Current ACA President, Anthony Hamm, DC, Discusses College of Pharmacology and Affordable Care Act
POLITICS
TAC
Anthony W. Hamm, DC, FACO, is currently serving his second one-year term as president of the American Chiropractic Association (ACA). He is a second-generation DC and a 1979 graduate of the National University of Health Sciences. He has managed a chiropractic practice for the past 35 years, concentrating on adult orthopedics and pain management. His diplomate certifications include orthopedics and forensics, and he is certified in acupuncture. During the past 15 years, he has taught and written on the subjects of coding, documentation, risk management, and Medicare compliance. He recently completed a four-year term as cochairperson of the American Medical Association's (AMA)/Specialty Society Relative Value Scale Update Committee (RUC) Health Care Professionals Advisory Committee Review Board (HCPAC). Dr. Hamm is a member and past officer of the North Carolina Chiropractic Association. His forensic work includes professional liability review and fraud investigations. He has served as past chair of the ACA’s Coding and Reimbursement Committee and Ethics Committee.
What are some of the new projects that the American Chiropractic Association (ACA) has been working on?
The ACA’s short-term focus is on becoming more membercentric. We have learned there are many issues plaguing our profession, some more manageable than others. The ACA’s leadership has decided to concentrate our efforts primarily on national issues. These include Medicare, current statutory restrictions, communications and media response, and government relations issues, among others.
“We did not create a college of pharmacotherapy, as some have asserted.
The ACA is reaching out to individual state organizations in an attempt to develop meaningful partnerships. If we could somehow share our limited resources and avoid duplicative work, think of the potential benefit for the practicing doctors. Chiropractic has the distinction of being one of the few professions that has no official link between the state and national organization. On a personal note, I think that demonstrates a lack of professional maturity.
Internally, we are transitioning our old insurance department into a new and improved public policy and advocacy division include both public and private payer management. Goals of payment policy include working closely with Medicare Admin-
istrative Contractors (MACs) and contract medical directors. In fact, we have personally met with each individual contract medical director and many of their staff to begin discussions on ways we can effectively reduce our claims error rates. We are also continuing to advocate for expanding Medicare reimbursement to include evaluation and management services. Interaction with private payers is ongoing.
The major long-term objective of the ACA is to update the statutory language that defines chiropractic reimbursement in the Social Security Act (1861 r -5). The current statute has not been changed since it was enacted more than 40 years ago, and, of course, it limits us to correction of a subluxation by manual manipulation only. The ACA strongly feels that this limiting language does not represent the contemporary practice of chiropractic.
Can you explain the purpose of the College of Pharmacology and Toxicology?
The ACA represents members with diverse interests. That’s why we support specialty councils and colleges. These of course include diagnostic imaging, pediatrics, orthopedics, neurology, occupational health, and many more. We are of the opinion that this diversity and these special interests strengthen our profession and benefit our patients.
“The major long-term objective of the ACA is to update the statutory language that defines chiropractic reimbursement in the Social
Security Act (1861 r -5). 55
It is clear to anyone paying attention that chronic pain is a true burden to society. The population is living longer and presenting with increasing numbers of comorbidities. There simply is more chronic disease. These patients present to us with a list of medications and often have questions. As chiropractic physicians become more integrated into the management of these patients, it becomes critical that we had better understand drug-drug and drug-allergy dynamics. In fact, being compliant with electronic health records mandates this knowledge. Those of us who are in the National Registry of Certified Medical Examiners also require a working knowledge of medications that help manage chronic diseases in order to serve the nation’s truck drivers. So the purpose
of the ACA’s College of Pharmacology and Toxicology is to offer advanced education beyond what is currently being offered in all chiropractic colleges, to those who are interested.
What was the spirit of the debate around the decision to create this college?
All of the ACA’s policies and position statements are fully vetted through a rigorous process. The consideration to create this college was no different.
When the ACA debates any healthcare policy or the creation of educational content, we take into consideration the potential impact it will have on our membership, on the profession at large, and more importantly, on the patients we serve.
Once it was explained that the purpose of the college was simply educational in nature, there was more agreement. And of course clarification of definitions was necessary. Pharmacology is the discipline concerned with the use, effects, and modes of actions of drugs. Pharmacotherapy, on the other hand, is medi-
cal treatment by use of drugs. We did not create a college of pharmacotherapy, as some have asserted.
