other countries is covered further on in this chapter.]
The 1998 report “Chiropractic Care; Medicaid Coverage, (OEI-06-97-00480)” [12] describes what were then current and expected chiropractic care benefits under State Medicaid programs. This report was also developed through the Office of Inspector General of the Department of Health and Human Services. With this particular project ‘The Office of Evaluation and Inspections’ in the Dallas Regional Office, was responsible for preparing the report, under the direction of Chester B. Slaughter the Regional Inspector General [12].
The stated purpose of the investigation and the report was ‘to determine and describe the current and anticipated care benefits provided under each State Medicaid program’
An expressed concern relating to the Medicaid program was ‘whether there were any indications of potential explosive growth in the program overall’.
As part of background information provided in the ‘Introduction’ to the report, in an explanatory note on chiropractic care, it was stated that research supported the use of chiropractic for acute lower back pain and that chiropractors use spinal manipulation to make changes in spinal alignment. Another important fact relating to the chiropractic profession was also highlighted in this introduction [12]
‘Section 273 of the 1972 Social Security Act Amendments expanded the Medicare definition of “physician” to include chiropractors. Expansion of this definition allowed chiropractors to participate in the Medicare and Medicaid programs’.
Current Medicaid Coverage’[12]:
Coverage limited to only those services as licensed by each State and consist of treatment by means of manual manipulation of the spine. Some States allow x-ray services coverage. The coverage from state to state varies widely, with some states having little restriction, whereas others have tight controls, such as limiting number of visits.
The ‘Scope and Methodology’ as outlined by the authors of the report revealed a straight forward and comprehensive attempt to gain the widest possible understanding of each State’s approach to the provision of Medicaid services. The authors [12] posted out a questionnaire to all the state Medicaid Administrators with the person to complete being the most knowledgeable on chiropractic benefits. 51 questionnaires were completed with follow-up phone calls to seek clarification as needed.
Data analysis was conducted on “fee for service plans” due to large variation in coverage across all of the states.
2.2.3 FINDINGS AND USEFUL TABLES
It is not our intention to present the detailed material which is clearly available on the referenced URL, but so as to give some understanding of the extent of Medicaid cover we add some comment to the investigators material and do reproduce the data compiled in six clear tables [12]:
It can be seen that thirty states offer fee-for-service Medicaid Chiropractic Benefit (See Table 1).
Reported utilization data show no discernable trends suggesting explosive growth in Medicaid expenditures. No State reported legislative or regulatory plans to expand their Medicaid chiropractic benefit beyond the current coverage at that time.
| STATE | MEDICALLY NEEDY | CATERGORICALLY NEEDY | EPSDT |
| Arkansas | / | / | / |
| California | / | / | |
| Connecticut | / | / | / |
| Florida | / | / | / |
| Idaho | / | / | |
| Illionis | / | ||
| Indiana | / | / | |
| Iowa | / | / | / |
| Kansan | / | ||
| Lousiana | / | / | / |
| Maine | / | / | / |
| Massachusetts | / | / | / |
| Michigan | / | / | / |
| Minessota | / | / | / |
| Montana | / | ||
| Nebraska | / | / | / |
| New Hampshire | / | / | / |
| New Jersey | / | / | |
| New York | / | / | |
| N. Carolina | / | / | / |
| North Dakota | / | / | / |
| Ohio | / | / | / |
| Oregon | / | / | |
| Pensylvania | / | / | / |
| South Dakota | / | / | / |
| Texas | / | / | |
| Utah | / | / | / |
| Vermont | / | / | / |
| West Virginia | / | / | / |
| Wisconsin | / | / | / |
[NB: Early Periodic Screening, Diagnosis and Treatment (EPSDT)]
The Conditions and Services that qualify for reimbursement are different from state to state (See Table 2).
Twenty States follow the Medicare definition and limit coverage to only spinal manipulation treatment of back pain with nerve involvement is covered by five states. Coverage for more treatments is offered by eight states. Only Kansas covers an annual chiropractic examination.
| STATE | SPINAL SUBLUXATION | NERVE DAMAGE | ORTHER or ADDITIONAL COVERAGE |
| Arkansas | / | ||
| California | / | Strain, Sprain or dislocation of spine or neck | |
| Connecticut | / | ||
| Florida | / | Other Medically Necessary Treatment | |
| Idaho | / | ||
| Illinois | / | ||
| Indiana | / | Medically Necessary Treatment | |
| Iowa | / | ||
| Kansas | / | ||
| Lousiana | / | / | |
| Maine | / | ||
| Massachusetts | / | / | |
| Michigan | / | ||
| Minnesota | / | ||
| Montana | / | No Restriction By Medical Condition | |
| Nerbraska | / | ||
| New Hampshire | / | ||
| New Jersey | / | / | Cover Any Conditions Within Scope of Chiropractic Care Under State Law |
| New york | / | ||
| North Carolina | / | / | |
| North Dakota | / | / | Strains/sprains |
| Ohio | / | ||
| Oregon | / | ||
| Pensylvania | / | ||
| Texas | / | ||
| Utah | / | ||
| Vermont | / | ||
| West virginia | / | ||
| Winconsin | / |
- States Limits to Coverage. (See Table 3).
