RE: Frustrating developments...

[Guest guest]

HOW MANY DC’S HAVE PATIENTS NEEDING WEEKLY TREATMENTS IF PEROPER MANIPULATION IS PERFORMED???????????? BOB W. Pfeiffer, D.C., D.A.B.C.O.Lee Pfeiffer, R.N., B.S.46 N.E. Mt. Hebron Dr. (no USPS mail)P.O. Box 606 Pendleton, OR 97801drbob@...leernbs@... All people smile in the same language From: oregondcs [mailto:oregondcs ] On Behalf Of Jamey DysonSent: Wednesday, July 25, 2012 12:54 PMTo: oregondcs DC'SSubject: Frustrating developments... Featured Health Business Daily Story, July 24, 2012Blues Plans Limit Chiropractic Care, Citing Excessive Costs, Spiking UtilizationReprinted from THE AIS REPORT ON BLUE CROSS AND BLUE SHIELD PLANS, a hard-hitting independent monthly newsletter on new products, market share, strategies, conversions, financing, profitability and strategic alliances of BC/BS plans. (Not affiliated with the Blue Cross and Blue Shield Association or its member companies.)By Connole, Editor - July 2012 - Volume 11 Issue 7 Highmark Inc. is the latest Blues plan to change the way it pays for outpatient, non-emergency physical and occupational therapy and chiropractic care, informing customers on June 19 that beginning Sept. 1, 2012, providers must get prior authorization before performing services in those areas. It also has contracted with vendor Healthways to implement the new requirements. The insurer joins a number of Blues plans from Arizona to Massachusetts that have sought out ways to control costs in this area.Highmark says it wants to clamp down on members receiving dozens upon dozens of visits with providers performing chiropractic and related services. An analysis by Healthways of initial claims data provided by Highmark indicates a high frequency of visits overall, with a handful of members receiving more than 100 visits over the course of a calendar year, says Olson, director of clinical services for Healthways.Highmark says the claims analysis put chiropractic care second only to cardiac care as the highest-paid service for members in some practices during the past two years. The insurer adds that in 2010, it paid more than $100 million for chiropractic-related services; in that same year, combined claims data for occupational and physical therapy cost Highmark an additional $100 million.“Working with our vendor, we believe close to one-third of these claims may not represent optimal utilization,” says Virginia Calega, M.D., Highmark’s vice president of medical management and policy. She tells The AIS Report that Highmark is turning to prior-authorization programs for help.“A look at the claims data revealed unwarranted variations in the delivery of care,” she says. Noting Highmark is not unique in seeking to address chiropractic and related care cost issues, Calega says the changes only came about after long discussions with vendors and other health plans seeking to address the same cost concerns.Healthways, for instance, has worked on the problem with Blue Cross Blue Shield of Massachusetts, helping the insurer to institute a prior-authorization policy for chiropractic care. Healthways reported on its website that in 2008 the insurer established a threshold of 12 visits before requiring prior authorization for additional visits. The vendor said the Massachusetts Blues plan saw “substantial” savings and met return-on-investment goals, although it did not disclose specific figures. The insurer did not return a request for comment on the program.The prior-authorization program applies to Highmark members in insured groups in Pennsylvania and West Virginia, as well as the plan’s individual and Medicare Advantage members in those areas. Groups that are self-insured may also participate, Highmark says, and no member will need to take special steps since providers will work directly with Healthways to obtain authorizations via an electronic health record information portal.Calega stresses that each and every instance of provider care is not subject to prior authorization come Sept. 1; instead the prior-authorization requirement kicks in only after eight visits. “If additional visits are medically necessary, we simply want to ensure there is a proper and appropriate treatment plan in place,” she says. The insurer’s data points to the fact that nearly two-thirds of members have their chiropractic and physical therapy needs met and resolved within eight visits. “We are not doing the program to say we want to see ‘X’ number of visits. We know this is a large area of our spending and presents an opportunity for improvement,” Calega says.Highmark Joins the CrowdAfter one year of the prior-authorization program, Highmark will review in aggregate how the process is working and possibly make further changes. The Blues plan also says it is forming a provider advisory group to ensure proper care in an efficient manner. “We have really spent a lot of time sitting down with the specialty [care] societies before making this public announcement, and they gave us good feedback,” Calega says.Highmark is not breaking new ground in this space. For example, on Jan. 1, 2011, Blue Cross Blue Shield of Arizona stopped providing its own chiropractic network for PPO members and began using the American Specialty Health network of chiropractors. The Blues plan cited time-consuming claims processing, claims not being reviewed by chiropractic specialists and chiropractors in the PPO network receiving payment for care that wasn’t a covered service, among other factors.“Our goal was not only to bend the cost curve but to provide a higher level of service to our members who require chiropractic care by using best-in-class resources that specialize in chiropractic management. All decisions regarding medical necessity are evidence-based and chiropractors will have the opportunity for peer-to-peer review and discussion with chiropractors,” Arizona Blues spokesperson Regena Frieden tells The AIS Report.The Blues plan says about 7% of its members use chiropractic services as part of their overall medical care. And before making the change to an outside vendor, billed charges for chiropractic care reached $68 million annually despite the small proportion of members using such services.“These costs were unsustainable and impacted the overall costs of health care coverage for everyone,” Frieden says.