Could you talk about the project you worked on regarding the “Six Key Elements of a Modern Chiropractic Act”? How will this influence decision making in the future?
During the annual meeting of the ACA’s House of Delegates in February, we passed a resolution supporting key elements that we believe should be considered in any efforts to renew or update state scopes of practice. Variability of state chiropractic regulations has created uncertainty and confusion for the general public, chiropractic patients, and chiropractic physicians, which impedes development and progress of the profession. The resolution on six key elements of a modern scope of practice supports the terms “chiropractic physician” and “chiropractic medicine.” These terms are part of the ACA’s lexicon because they support our profession’s ability to practice to our full level of training and competencies. As the leading organization
supporting contemporary chiropractic practice, we have embraced this terminology.
Further defined in the scope resolution are full management, referral, and prescriptive authority for patient examination, diagnosis, differential diagnosis, and health assessment. As we are all aware, this language protects our ability to maintain first contact physician-level authority to manage our patients. This language is consistent with the AC As mission to preserve, protect, improve, and promote the profession and the services we deliver for the benefit of the patients we serve.
Through research, we have discovered that some existing state practice laws and regulations can limit the optimal healthcare workforce when they create a mismatch between legal scope of practice and professional competence.
In fact, some state laws and regulations limit practice to standards below our education and tested competencies.
In order to be inclusive in new and emerging healthcare delivery models, our profession should be allowed to practice in all states and territories uniformly.
How is the effort for achieving parity, as stipulated in the Affordable Care Act, developing?
We are pleased that many of the new plans coming on line include the essential services provided by doctors of chiropractic. Included is the Federal Employee Plan (FEP), which modified its benefit language last year to account for the provisions of Section 2706(a). And there was a meeting with the AC As staff in order to clarify the changes to benefit language and assist the ACA in developing an overview specifically for doctors of chiropractic to delineate those changes. We have found that some, but not all, of the smaller Blues plans have followed suit and adopted similar language to FEP. However, we still view the federal and many states’ disregard for Sec. 2706 of PPACA to be a serious issue, one we are working to rectify. Through our public policy and advocacy division, the ACA is gathering examples of discrimination against doctors of chiropractic and actively advocating for the profession.
However, we must take into account that the Affordable Care Act and section 2706 are not limited to reimbursement issues only. The main thrust from our perspective is inclusion. Our profession, at least the chiropractic physicians interested in participation, should have the opportunity to participate
“The Centers for Medicare and Medicaid Innovation (CMMI) have advised us to define our role in management of specific conditions, not as stand-alone providers but from a team-based approach. J J
in accountable care organizations, patient-centered medical homes, community health centers, and health exchanges without discrimination.
An unfortunate challenge to full inclusion is the definition of our roles in health care. Whether we like it or not, the new healthcare models are based on integration and collaboration with other disciplines. The Centers for Medicare and Medicaid Innovation (CMMI) have advised us to define our role in management of specific conditions, not as stand-alone providers but from a team-based approach. In the new quality-based payment system, the payers will attempt to define the best outcomes with the lowest price tag for management of those conditions. For whatever condition that we provide care for, we will need
datato support our assertions.
The public, not only in the US but globally, identifies us with spine care. Current evidence supports our role in spine care. Despite this public-driven identity, our profession continues the debate concerning our rightful positions in health care. Our strength is in musculoskeletal assessment and management. If we truly want to be a part of the evidence-based prevention and wellness model, or if we want to be a part of the team that manages chronic internal diseases or comorbidities, then we need to develop the care pathways and the outcomes data to support that inclusive care. Through intense lobbying and advocacy efforts, the ACA has played an integral role in positioning the profession to participate in and provide quality health care to the US population. We must remain focused and diligent in advancing and protecting our positions.
Is the ACA “anti-cash-based practices”?
The ACA is not opposed to cash-based practices, and, in fact, provides support to many of our members who have chosen to become cash only. We feel that doctors of chiropractic should follow whatever business model works best for their practice. However, we always caution doctors who are adopting a cash model to make sure that they are following all pertinent state and federal rules and regulations, and we strongly recommend that they consult a healthcare attorney.
What do you think of the pursuit of other professions performing manipulation?