26 States limit the number of chiropractic sessions a person may receive. The range is vast, namely from one treatment per day to one treatment per year. Limiting the period of treatment is a policy in some States.
| STATE | LIMITS to COVERAGE |
| Arkansas | 12 Treatments per State Fiscal Year for Adults. |
| California | 2 Treatments per Month. (24 per year) |
| Connecticut | No More Than 1 Visit in 24 hours. Maximum of 4 Exams or Treatments in Single Visit to |
| Florida | 24 visits per calendar year. |
| Idaho | 2 Office Visits per Month. (24 per year) |
| Indiana | 5 Office Visits per Year, 50 Therapeutic Treatments per Year |
| Iowa | Acute Condition 40 Treatments in 6 months (80 per year) Chronic Condition 2 Treatments per month |
| Kansas | 1 Chiropractic History per Year 1 Physical |
| Lousiana | 8 Treatments per Year Without Pre-authorization for EPSDT 12 Treatments per Year Without Pre-authorization for Adults, Maximum of 18 |
| Maine | Acute Condition 2 Treatments per Week for 1 month Chronic Condition 1 Treatment per Week |
| Massachusetts | 20 Treatments per Year. State Does Not Cover Treatment and Initial Examination on the same day |
| Michigan | 18 Visits per 12 Month Period |
| Minessota | 6 Manipulations per Month 24 Manipulations per Year |
| Nebraska | 18 Visits in First 5 Months of Treatment 1 Visit per Month Thereafter if Needed (25 per year) |
| New Hampshire | 6 Treatments per State Fiscal Year |
| New Jersey | 1 Treatment per Calendar Day (365 per year) |
| North Carolina | 24 Visits per State Fiscal Year for Combination of All Physician Services |
| Ohio | 4 Treatments per Month (48 per year) |
| Oregon | 1 Treatment per Day (365 per year) |
| Pensylvania | 1 Treatment per Day (365 per year) |
| South Dakota | 1 Treatment per Day 30 Treatments per 12 Month Period |
| Texas | 12 Treatments per Benefit Period Benefit Period is 12 months Beginning With First Treatment |
| Utah | Limited to Number Appropriate for Diagnosis 1 Evaluation, All Additional Services are Preauthorized |
| Vermont | 10 Treatments per Year |
| West Virginia | 12 Treatments per 12 Month Period |
| Winconsin | 20 Treatments per Spell of Illness (New spell of illness required to exceed 20 per year) |
- Exceptions to Chiropractic Coverage Limits by State (See Table 4).
Some states allow chiropractic care to continue beyond set limits on a “medically necessary”, basis. Documentation and authorisations is usually needed.
| STATE | EXCEPTIONS TO COVERAGE LIMITS |
| Connecticut | Authorized Treatment Must be Initiated Within 6 Months of Date of Authorization |
| Iowa | Medically Necessary Treatment May be Authorized Upon Review by Chiropractic Consultant |
| Michigan | Documented Medically Necessary Treatments Can Exceed Limits |
| Minnesota | Prior Authorization and Documented Medical Necessity. Can Exceed Limit |
| New Hampshire | Overridden by Medical Director with Substantial Evidence of Medical Necessity |
| North Carolina | Medically Necessary Treatment May be Authorized by Medical Director |
| Ohio | Medically Necessary Treatment Can be Authorized by the Department on a Case by Case Basis |
| South Dakota | Medically Necessary Treatment May be Authorized Upon Review by Chiropractic Consultant |
| Utah | Additional Services May be Approved Through Preauthorization |
| Vermont | Prior Authorization Based on Documentation of Medical Necessity |
| West Virginia | Medical Necessity Documented and Reviewed by State Chiropractic Consultant No More Than 40 Total Treatments |
| Winconsin | Medical Necessity Reviewed by Chiropractic Consultant |
- Changes in Chiropractic Benefit since 1990: (See Table 5).
As can be seen two States changed policy to limit their programs. Most states made changes with some benefits increasing and others decreasing. For example, treatment numbers were decreased but more beneficiaries. It was found that no State was planning to expand coverage and those without coverage were not planning to add the benefit.
| STATE | YEAR | EXPAND | LIMIT | CHANGE |
| Arkansas | 1991 | / | Limited coverage to under 21 only(12/1/91) | Expanded to include adults(7/91) |
| 1994 | / | / | One x-ray per State fiscal year covered (7/94) | |
| 1996 | / | Expand to all ages (7/96) | ||
| Florida | 1992 | / | The treatment limit expanded from 12 to 24 per year | |
| Illinois | 1995 | / | Limited to EPSDT and Qualified Medicare Beneficiaries | |
| Indiana | 1992 | / | Treatment and diagnosis limits added | |
| Kansas | 1983 | / | Limited or eliminated many services | |
| 1991 | / | Limited to history and physical for EPSDT | ||
| Louisiana | 1995 | / | Limit to EPSDT only | |
| 1997 | / | Expanded to include all Medicaid beneficiaries | ||
| Michigan | 1991 | / | Eliminated adults | |
| 1993 | / | Reinstated adults with 12 visits per year | ||
| 1996 | / | Increased 12 visits to 18 | ||
| Nerbraska | 1993 | / | Limited number of treatments | |
| New Hampshire | 1995 | / | Allow coverage of x-rays | |
| New Jersey | 1997 | / | Added initial diagnostic visit to coverage | |
| North Carolina | 1991 | Budget neutral. Allows chiropractor to perform x-ray, no Longer requires physicians. | ||
| West Virginia | 1992 | / | Began x-ray reimbursement and raised limits from 6 treatments to 40 per year (more than 12 require prior approval) |
- Chiropractic care represents only a small part of total State Medicaid expenditures. Although there are no definite trends, some states have lower costs and others show only minor changes in expenditure. (See table 6).
Only 15 States were able to provide financial data showing total Medicaid expenditures and chiropractic benefit payments.