[Guest guest]

That's a question I have also. Wasn't there a time in chiropractic when a DC prided him or herself in fixing a person with as little treatment as necessary? It's funny that in many chiro circles you are seen as a great DC if your patients are coming in to see you 100 visits per year. Are those people REALLY getting the most bang for the healthcare buck with all that adjusting? The chiropractic story seems to have become "the body is self-healing and self-regulating as long as you get adjusted 1-2 x per week for the rest of your life". I don't think there is any evidence to support this concept however. Maybe someone can enlighten me?Jamey Dyson, DCHOW MANY DC’S HAVE PATIENTS NEEDING WEEKLY TREATMENTS IF PEROPER MANIPULATION IS PERFORMED???????????? BOB W. Pfeiffer, D.C., D.A.B.C.O.Lee Pfeiffer, R.N., B.S.46 N.E. Mt. Hebron Dr. (no USPS mail)P.O. Box 606Pendleton, OR 97801drbob@...leernbs@... All people smile in the same language From: oregondcs [mailto:oregondcs ] On Behalf Of Jamey DysonSent: Wednesday, July 25, 2012 12:54 PMTo: oregondcs DC'SSubject: Frustrating developments... Featured Health Business Daily Story, July 24, 2012Blues Plans Limit Chiropractic Care, Citing Excessive Costs, Spiking UtilizationReprinted from THE AIS REPORT ON BLUE CROSS AND BLUE SHIELD PLANS, a hard-hitting independent monthly newsletter on new products, market share, strategies, conversions, financing, profitability and strategic alliances of BC/BS plans. (Not affiliated with the Blue Cross and Blue Shield Association or its member companies.)By Connole, Editor - July 2012 - Volume 11 Issue 7Highmark Inc. is the latest Blues plan to change the way it pays for outpatient, non-emergency physical and occupational therapy and chiropractic care, informing customers on June 19 that beginning Sept. 1, 2012, providers must get prior authorization before performing services in those areas. It also has contracted with vendor Healthways to implement the new requirements. The insurer joins a number of Blues plans from Arizona to Massachusetts that have sought out ways to control costs in this area.Highmark says it wants to clamp down on members receiving dozens upon dozens of visits with providers performing chiropractic and related services. An analysis by Healthways of initial claims data provided by Highmark indicates a high frequency of visits overall, with a handful of members receiving more than 100 visits over the course of a calendar year, says Olson, director of clinical services for Healthways.Highmark says the claims analysis put chiropractic care second only to cardiac care as the highest-paid service for members in some practices during the past two years. The insurer adds that in 2010, it paid more than $100 million for chiropractic-related services; in that same year, combined claims data for occupational and physical therapy cost Highmark an additional $100 million.“Working with our vendor, we believe close to one-third of these claims may not represent optimal utilization,” says Virginia Calega, M.D., Highmark’s vice president of medical management and policy. She tells The AIS Report that Highmark is turning to prior-authorization programs for help.