Clinical Briefs: CAM Usage and Insurance Coverage
Clinical Briefs: CAM Usage and Insurance Coverage
With Comments from John La Puma, MD, FACP
Source: Wolsko PM, et al. Insurance coverage, medical conditions, and visits to alternative medicine providers. Arch Intern Med 2002;162:281-287.
In 1997, patients made an estimated 629 million visits to complementary and alternative medicine (CAM) providers; however, little is known about factors associated with visits to CAM providers.
To examine the effect of insurance coverage on frequency of use of CAM providers, a nationally representative telephone survey was conducted between November 1, 1997, and February 28, 1998. Random-digit dialing with random selection of one English-speaking household resident 18 years or older was used to conduct a nationally representative, random household telephone survey of 2,055 adults. Therapies specifically not included in the definition of CAM for this analysis were spiritual healing by others, self-prayer, and exercise. Extent of insurance coverage was classified as none, partial, or full. CAM insurance information for respondents who did not report visits to providers was not collected.
The main outcome measure was the number of visits made to CAM providers. Correlates of use of chiropractors have not been examined in a national sample. The effect of CAM provider insurance coverage or other factors on frequency of CAM provider use for providers other than chiropractors has not been examined previously.
An estimated 44% of the U.S. population used at least one CAM therapy in 1997. Of those using CAM, 52% had seen at least one CAM provider in the last year. Among those who used a CAM therapy, factors independently associated with seeing a provider were having been in the upper quartile of visits to conventional providers in the last year (adjusted odds ratio [AOR] 2.00, 95% confidence interval [CI] 1.33-3.01), female sex (AOR 1.67, 95% CI 1.17-2.38), and having used the therapy to treat diabetes (AOR 5.20, 95% CI 1.40-19.40), cancer (AOR 2.99, 95% CI 1.04-8.62), or back or neck problems (AOR 1.51, 95% CI 1.02-2.23).
Factors independently associated with frequent use (eight visits per year) of a CAM provider were full insurance coverage of the CAM provider (AOR 5.06; 95% CI 2.45-10.47), partial insurance coverage (AOR 3.26, 95% CI 1.72-6.19), having used the therapy for wellness (AOR 2.85, 95% CI 1.63-4.98), and having seen the provider for back or neck problems (AOR 2.26, 95% CI 1.29-3.94).
Conservative extrapolation to national estimates suggests that 8.9% of the population (17.5 million adults) accounted for more than 75% of the 629 million visits made to CAM providers in 1997. A small minority of persons accounted for more than 75% of visits to CAM providers. Extent of insurance coverage for CAM providers and use for wellness are strong correlates of frequent use of CAM providers.
Comment
This is one of several reports of the follow-up to the well-known Eisenberg prevalence study (Eisenberg DM, et al. JAMA 1998;280:1569-1575), now demonstrating that relatively few patients visit CAM providers relatively often, not unlike patterns in allopathic medicine. And patients who have CAM insurance coverage and those who use CAM for wellness (instead of treating an illness) are those who see CAM providers most often.
Almost two-thirds of enrollees who had full coverage for manipulation delivered by CAM providers—chiropractors, primarily—made eight or more visits in the last year of the survey; only one of six enrollees with no (chiropractic) coverage made eight or more visits. Whether the coverage was full or partial did not matter.
For non-manipulative providers, the only factor from the primary model significantly associated with high-frequency provider use was having used the therapy for wellness.
The $64 question, of course, is whether enrollees chose health insurance coverage because they knew chiropractic (and massage, to be fair) would be covered, or whether enrollees simply used chiropractic and massage more because it was there.
Patients obtain information for prevention from CAM providers, allopathic providers, the lady next door, and on the web. Those who seek help from CAM providers are, in general, health- minded—they want to know their blood pressure, cholesterol levels, how much protein they should be eating.
The upshot? Even patients who have many chronic illnesses do not consider themselves ill in such a way that they require CAM. They do not seek CAM to treat their hypertension, diabetes, and heart failure (even though the supplements they are taking may aim to do so). Instead, people with chronic illness seek CAM so they can feel better and improve their general health.
Certainly there are economics involved. The authors report that chiropractic "maintenance care" is recommended to four of five chiropractic patients, and may account for nearly a quarter of a chiropractor’s income. "Maintenance care" may include manipulation and counseling about food and fitness.
Recommendation
As the provision of CAM is so directly correlated with insurance coverage, carriers will want to make sure that their providers are licensed, insured, and credentialed optimally. The risks and interactions of their CAM providers’ prescriptions should be well known to providers and available to patients. Because prevention of medical illness also drives patients to see CAM providers, thoughtful, systematic processes in nutrition, fitness, exercise, spirituality, supplementation, and environmental health ought to be tested and if successful, integrated into standard benefits packages.
La Puma J. CAM usage and insurance coverage. Altern Med Alert 2002;5:63-64.Subscribe Now for Access
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