| 1994 | 1995 | 1996 | ||||
| STATE | Chiropractic | % | Chiropractic | % | Chiropractic | % |
| Payment | Total | Payment | Total | Payment | Total | |
| Arkansas | 36,912 | 0.0034 | 44,095 | 0.0035 | 36,407 | N/A |
| California | 638,226 | 0.0064 | 607,915 | 0.0056 | 632,545 | 0.0553 |
| Idaho | 42,117 | 0.0127 | 41,962 | 0.0117 | 52,622 | 0.0130 |
| Indiana | 7,068,000 | 0.3020 | 2,822,000 | 0.1388 | 6,736,000 | 0.2766 |
| Iowa | 1,664,533 | 0.1665 | 1,676,029 | 0.1523 | 1,648,935 | 0.0384 |
| Lousiana | 9,177,891 | 0.3412 | 15,995,086 | 0.5777 | 4,282,654 | 0.1746 |
| Maine | 408,795 | 0.0455 | 376,786 | 0.0384 | 359,034 | 0.0363 |
| Minnesota | 1,758,851 | 0.0811 | 2,246,935 | 0.0843 | 1,814,085 | 0.0617 |
| Montana | N/A | N/A | 15,693 | 0.0049 | 10,488 | 0.0031 |
| New Jersey | 439,919 | 0.0111 | 568,693 | 0.0135 | 503,829 | 0.0115 |
| North Carolina | 459,733 | 0.0161 | 700,158 | 0.0208 | 770,540 | 0.0207 |
| North Dakota | 255,085 | 0.0898 | 231,086 | 0.0779 | 224,490 | 0.0753 |
| Texas | 783,882 | 0.0101 | 777,752 | 0.0101 | 1,028,304 | 0.0134 |
| Utah | 64,451 | 0.0125 | 235,237 | 0.0423 | 349,088 | N/A |
| Vermont | 166,557 | 0.0409 | 116,211 | 0.0345 | 114,374 | N/A |
2.2.4 AN ADENDUM: THE WINDS OF CHANGE?
Interesting Changes in Michigan
In 2010 a legislative proposal namely Senate Bill No. 969 was presented to the Michigan state that would see an expansion in chiropractic services in the state. Basically the expansion would come about through a change in insurance coverage. The state will subtly change their agreed definition of chiropractic and thus allow chiropractors in Michigan to offer a broader range of treatments. Michigan has very strict regulations on chiropractic treatment. [13]
2.3 CANADA
2.3.1 THE CANADIAN HEALTH CARE SYSTEM
The Canadian system of health care coverage is somewhat different to the coverage that exists in the United States of America. The Canadians do not have a single health care plan. They do have a national health insurance program, often referred to as ‘Medicare’, which consists of a series of thirteen interlocking provincial and territorial health insurance plans all of which do share certain common features and basic standards. They are grouped together under the ‘Canada Health Act’ (CHA) but with slight differences from province to province. The Act makes provision for all Canadians and indeed ’all residents of Canada to have reasonable access to medically necessary hospital and physician services on a pre-paid basis, and on uniform terms and conditions [14].’
Under the provisions of the act, the Federal Government has the following responsibilities:
- Establishing and maintaining the principles and standards of care for the whole health care system.
- Provide financial provisions to of the provinces health care services.
- Provide health services to key groups such as Police, military, veterans and native Canadians
- General health activities such as, disease prevention. .
Whereas, the provincial and territorial governments are responsible for:
- Managing and delivering health care services
- Planning, financing, and evaluating the provision of hospital care
- Physician and allied health care service managing some aspects of prescription care and public health. [15]
Extra benefits can be offered by the Provinces and territories based on their own rationale. For example include dental and chiropractic services.’ [14].
Within the CHA are certain criteria and conditions that the provinces and territories must meet in order to receive full federal government financial support. The governments of the Provinces and Territories are obligated to manage and deliver the services to their residents [16].
2.3.2 PROVINCIAL INSURANCE COVERAGE OF CHIROPRACTIC [GENERAL]
Chiropractic care is offered by the Workers’ compensation boards in all provinces and territories. The Provinces health insurance plans offer some cover for complementary/alternative therapies. Alberta, British Columbia, Manitoba, Ontario, Saskatchewan provide chiropractic cover. New Brunswick offers it only to seniors that buy extra coverage. [17].
Almost all private health insurance used in Canada is company bought group policies. [17].
2.3.3 INDIVIDUAL PROVINCIAL COVERAGE: A FEW VARIED EXAMPLES
Alberta
a) Alberta Health Care Insurance Plan
In accordance with the ‘Canada Health Act’, Alberta has a publicly administered and funded health care system that guarantees Albertans receive universal access to medically necessary hospital and health care services.
For a considerable period of time chiropractic services were covered under the ‘Alberta Health Care Insurance Plan.’ However, since July 1, 2009, payment for chiropractic services was discontinued. The cut should save about $53 million, but will pass on costs of about $200 each year to patients [18].
b) Workers Compensation Board of Alberta
In Alberta the Chiropractic profession is recognized under the provisions of the Health Professions Act. Members of the profession are licensed to practice their healing art in Alberta and therefore provide ‘medical aid’ to injured workers under the provisions of the Workers’ Compensation Act [19].
British Columbia
a) Medical Services Plan (MSP)
There is some Chiropractic coverage under the category of “Supplementary Benefits”
Supplementary Benefits are services such as Acupuncture, Chiropractic,Massage Therapy and Physical Therapy. The MSP will cover $23 per visit over a combined 10 visits per year for chiropractic and other supplementary benefits. [20].
b) Work Safe BC
WorkSafeBC is the workplace health, safety and workers compensation provider for British Columbia. [21]
The‘Chiropractic Services Memorandum of Agreement’ made effective Oct 11, 2010sets out the terms and conditions for chiropractors to provide care to patients making workers compensation claims. There are 3 schedules: “Schedule A – Description of Services, Schedule B – Fee Schedule and Schedule C – Privacy Protection Schedule”.
Schedule A provides detailed information about the types of chiropractic services that can be provided under Worksafe BC. Under service expectation, the chiropractor is expected to be compliant with the province workers compensation legislation and provide the injured worker with education focused on return to activity. Communication and reporting requirements are also set out and include information on telephone communications and form submission. For example the Chiropractic First Report (F8C) and the Chiropractic Progress Report (F11C) have to be sent to Worksafe BC electronically.
Schedule B sets out the type of services that can be performed, gives the Worksafe BC rules and gives the actual fee payable. For example, “Chiropractic First report is Item number 19134 and requires the use of Form 8C. The fee payable is $102.75 and includes the initial report and 2 visits. Forms need to be submitted electronically and within 5 days of the patients’ first visit or penalties apply. Penalty involves deduction of $15-$40 from the fee.
Schedule C provides information on compliance with the Freedom of Information and Protection of Privacy Act (British Columbia). It provides details on how a Worksafe BC and the treating doctor are to handle the personal information obtained from patients under care.