“A look at the claims data revealed unwarranted variations in the delivery of care,” she says. Noting Highmark is not unique in seeking to address chiropractic and related care cost issues, Calega says the changes only came about after long discussions with vendors and other health plans seeking to address the same cost concerns.Healthways, for instance, has worked on the problem with Blue Cross Blue Shield of Massachusetts, helping the insurer to institute a prior-authorization policy for chiropractic care. Healthways reported on its website that in 2008 the insurer established a threshold of 12 visits before requiring prior authorization for additional visits. The vendor said the Massachusetts Blues plan saw “substantial” savings and met return-on-investment goals, although it did not disclose specific figures. The insurer did not return a request for comment on the program.The prior-authorization program applies to Highmark members in insured groups in Pennsylvania and West Virginia, as well as the plan’s individual and Medicare Advantage members in those areas. Groups that are self-insured may also participate, Highmark says, and no member will need to take special steps since providers will work directly with Healthways to obtain authorizations via an electronic health record information portal.Calega stresses that each and every instance of provider care is not subject to prior authorization come Sept. 1; instead the prior-authorization requirement kicks in only after eight visits. “If additional visits are medically necessary, we simply want to ensure there is a proper and appropriate treatment plan in place,” she says. The insurer’s data points to the fact that nearly two-thirds of members have their chiropractic and physical therapy needs met and resolved within eight visits. “We are not doing the program to say we want to see ‘X’ number of visits. We know this is a large area of our spending and presents an opportunity for improvement,” Calega says.Highmark Joins the CrowdAfter one year of the prior-authorization program, Highmark will review in aggregate how the process is working and possibly make further changes. The Blues plan also says it is forming a provider advisory group to ensure proper care in an efficient manner. “We have really spent a lot of time sitting down with the specialty [care] societies before making this public announcement, and they gave us good feedback,” Calega says.Highmark is not breaking new ground in this space. For example, on Jan. 1, 2011, Blue Cross Blue Shield of Arizona stopped providing its own chiropractic network for PPO members and began using the American Specialty Health network of chiropractors. The Blues plan cited time-consuming claims processing, claims not being reviewed by chiropractic specialists and chiropractors in the PPO network receiving payment for care that wasn’t a covered service, among other factors.“Our goal was not only to bend the cost curve but to provide a higher level of service to our members who require chiropractic care by using best-in-class resources that specialize in chiropractic management. All decisions regarding medical necessity are evidence-based and chiropractors will have the opportunity for peer-to-peer review and discussion with chiropractors,” Arizona Blues spokesperson Regena Frieden tells The AIS Report.The Blues plan says about 7% of its members use chiropractic services as part of their overall medical care. And before making the change to an outside vendor, billed charges for chiropractic care reached $68 million annually despite the small proportion of members using such services.“These costs were unsustainable and impacted the overall costs of health care coverage for everyone,” Frieden says.

[Guest guest]

Yes, Jamey, Bob as your colleague and lobbyist tell me about it…this doesn’t make my job any easier in Salem….Vern

-----

Vern Saboe, Jr, DC., DACAN., FICC., DABFP., FACO.

915 19th Ave SE

Albany, OR 97322

phone:

e-mail: vern@...

website: www.drvernsaboe.com

From: oregondcs [mailto:oregondcs ]

On Behalf Of Jamey Dyson

Sent: Wednesday, July 25, 2012 3:29 PM

To: Pfeiffer

Cc: 'oregondcs DC'S'

Subject: Re: Frustrating developments...