We can agree that doctors of chiropractic receive the most extensive training in all manipulation procedures. Spinal
manipulation has been proven scientifically to provide health benefits. Most current research literature on the effects of manipulation does not distinguish between provider types delivering the manipulation. The ACA supports the assertion that we should maintain the highest standards in chiropractic manipulation therapy procedures.
How do you see the influence of the ACA, shaping the delivery of chiropractic care five, 10, or even 20 years into the future?
The ACA supports conservative, value-driven, evidencebased quality health care. We support the individual chiropractic physician’s authority to deliver this care commensurate with his or her training and competency levels. And we strongly support being reimbursed at the same or similar levels as other physician-level providers. We have adopted policy that supports each state’s right to determine its scope of practice.
The next generation of DCs will be faced with opportunities and challenges that are vastly different from those my generation faced. Patients continue to search for nonmedical conservative approaches to their health and well-being, and the policy makers are now less reluctant to embrace nontraditional health delivery models. The National Center for Complementary and Integrative Health (NCCIH) continues to
“Patients continue to search for nonmedical conservative approaches to their health and well-being, and the policy makers are now less reluctant to embrace nontraditional health delivery models. 5 5
fund research grants on manipulation, acupuncture, massage, and yoga, to name a few.
Many chiropractic graduates are now expecting to enter into integrated or interdisciplinary settings. There are more and more opportunities to enter the research or public health arenas. The Veterans Affairs Administration and the Department of Defense are utilizing chiropractic at higher levels.
Through the hard work and dedication of past leaders, the ACA has created a vast pool of talented clinicians, researchers, educators, and volunteer leaders and placed them in positions of authority. These volunteers gladly give of their time and talents
to serve on regulatory agencies, expert panels, guideline development panels—all advocating for chiropractic participation and inclusion.
Advocacy, education, legal action, and communications all interweave into the AC As strategic plan for the advancement of our profession. Our primary objective is to help transform the environment in which we practice the art and science of chiropractic. Through interprofessional relationships developed over many years, we are not simply in a position to participate in healthcare delivery, but to actually shape the landscape of health care.
What are your thoughts on the current state of the profession, and how it will affect a practicing chiropractor five, 10, or even 20 years in the future?
With the advent of the Affordable Care Act, healthcare delivery in the US is in a state of flux. Despite the ongoing political wrangling on both sides of the aisle, how we get paid for our services remains open for debate. That’s why it remains critical to have one strong voice on Capitol Hill. Medicare, for instance, is not an entitlement. We pay into the system through taxes, we pay premiums, and we have copays and coinsurance liabilities. The aging US population needs and deserves to have access to and reimbursement for the full array of chiropractic services, should they choose.
Our military and their dependents as well as our veterans should have unobstructed access to chiropractic services. It is critical that we defend the nondiscrimination provision of the Affordable Care Act so our patients have access to us through the health insurance exchanges.
On a personal note, our profession has so many wonderful opportunities ahead of it. As a result of our unique talents and expertise, we truly offer society viable nondrug and nonsurgical solutions for the chronic pain epidemic in the US. We provide valuable assessment and management for spine pain patients and many more musculoskeletal issues.
The American Chiropractic Association, under current leadership, has made the conscious decision to take an active role in advocating for our membership. We are unable to solve each and every insurance grievance, to solve all managed care issues, to alter all private-payer reimbursement policies. But what we can do and are good at doing is answering our critics through the media; petitioning the federal government and lobbying for inclusion in public healthcare delivery models; working with Medicare to educate our members on documentation and compliance issues to decrease our collective error rates; and developing meaningful partnerships with states and our colleges for the express purpose of making chiropractic available to a greater number of people in the US and its territories.
“The aging US population needs and deserves to have access to and reimbursement for the full array of chiropractic services, should they choose. J Ï
The ACA believes it is critical to prepare our profession for the future of health care. The relationships we have built and continue to build with legislators, policy makers, regulatory agencies, and other specialty societies remain important to our success. What often gets lost in these conversations is the patient. We should all understand that what is good for the patient will be good for our profession.
Any final words for our readers?
Please visit our website at www.acatoday.org.
Yon may contact Dr. Anthony Hamm at [email protected]. You can also follow him on Twitter @ACA_Prez or on his www.acatoday.org/president.