Chiropractors do not have to sign the Agreement, although if they provide treatment to an injured worker it is considered that they have agreed to the terms. Those Chiropractors unwilling to agree are asked to not treat injured workers [22].
c) Motor Vehicle Accidents
ICBC/ Autoplan Insurance, is a Crown corporation that provides auto insurance for all B.C. motorists. All drivers in B.C. must have Basic Autoplan. It gives the compulsory minimum coverage that any motorist needs. This Basic coverage is only available from ICBC. Optional extended coverage is also available through this company. Through good liaison between the British Columbia Chiropractic Association and ICBC, chiropractic care is covered for all insured motorists, family members and other persons involved in a motor vehicle accident [23].
Insurance Corporation of British Columbia (ICBC) provides good explanations and advice to the Consumer/ customer/ client on the steps to take before settling any injury claim. ICBC provide basic information on their web-site to help the injured driver or occupant of a vehicle involved in an accident to understand the injury settlement process. The organizations give advice to settle an injury claim, by contacting the ‘Adjuster’ and requesting that your injury claim be evaluated.
In determining a fair settlement, adjuster will consider the following:
- medical reports from health care advisors
- The impacts the injuries had on patients lifestyle
- history of similar settlement payments
- Court cases
All sound advice accompanied by details given on the Web-site regarding contact facilities. The details provided are far more than one might usually expect from an insurance firm or agency.
Manitoba
a) Manitoba Health
As a provincial government department, Manitoba Health oversees health care services available to all Manitobans. The services provided seem quite comprehensive and very well presented on their Web-site. Coverage for chiropractic treatment or adjustment is quite clear, insuring that a maximum of 12 visits per Manitoba resident per calendar year is available and clearly stating that the adjustment of the spinal column, pelvis and extremities are insured chiropractic services [24].
b) Workers Compensation
‘Chiropractor’ is listed in ‘The Workers Compensation Act’ of Manitoba [unofficial version; current as of June 29, 2012 in effect since June 16, 2011] along with other health care professionals. The grouping is defined as ‘health care provider’. [25]
“Health care provider” as defined in the act includes physicians, nurses, dentists, chiropractors and other professions. [25]
The Workers’ Compensation Board totally covers the patient for chiropractic examination & treatment, X-rays, supports and for report writing. [26]
c) Motor Vehicle Accidents
Chiropractic treatments as a result of a motor vehicle accident are covered by ‘Manitoba Public Insurance’. The Manitoba Public Insurance provides full coverage for chiropractic services. [26]
New Brunswick
a) Medicare
The New Brunswick Medicare provides payment for most medical services in offices and hospitals. They also give cover for some dental procedures.
Among services that are not insured by either New Brunswick Medicare or by the province’s hospital services include services provided by chiropractors, chiropodists, dentists (except as stated above), massotherapists, naturopaths, opticians, optometrists, orthodontists, osteopaths, pharmacists, physiotherapists, podiatrists, psychologists or private duty nurses. [27]
Newfoundland and Labrador
a) Medical Care Plan
Chiropractic treatments are not covered under the Medical Care Plan. However X-rays when ordered by a chiropractor, but taken at a local hospital will be covered by the MCP. [28]
b) Workplace Health, Safety & Compensation Commission (WHSCC)
The WHSCC allows injured workers to undergo chiropractic treatment. Some regulations exist, such that newly injured workers can start treatment without pre-approval from WHSCC. For injuries that occurred more than 90 days ago, the worker can seek chiropractic assessment, but needs WHSCC approval before the treatment can begin. [28]
c) Health Insurance Coverage
There is limited coverage for chiropractic examination and treatments under most extended health insurances (private) for chiropractic examination and treatments. [28]
d) Motor Vehicle Accidents (MVA)
Chiropractic treatment costs are covered for motor vehicle accident injuries. [28]
e) Department of Veterans Affairs (DVA)
Chiropractic treatment for Veterans is covered. [28]
Northwest Territories
a) NWT Health Care Insurance Plan
NWT Health Care Insurance Plan provides coverage for medical services by licensed Doctors to all theResidents of the NWT. Among services which are not covered by NWT Health Care Insurance Plan includes services for chiropractors, naturopaths, podiatrists, osteopaths, and acupuncture treatments [29].
b) Workers Safety and Compensation Commission
The Workers’ Safety and Compensation Commission (WSCC) is responsible for administering the various Government Acts that protect workers in the Northwest Territories and Nunavut. Injured workers can seek Alternative treatment under certain circumstances. Chiropractic is listed under Alternative treatments, alongside include acupuncture, and massage therapy and others. [30]
c) Motor Vehicle Accidents
All vehicles in Canada have to have insurance coverage with certain minimum coverage requirements. A private insurance company is the provider of these policies in the Northwest Territories, Yukon, Nunavut, Alberta, Ontario, New Brunswick, Newfoundland and Labrador, Prince Edward Island, and Nova Scotia. No matter where, Chiropractic care is covered by such insurance. [31]
Nova Scotia
a) Medical Service insurance
Nova Scotia health care does not cover Chiropractic care. Supplemental health care coverage, which many people have, often provides limited chiropractic coverage. [32]
b) Work Safe. For Life Workers Compensation Board of Nova Scotia
Chiropractors can recommend time off work and prescribe supports, braces and orthotics to injured workers in Nova Scotia. [33]
c) Motor Vehicle Insurance Coverage in Nova Scotia
The Insurance Act outlines the benefits covered following an accident. Chiropractic treatments are covered, along with medical, dental hospital and ambulance. Coverage is restricted to “all reasonable” costswithin four years from the date of the accident [34]
Nunavut
a) Nunavut Health Care Plan
While Nunavut Health covers many services, the following are among the services NOT covered:
- Yearly physicals, especially those for a third party
- Cosmetic surgery or experimental procedures
- Prescription drugs
- Chiropractic, naturopathic, podiatry, osteopathic or acupuncture treatments
- Private or semi-private hospital rooms [35]
b) Workers Compensation Nunavut
The Workers’ Safety and Compensation Commission (WSCC) is responsible for administering the various Government Acts that protect workers in the Northwest Territories and Nunavut. [30]
Injured workers can seek Alternative treatment under certain circumstances. Chiropractic is listed under Alternative treatments, alongside include acupuncture, and massage therapy and others. [30]
c) Motor Vehicle Accidents
All vehicles in Canada have to have insurance coverage with certain minimum coverage requirements. A private insurance company is the provider of these policies in the Northwest Territories, Yukon, Nunavut, Alberta, Ontario, New Brunswick, Newfoundland and Labrador, Prince Edward Island, and Nova Scotia. No matter where, Chiropractic care is covered by such insurance. [31]
Ontario
a) Ontario Health Insurance Plan
Effective December 1, 2004, chiropractic services are no longer covered by the Ontario Health Insurance Plan (OHIP). People are responsible for paying the fees charged by chiropractors. People with private insurance may have these services covered in part or full by their private plans.