That's a question I have also. Wasn't there a time in chiropractic when a DC prided him or herself in fixing a person with as little treatment as necessary? It's funny that in many chiro circles you are seen as a great DC if your patients are coming in

to see you 100 visits per year. Are those people REALLY getting the most bang for the healthcare buck with all that adjusting? The chiropractic story seems to have become " the body is self-healing and self-regulating as long as you get adjusted 1-2 x per

week for the rest of your life " . I don't think there is any evidence to support this concept however. Maybe someone can enlighten me?

Jamey Dyson, DC

HOW MANY DC’S HAVE PATIENTS NEEDING WEEKLY TREATMENTS IF PEROPER MANIPULATION IS PERFORMED????????????

BOB

W. Pfeiffer, D.C., D.A.B.C.O.

Lee Pfeiffer, R.N., B.S.

46 N.E. Mt. Hebron Dr. (no USPS mail)

P.O. Box 606

Pendleton, OR 97801

drbob@...

leernbs@...

All people smile in the same language

From: oregondcs [mailto:oregondcs ] On

Behalf Of Jamey Dyson

Sent: Wednesday, July 25, 2012 12:54 PM

To: oregondcs DC'S

Subject: Frustrating developments...

Featured Health Business Daily Story, July

24, 2012

Blues Plans Limit Chiropractic Care, Citing Excessive Costs, Spiking Utilization

Reprinted from THE AIS REPORT ON BLUE CROSS AND BLUE SHIELD PLANS, a hard-hitting independent monthly newsletter on new

products, market share, strategies, conversions, financing, profitability and strategic alliances of BC/BS plans. (Not affiliated with the Blue Cross and Blue Shield Association or its member companies.)

By Connole, Editor - July 2012 - Volume 11 Issue 7

Highmark Inc. is the latest Blues plan to change the way it pays for outpatient, non-emergency physical and occupational therapy and chiropractic care, informing customers on June 19 that beginning Sept. 1, 2012, providers must get prior authorization before

performing services in those areas. It also has contracted with vendor Healthways to implement the new requirements. The insurer joins a number of Blues plans from Arizona to Massachusetts that have sought out ways to control costs in this area.

Highmark says it wants to clamp down on members receiving dozens upon dozens of visits with providers performing chiropractic and related services. An analysis by Healthways of initial claims data provided by Highmark indicates a high frequency of visits

overall, with a handful of members receiving more than 100 visits over the course of a calendar year, says Olson, director of clinical services for Healthways.

Highmark says the claims analysis put chiropractic care second only to cardiac care as the highest-paid service for members in some practices during the past two years. The insurer adds that in 2010, it paid more than $100 million for chiropractic-related

services; in that same year, combined claims data for occupational and physical therapy cost Highmark an additional $100 million.

“Working with our vendor, we believe close to one-third of these claims may not represent optimal utilization,” says Virginia Calega, M.D., Highmark’s vice president of medical management and policy. She tells The

AIS Report that Highmark is turning to prior-authorization programs for help.

“A look at the claims data revealed unwarranted variations in the delivery of care,” she says. Noting Highmark is not unique in seeking to address chiropractic and related care cost issues, Calega says the changes only came about after long discussions with

vendors and other health plans seeking to address the same cost concerns.

Healthways, for instance, has worked on the problem with Blue Cross Blue Shield of Massachusetts, helping the insurer to institute a prior-authorization policy for chiropractic care. Healthways reported on its website that in 2008 the insurer established

a threshold of 12 visits before requiring prior authorization for additional visits. The vendor said the Massachusetts Blues plan saw “substantial” savings and met return-on-investment goals, although it did not disclose specific figures. The insurer did not

return a request for comment on the program.

The prior-authorization program applies to Highmark members in insured groups in Pennsylvania and West Virginia, as well as the plan’s individual and Medicare Advantage members in those areas. Groups that are self-insured may also participate, Highmark says,

and no member will need to take special steps since providers will work directly with Healthways to obtain authorizations via an electronic health record information portal.

Calega stresses that each and every instance of provider care is not subject to prior authorization come Sept. 1; instead the prior-authorization requirement kicks in only after eight visits. “If additional visits are medically necessary, we simply want

to ensure there is a proper and appropriate treatment plan in place,” she says. The insurer’s data points to the fact that nearly two-thirds of members have their chiropractic and physical therapy needs met and resolved within eight visits. “We are not doing

the program to say we want to see ‘X’ number of visits. We know this is a large area of our spending and presents an opportunity for improvement,” Calega says.

Highmark Joins the Crowd

After one year of the prior-authorization program, Highmark will review in aggregate how the process is working and possibly make further changes. The Blues plan also says it is forming a provider advisory group to ensure proper care in an efficient manner.

“We have really spent a lot of time sitting down with the specialty [care] societies before making this public announcement, and they gave us good feedback,” Calega says.

Highmark is not breaking new ground in this space. For example, on Jan. 1, 2011, Blue Cross Blue Shield of Arizona stopped providing its own chiropractic network for PPO members and began using the American Specialty Health network of chiropractors. The

Blues plan cited time-consuming claims processing, claims not being reviewed by chiropractic specialists and chiropractors in the PPO network receiving payment for care that wasn’t a covered service, among other factors.

“Our goal was not only to bend the cost curve but to provide a higher level of service to our members who require chiropractic care by using best-in-class resources that specialize in chiropractic management. All decisions regarding medical necessity are

evidence-based and chiropractors will have the opportunity for peer-to-peer review and discussion with chiropractors,” Arizona Blues spokesperson Regena Frieden tells The AIS Report.

The Blues plan says about 7% of its members use chiropractic services as part of their overall medical care. And before making the change to an outside vendor, billed charges for chiropractic care reached $68 million annually despite the small proportion

of members using such services.

“These costs were unsustainable and impacted the overall costs of health care coverage for everyone,” Frieden says.

[Guest guest]

Amen, brother! Seitz, DC Tuality Physicians 730-D SE Oak St Hillsboro, OR 97123 (503)640-3724To: drjdyson1@...; drbob@...CC: oregondcs From: Vern@...Date: Wed, 25 Jul 2012 23:01:31 +0000Subject: RE: Frustrating developments...

Yes, Jamey, Bob as your colleague and lobbyist tell me about it…this doesn’t make my job any easier in Salem….Vern

-----

Vern Saboe, Jr, DC., DACAN., FICC., DABFP., FACO.

915 19th Ave SE

Albany, OR 97322

phone:

e-mail: vern@...

website: www.drvernsaboe.com

From: oregondcs [mailto:oregondcs ]

On Behalf Of Jamey Dyson

Sent: Wednesday, July 25, 2012 3:29 PM

To: Pfeiffer

Cc: 'oregondcs DC'S'

Subject: Re: Frustrating developments...

That's a question I have also. Wasn't there a time in chiropractic when a DC prided him or herself in fixing a person with as little treatment as necessary? It's funny that in many chiro circles you are seen as a great DC if your patients are coming in

to see you 100 visits per year. Are those people REALLY getting the most bang for the healthcare buck with all that adjusting? The chiropractic story seems to have become "the body is self-healing and self-regulating as long as you get adjusted 1-2 x per

week for the rest of your life". I don't think there is any evidence to support this concept however. Maybe someone can enlighten me?

Jamey Dyson, DC

HOW MANY DC’S HAVE PATIENTS NEEDING WEEKLY TREATMENTS IF PEROPER MANIPULATION IS PERFORMED????????????

BOB

W. Pfeiffer, D.C., D.A.B.C.O.

Lee Pfeiffer, R.N., B.S.

46 N.E. Mt. Hebron Dr. (no USPS mail)

P.O. Box 606

Pendleton, OR 97801

drbob@...

leernbs@...