b) Chiropractic after delisting
Chiropractic services are covered under the majority of Extended Health Care (EHC) plans. EHC plans are the main third-party provider for most patients. About
7 in 10 Ontario residents have an Extended Health Care plan of some type. Unfortunately many people in need of chiropractic services (e.g Elderly and the working poor) are unable to seek care due to lack of an EHC and none coverage in the OHIP. [36]
c) The Workplace Safety and Insurance Board (WSIB)
The WSIB promotes workplace health and safety, and provides workers compensation system for the employers and workers of Ontario.
Injured workers are eligible for necessary health care and they are allowed to choose their initial health professional. The WSIB maintains control of payment and the determination of necessary care.
The injured workers initial choice of health professional can be either a: chiropractor; physician; physiotherapist; or registered nurses as long as the injury falls within the scope of practice of the professional. [37]
d) Motor Vehicle Accidents
All vehicles in Canada have to have insurance coverage with certain minimum coverage requirements. A private insurance company is the provider of these policies in the Northwest Territories, Yukon, Nunavut, Alberta, Ontario, New Brunswick, Newfoundland and Labrador, Prince Edward Island, and Nova Scotia. No matter where, Chiropractic care is covered by such insurance. [31]
Prince Edward Island
a) Hospital and Medical Services Insurance
Hospital and Medical Services Insurance on Prince Edward Island do not cover chiropractic services. Chiropractors should not ‘feel lonely’ however, as services provided by audiologists, chiropodists, dietitians, homeopaths, naturopaths, optometrists, osteopaths, physiotherapists, podiatrists, psychologists and services performed by a dentist are also excluded [38].
b) Safety Matters @Work: Workers Compensation Board of PEI
The Workers compensation Board offers medical aid to injured workers. Medical aid providers include chiropractors. Chiropractic care is available to injured workers through referral from a medical doctor or as the principal doctor for acute injuries. [39]
c) Motor Vehicle Accidents
All vehicles in Canada have to have insurance coverage with certain minimum coverage requirements. A private insurance company is the provider of these policies in the Northwest Territories, Yukon, Nunavut, Alberta, Ontario, New Brunswick, Newfoundland and Labrador, Prince Edward Island, and Nova Scotia. No matter where, Chiropractic care is covered by such insurance. [31]
Quebec
a) La Régie de l’assurance Maladie du Québec
Since November 1, 1970, coverage under the Health Insurance Plan has been compulsory for every resident or temporary resident of Québec who fulfills the conditions provided for by law. The Régie issues a Health Insurance Card to persons eligible for the Québec Health Insurance Plan. Because the Health Insurance Card gives access to insured healthcare services, it is important for insured persons to carry their card with them at all times. In addition to medical services, the Health Insurance Plan covers a range of other services designed to meet special needs. Persons insured under the Public Prescription Drug Insurance Plan are also covered for prescription drugs. [40]
Chiropractic care is not covered by La Régie de l’assurance maladie du Québec. Many insurance companies cover a portion of the cost for chiropractic. Additionally out of pocket expenses for chiropractic care can be applied to a patient’s income tax claim. [41]
b) Québec Workers’ Compensation
In Quebec an injured worker has the right to medical assistance, income replacement, rehabilitation and a return to work. The “Commission de la santé et de la sécurité du travail” (CSST) is in charge of deciding who can receive benefits. [42]
Chiropractic service costs might be covered by CSST, along with treatments such as physiotherapy and occupational therapy. Usually costs are refunded to the injured worker by CSST. Thus a worker needs to be sure that his care is covered before proceeding. [42]
c) Auto insurance in Quebec
Auto Insurance in Quebec is available from both the government insurer and private insurers. Government insurance only covers against injuries to people whereas private insurance offers cover for property damage. [43].
The Quebec Automobile Insurance Society covers all cars in Quebec. They had a history of paying for a high number whiplash claims. Thus in 1989 they created a task force to examine the science on treating whiplash. This group is known as the Quebec Task Force on Whiplash-Associated Disorders. [44]
Saskatchewan
a) Saskatchewan Health Benefits.
Saskatchewan Health Benefits provides full medical coverage as well as physiotherapy and occupational therapy. Various other services (e.g. screening tests) are included. Chiropractic care is included as a supplementary benefit only. Supplementary benefits allow up to 12 chiropractic treatments per year for those people with approval from Social Services. [45]
b) Chiropractor Information
From April 2010, only low-income individuals are eligible for a maximum of 12 treatments a year. They must be receiving Supplementary Health Plan, Family Health Plan and Seniors’ Income Plan to receive the benefit. All other chiropractic coverage has been eliminated. [46]
c) WCB Saskatchewan Workers’ Compensation Board
The Saskatchewan Workers’ Compensation Board covers the full cost of treatment for injured workers in the Province. [47]
Chiropractors need not apply to join as they are automatically accredited with the WCB via the Saskatchewan Medical Services Branch. When treating WCB clients, chiropractors have to follow the standards set by the Saskatchewan Chiropractors’ Association and the WCB. Injured workers have direct access to chiropractors without need for referral. [48]
d) Motor Vehicle Accident Insurance
Under the Automobile Accident Insurance Act of Saskatchewan we find:-
e) Medical or rehabilitation benefits
21(1) Subject to the maximum benefit amounts mentioned in subsections (3) and (4), an insured is entitled to reimbursement for all medical services authorized by the insurer, including [49]:
- Surgical, dental, hospital, ambulance or professional nursing services; and
- Any necessary physical therapy, chiropractic treatments, occupational therapy, speech therapy, prosthesis or orthosis.