All people smile in the same language

From: oregondcs [mailto:oregondcs ] On

Behalf Of Jamey Dyson

Sent: Wednesday, July 25, 2012 12:54 PM

To: oregondcs DC'S

Subject: Frustrating developments...

Featured Health Business Daily Story, July

24, 2012

Blues Plans Limit Chiropractic Care, Citing Excessive Costs, Spiking Utilization

Reprinted from THE AIS REPORT ON BLUE CROSS AND BLUE SHIELD PLANS, a hard-hitting independent monthly newsletter on new

products, market share, strategies, conversions, financing, profitability and strategic alliances of BC/BS plans. (Not affiliated with the Blue Cross and Blue Shield Association or its member companies.)

By Connole, Editor - July 2012 - Volume 11 Issue 7

Highmark Inc. is the latest Blues plan to change the way it pays for outpatient, non-emergency physical and occupational therapy and chiropractic care, informing customers on June 19 that beginning Sept. 1, 2012, providers must get prior authorization before

performing services in those areas. It also has contracted with vendor Healthways to implement the new requirements. The insurer joins a number of Blues plans from Arizona to Massachusetts that have sought out ways to control costs in this area.

Highmark says it wants to clamp down on members receiving dozens upon dozens of visits with providers performing chiropractic and related services. An analysis by Healthways of initial claims data provided by Highmark indicates a high frequency of visits

overall, with a handful of members receiving more than 100 visits over the course of a calendar year, says Olson, director of clinical services for Healthways.

Highmark says the claims analysis put chiropractic care second only to cardiac care as the highest-paid service for members in some practices during the past two years. The insurer adds that in 2010, it paid more than $100 million for chiropractic-related

services; in that same year, combined claims data for occupational and physical therapy cost Highmark an additional $100 million.

“Working with our vendor, we believe close to one-third of these claims may not represent optimal utilization,” says Virginia Calega, M.D., Highmark’s vice president of medical management and policy. She tells The

AIS Report that Highmark is turning to prior-authorization programs for help.

“A look at the claims data revealed unwarranted variations in the delivery of care,” she says. Noting Highmark is not unique in seeking to address chiropractic and related care cost issues, Calega says the changes only came about after long discussions with

vendors and other health plans seeking to address the same cost concerns.

Healthways, for instance, has worked on the problem with Blue Cross Blue Shield of Massachusetts, helping the insurer to institute a prior-authorization policy for chiropractic care. Healthways reported on its website that in 2008 the insurer established

a threshold of 12 visits before requiring prior authorization for additional visits. The vendor said the Massachusetts Blues plan saw “substantial” savings and met return-on-investment goals, although it did not disclose specific figures. The insurer did not

return a request for comment on the program.

The prior-authorization program applies to Highmark members in insured groups in Pennsylvania and West Virginia, as well as the plan’s individual and Medicare Advantage members in those areas. Groups that are self-insured may also participate, Highmark says,

and no member will need to take special steps since providers will work directly with Healthways to obtain authorizations via an electronic health record information portal.

Calega stresses that each and every instance of provider care is not subject to prior authorization come Sept. 1; instead the prior-authorization requirement kicks in only after eight visits. “If additional visits are medically necessary, we simply want

to ensure there is a proper and appropriate treatment plan in place,” she says. The insurer’s data points to the fact that nearly two-thirds of members have their chiropractic and physical therapy needs met and resolved within eight visits. “We are not doing

the program to say we want to see ‘X’ number of visits. We know this is a large area of our spending and presents an opportunity for improvement,” Calega says.

Highmark Joins the Crowd

After one year of the prior-authorization program, Highmark will review in aggregate how the process is working and possibly make further changes. The Blues plan also says it is forming a provider advisory group to ensure proper care in an efficient manner.

“We have really spent a lot of time sitting down with the specialty [care] societies before making this public announcement, and they gave us good feedback,” Calega says.