(2) The amount of a benefit pursuant to subsection (1) is the amount of the expense that the insured is not entitled to be reimbursed for pursuant to any other Act.
(3) The maximum benefit amount payable pursuant to this section is $20,000 unless the insured sustains a catastrophic injury.
(4) If an insured sustains a catastrophic injury, the maximum benefit amount payable pursuant to this section is $150,000.
Yukon
a) Yukon Health Care Insurance Plan
Chiropractic Services not covered within the Yukon Health Care Insurance Plan [50]:
b) Yukon Workers’ Compensation Health and Safety Board (YWCHSB)
The YWCHSB provides coverage for chiropractic services. The care has to be deemed necessary and appropriate. Injured workers can access chiropractic care without referral. Chiropractors can prescribe “ready made device” to patients [51].
2.4 EUROPE
2.4.1 GENERAL
In all European countries there is social insurance and in some countries there is also private insurance. The coverage of complementary medicine varies. It can be complete or restricted by number or type of treatments. The following categories were created to obtain a schematic overview concerning the reimbursement of complementary medicines by different insurance systems around the European Union. [Note: Little information is unavailable concerning Greece and Hungary].
- Countries where complementary medicines are not reimbursed, neither by social insurance nor by private / complementary insurance (exclusive system);
- Countries in which complementary medicines are covered only by social (public) insurance (public system);
- Countries where complementary medicines are reimbursed only by complementary / private insurance (private system);
- Countries in which complementary medicines are covered by social and by complementary / private insurance (double system).
Countries with the exclusive system are Iceland and the Ukraine. Countries with the public system are Austria, Denmark (chiropractic, acupuncture and osteopathy), Ireland, Finland (acupuncture, chiropractic, naturopathy, osteopathy and lymphotherapy) Latvia (acupuncture, homeopathy, electro-acupuncture, iridology and bio-resonance) Luxembourg, Malta (Chinese medicine), Norway (homoeopathy, acupuncture and chiropractic) Portugal and Sweden.
Countries with the private system are: Belgium (homeopathy, osteopathy, chiropractic and acupuncture), Liechtenstein, Spain, Great Britain (chiropractic, osteopathy and manipulative techniques). Countries with the double system are: France (homeopathy, acupuncture, osteopathy), Italy (acupuncture, hypnosis, laser therapy, pressing massotherapy, lymphatic drainage, reflexotherapy), Germany and Switzerland (acupuncture, chiropractic, homeopathy).
Generally speaking, it can be noted that the actual trend is to official recognition that complementary medicine can play an important role within health care systems.
The tolerance regarding alternative practitioners / non physicians is increasing, and training in complementary medicine is becoming more accepted and recognized. The reimbursement for complementary medicine by social and / or private insurance follows the same dynamic; the trend is to extend the coverage of alternative techniques. This is not, however without a struggle: [52]
2.4.2 AUSTRIA
Insurance coverage
In Austria, there are Public insurance funds that offer coverage for medical treatments. They mostly do not cover Complementary/alternative medicine practices. [53]
2.4.3 BELGIUM
Insurance coverage
Allopathic physicians monopolized the practice of medicine in Belgium for over 3 decades following the passage of the Practice of Medicine Act in 1967. It took the influence of the European Commission relative to the lack of action in Belgium on European Directives relating to homeopathic products, to bring the Belgian Government to request its Federal Department of public health to draft legislation that would lead to recognition to Complementary/ alternative medicine. This occurred only as recently as 1999. [54]
The Belgian Ministry of Health recognises some also alternative treatments as reimbursable; they are homoeopathy, acupuncture, osteopathy and chiropractic. Reimbursement is only possible if the practitioner is qualified. [55][56]
As in most other countries, private insurance companies in Belgium do reimburse chiropractic care and partially acupuncture treatments [54].
2.4.4 DENMARK
Insurance coverage
There is a state funded and a private healthcare sector within Denmark. Consultation and treatment costs from a medical practitioner are fully covered under public healthcare insurance, but only subsidised rates are covered for dental and chiropractic care. [57][58]
2.4.5 FINLAND
Insurance coverage
The Social Insurance Institution (SII) does provide cover for chiropractic treatments as long as certain conditions are met. The conditions are the patient must be referred by a medical doctor after getting diagnosed and treatment plan. Additionally the chiropractor must operate in a centre led by a doctor or physiotherapist. [59]
2.4.6 FRANCE
Insurance coverage
In France, the social security does provide reimbursement for chiropractic services in France. [60]
2.4.7 GERMANY
Insurance coverage
In Germany, there are public and private insurance schemes that offer the same coverage. Both offer reimbursement for some complementary/alternative treatments. [61]
2.4.9 IRELAND
Insurance coverage
As far as can be ascertained at this stage there is no recompense through Private or Government Insurance for the service given to the patients of chiropractors [62].
2.4.10 ITALY
Insurance coverage
Reimbursement of health care depends on the regulations of each Italian region. As an example,Lombardy provides co-payment for complementary/alternative medicine with the National Health Service covering the remainder.
Reimbursement of complementary/alternative health care is covered by private insurance programmes, but not by all of them. [63]
2.4.11 LATVIA
Insurance coverage
Compulsory health insurance in Latvia covers Acupuncture and Homeopathy, but other complementary/ alternative treatments are excluded. Two private insurance companies, Balta and Parex provide cover for legal complementary/alternative medicine. [64]
2.4.12 LICHTENSTEIN
Insurance coverage
Compulsory social insurance does not cover for Complementary/alternative treatments. There are complementary/alternative medical insurance policies available which provide reimbursement for CAM. Annual coverage is about 500-1500 Swiss francs per year [65].
2.4.13 LUXEMBOURG
Complementary/alternative medicine in Luxembourg is heavily opposed by the Medical College. [66]
Insurance coverage
There is coverage for only Homeopathy. Reimbursement is about 80% of fees. There is no private insurers providing coverage for complementary/alternative medicine [66]
2.4.14 MALTA
In Malta ‘CAM’ is alive and well practised. Traditional Chinese medicine, chiropractic, and osteopathy are common. [68]
Although the WHO reported in 2001 that ’there are no established professional organizations or self-regulating bodies for complementary/alternative practitioners in Malta’ [67] However by the year 2004, the chiropractic profession had formed the Malta Association of Chiropractors. [68].
Insurance coverage
The State operates acupuncture clinics and provides treatment free of charge. There is no private insurance cover for complementary/alternative care. [68]
2.4.15 NETHERLANDS
Insurance coverage
In the Netherlands, anthroposophic medicine and homeopathic practitioners are reimbursed under social insurance. There is no coverage under social Insurance for chiropractic care at this stage. Public demand has of course brought coverage for chiropractic services for the two-thirds of the population who have purchased private health Insurance [69].
It is noted that in 1988, the Netherlands large private insurance companies, around 45 of them, began to include cover in their standard or supplementary packages for such therapeutic approaches as homeopathy, acupuncture and manipulative therapy. The standard package is of course legally defined. Twenty six of these funds do give reimbursement for some forms of so called complementary or alternative medicine but only when such care is provided by allopathic physicians or a physiotherapist. These practitioners apparently provide homeopathy, acupuncture, and anthroposophical treatment which is considered as outside the standard package. It is reported that at times such reimbursement was only forthcoming if the practitioners were members of a specific professional association.
Within a few years, consumer demand brought an inclusion of chiropractic, naturopathy, and neural therapy where such treatment could be provided by practitioners outside the allopathic physicians and physiotherapists. It is reported that by 1998 some 47 insurance companies in the Netherlands were providing such insurance coverage for between 25 and 100 percent of complementary or alternative care. [69]
2.4.16 NORWAY
Insurance coverage
In Norway, there is partial reimbursement provided for chiropractic treatment as long as the practitioner is authorized as a health care professional without the necessity of being a member of the Norwegian Association on Chiropractic. Such reimbursement is only extended for 10 to 14 consultations in a given year and the requirement of referral from an allopathic physician. Other forms of what is regarded as complementary/alternative medicine have no such cover. For example coverage for homeopathic treatments is not included under the official health care system. [70]
In examining the situation relating to T & CAM practices, the World Health Organization makes it clear, In their extensive presentation on the “Legal Status of traditional medicine and complementary/alternative medicine‘:
‘In Norway, Norsk Helseforsikring, which is connected to International Health Insurance Denmark AS, is the only private insurance company offering partial reimbursement for complementary/alternative medicine. The insurance covers chiropractic and, when performed by a licensed allopathic physician as part of medical treatment, acupuncture.’
The WHO also asserts that since 1990, when the Norwegian government officially recognised chiropractors as health care professionals, it has set stringent requirements for licensure. Any candidate for licensure must have completed their chiropractic education at an institute that has accreditation from the American Council on Chiropractic Education or its counterpart in other regions, they must have undergone additional training in Norwegian health law and clinical training and be physically fit. No other practitioners may use the title ‘Chiropractor”.’ [70]
2.4.17 RUSSIAN FEDERATION
Regulatory situation
There is no known reimbursement for chiropractic services or care in the Russian Federation. [71]
2.4.18 SPAIN
Regulatory situation
In Spain,. coverage for chiropractic care is not known. [72]
2.4.19 SWEDEN
Insurance coverage
Care given by non-allopathic practitioners is not covered health care system in Sweden.There is some acupuncture cover when it is done by an allopathic physician. A Swedish Commission on Complementary/Alternative Medicine so far has not recommended that CAM treatments be reimbursed. [73]
2.4.20 SWITZERLAND
Insurance Coverage
Swiss residents on the whole have insurance coverage. They can choose either basic or extensive coverage. There are policies that provide coverage for CAM treatments. [74]Chiropractic care is reimbursed, even without referral. [75]
2.4.21 UKRAINE
Insurance coverage
Complementary/alternative medicine does not have any public or private reimbursement in the Ukraine. [76]
2.4.22 THE UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND
Chiropractic and the NHS
The availability of chiropractic on the National Health Services (NHS) is limited. Most people who visit a chiropractor will pay for private treatment. The cost of chiropractic varies and depends on the length of the treatment session. Costs vary from £20-35 for a 30-minute session, to up to £40-80 for an hour. [77]
Insurance coverage
Chiropractic services are reimbursed by some associations such as the Veterans association. [78]
2.5 WESTERN PACIFIC
2.5.1 AUSTRALIA
In Australia, the national health system (Medicare) does not provide cover for chiropractic care. [79]
Australians have a choice with Insurance of buying hospital coverage and ancillary coverage. Hospital coverage provides reimbursement for hospital treatment and accommodation. Ancillary insurance provides cover for chiropractic and other services. [80]
Transport Accident Commission (TAC)
Australia-wide, Motor Vehicle Third Party Personal Injury Insurance is compulsory and it is commonly known as Compulsory Third Party (CTP) Insurance. Throughout Australia motorists are covered for care from a chiropractor following an automobile accident. This coverage has been made available under the provisions of state laws. For instance, in South Australia under rules set by the ’Motor Accident Commission [MAC]’ [81]:
Motor Injury Insurance, or Compulsory Third Party (CTP) insurance, provides compensation to people injured in road crashes who are not at fault.
Compensation payments are funded by CTP insurance premiums paid by all SA motorists as part of their vehicle registration.
By paying CTP premium motorist are covered if motorist are at fault in a motor vehicle crash and cause someone else to be injured or killed.
South Australia’s CTP insurance scheme:
- Provides compensation arising from the use of a motor vehicle
- Compensates for reasonable treatment and other expenses.
The scheme does not:
- Provide full compensation for persons who contribute to their injuries. For example, by not wearing a seatbelt.
- Compensate the injured driver who is entirely at fault.
- Cover damage to vehicles.
Although the various State Authorities may function under different names they all provide similar coverage, In the State of Victoria the ‘Transport Accident Commission’ provides similar coverage to that in South Australia but its policies, with regard to payment for chiropractic care of road accident victims, is very clearly set out in a document updated as recently as 11 August 2010 [82].
Policy
Cost of chiropractic treatment for injuries sustained in an accident are covered by the TAC, as long as the care is deemed reasonable and carried out by a registered chiropractor. [82]
In the State of New South Wales, the Motor Accidents Authority operates NSW Motor Accidents Scheme. Chiropractic services are available to accident victims in NSW. Chiropractors have to follow certain regulations to provide treatment. [83]
In Western Australia the Insurance Commission is the sole Compulsory Third Party Insurer for motor vehicle personal injuries. The Commission will cover costs for chiropractic services, along with ambulance, doctor, hospitals and other services. [84]
Australia’s Workers Compensation
Similar to the Transport Accident Commission, in its various forms from state to state, workers compensation differs from state to state.
Essentially each state does cover workers who are injured and who seek chiropractic care, and although the states may differ in their approach to recompense there is a realization that chiropractors do return workers to a ‘pre-injury status’ with most cases at less financial outlay then with allopathic medicine and other forms of therapy.
In, New South Wales, chiropractors can join Work Cover to treat injured workers. The chiropractor must be registered and then complete a Work Cover Training Program [85]. All care to injured workers must be in accordance with procedures. A Chiropractors’ Guide to WorkCover NSW outlines the procedures. Of note is the submission of a Chiropractic management plan for provision of greater than 8 treatment sessions. [85]
Fees and invoicing
Chiropractic services are paid in accordance with the maximum fees set out in the ‘Chiropractic fees order 2010’. WorkCover-approved chiropractors are entitled to charge a higher fee for service, as detailed in the Chiropractic fees order. [85]
Much of the information relating to Chiropractic provided by the WorkCover Authority in New South Wales appears to be germane to workers compensation procedures in other states.
In South Australia WorkCoverSA has developed a comprehensive ‘Chiropractic fee schedule and guidelines’ document which became effective from 1 July 2009. The document provides full details on payments made for WorkCover related care provided by chiropractors. [86]
It is held out as an online resource to assist health providers managing workers compensation injuries in South Australia. A new chiropractic fee schedule and guideline will come into force from July 1, 2012. [87]
Multi-State Guidance Material
Multi-State Workers Compensation Guidance Material has been compiled to assist both employers and injured workers. It is a joint initiative by the State Workers Compensation Authorities of The Australian Capital Territory, New South Wales, Northern Territory, Queensland, South Australia, Tasmania, Victoria and Western Australia [88].
Department of Veterans Affairs.
Chiropractic services are available to Australian veterans and other serviceman on a referral basis from medical professionals. [89]
2.5.2 HONG KONG
Under the provisions of the Employees’ Compensation Ordinance, Chapter 282, as promulgated by the Labour Department of the Government of the Hong Kong Special Administrative Region, an injured worker is entitled to have his or her employer pay for medical, Chinese medicine and dental expenses. The employer also has to pay for chiropractor expenses when treatment is done by a registered chiropractor. [90]
Chiropractic offices and Insurance
Chiropractors practicing in Hong Kong do accept patients with insurance claims such as auto, personal injury and workers compensation. They will also accept insurance plans and Medicare payments. [91], [92]
2.5.3 MALAYSIA
The WHO summary of ‘Background Information’ on the Legal Status of Traditional and Complementary/Alternative Medicine within Malaysia is quite comprehensive. Suffice to repeat here [93]:
‘The diversity in medical systems in Malaysia reflects the diverse population of Malay, Chinese, Indian, and indigenous heritage. In addition to allopathic medicine, the major systems of medicine practised in Malaysia include Ayurveda, Siddha, Unani, Traditional Chinese Medicine, and traditional systems of medicine, such as that provided by traditional medicine practitioners, spiritualists, bonesetters, traditional birth attendants, and others who use home remedies. Medical options also include homeopathy, naturopathy, reflexology, aromatherapy and chiropractic.’
Government agencies and local private insurance companies do not provide cover for chiropractic. Some companies reimburse or pay for employers to visit chiropractors. Expatriate workers with overseas insurance company policies can claim for chiropractic services performed in Malaysia [Dr. Leigh Murrant, Personal communication; 14 Jan 2012]
2.5.4 NEW ZEALAND
Accident Compensation Corporation (ACC)
New Zealand has an Accident compensation system that provides cover for all. It is based on an insurance model which gives cover regardless of fault and cause. [94]
Chiropractic care is covered on a clinically justified, appropriate and necessary basis. [95] Chiropractors need to be ACC- registered. They can receive payments for vertebral injuries, but not for non-vertebral injuries. [96]
2.6 AFRICA
2.6.1 SOUTH AFRICA
Workers Compensation:
In accordance with the law, as clearly stated in the Government Gazette of 3 June 2009, the employee, seeking care under the provisions of the Compensation for Occupational Injuries and Diseases Act, 1993 is able to choose his or her own practitioner. They can choose a doctor, hospital or other service provider without interference on a reasonable and without prejudice basis. Chiropractic care is provided for under the Compensation for occupational injuries and diseases Act. [97]
Medical Aid (Health Insurance)
Chiropractic services are covered by many Medical aid providers in South Africa. [98], [99]
2.7 AMERICAS
2.7.1 BRAZIL
The Brazilian health care system is composed of both public and private sectors. Every Brazilian has the constitutional right to free health care, either from the public service or from the private. The national health system –Sistema Único de Saúde (SUS) takes care of about 78% of the health care needs in the country. Private Health plans such as Insurance are available in Brazil and may be purchased on an individual-basis or obtained as a work benefit. Public health care is still accessible for those who choose to obtain private health insurance. [100][101][102].
Workers’ compensation in Brazil
Brazil has a workers welfare scheme known as “Instituto Nacional do Seguro Social – INSS”. It provides income replacement for workers that are unable to work for a variety of reasons. [103] A search of the official government website of INSS reveals no information about chiropractic (Quiropraxia). [104]
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