Highmark is not breaking new ground in this space. For example, on Jan. 1, 2011, Blue Cross Blue Shield of Arizona stopped providing its own chiropractic network for PPO members and began using the American Specialty Health network of chiropractors. The

Blues plan cited time-consuming claims processing, claims not being reviewed by chiropractic specialists and chiropractors in the PPO network receiving payment for care that wasn’t a covered service, among other factors.

“Our goal was not only to bend the cost curve but to provide a higher level of service to our members who require chiropractic care by using best-in-class resources that specialize in chiropractic management. All decisions regarding medical necessity are

evidence-based and chiropractors will have the opportunity for peer-to-peer review and discussion with chiropractors,” Arizona Blues spokesperson Regena Frieden tells The AIS Report.

The Blues plan says about 7% of its members use chiropractic services as part of their overall medical care. And before making the change to an outside vendor, billed charges for chiropractic care reached $68 million annually despite the small proportion

of members using such services.

“These costs were unsustainable and impacted the overall costs of health care coverage for everyone,” Frieden says.

[Guest guest]

Stress is one of the causes of subluxations.

Sitting, caffeine, over stimulation, lack of sleep, divorce, conflict, traffic, toxins, etc. etc. etc.

Decreasing stressors helps.

Hard to get rid of enough of them to avoid the body’s overburdened responses.

Increasing coping methods can help.

More water, vegetables, fresh air, exercise, spinal adjustments to restore normal motion, and the company of good friends.

I can honestly tell you that if getting screamed at and flipped off in traffic for making an erroneous lane change were a 5 on a stress level of 0-10, then the stories I’ve read and seen about the Aurora shooting have caused several episodes of 5’s for me this week.

I also don’t think insurance should pay for spinal adjusting, bottled water, health club memberships, or supplements to stay well.

--

E. Abrahamson, D.C.

Chiropractic physician

Lake Oswego Chiropractic Clinic

315 Second Street

Lake Oswego, OR 97034

Website: http://www.lakeoswegochiro.com

Date: Wed, 25 Jul 2012 15:29:19 -0700

To: Pfeiffer

Cc: 'oregondcs DC'S' <oregondcs >

Subject: Re: Frustrating developments...

That's a question I have also. Wasn't there a time in chiropractic when a DC prided him or herself in fixing a person with as little treatment as necessary? It's funny that in many chiro circles you are seen as a great DC if your patients are coming in to see you 100 visits per year. Are those people REALLY getting the most bang for the healthcare buck with all that adjusting? The chiropractic story seems to have become " the body is self-healing and self-regulating as long as you get adjusted 1-2 x per week for the rest of your life " . I don't think there is any evidence to support this concept however. Maybe someone can enlighten me?

Jamey Dyson, DC

HOW MANY DC’S HAVE PATIENTS NEEDING WEEKLY TREATMENTS IF PEROPER MANIPULATION IS PERFORMED????????????

BOB

W. Pfeiffer, D.C., D.A.B.C.O.

Lee Pfeiffer, R.N., B.S.

46 N.E. Mt. Hebron Dr. (no USPS mail)

P.O. Box 606

Pendleton, OR 97801

drbob@...

leernbs@...

All people smile in the same language

From: oregondcs [mailto:oregondcs ] On Behalf Of Jamey Dyson

Sent: Wednesday, July 25, 2012 12:54 PM

To: oregondcs DC'S

Subject: Frustrating developments...

Featured Health Business Daily <http://aishealth.com/enews/businessnews> Story, July 24, 2012

Blues Plans Limit Chiropractic Care, Citing Excessive Costs, Spiking Utilization

Reprinted from THE AIS REPORT ON BLUE CROSS AND BLUE SHIELD PLANS <http://aishealth.com/marketplace/ais-report-blue-cross-and-blue-shield-plans> , a hard-hitting independent monthly newsletter on new products, market share, strategies, conversions, financing, profitability and strategic alliances of BC/BS plans. (Not affiliated with the Blue Cross and Blue Shield Association or its member companies.)

By Connole, Editor - July 2012 - Volume 11 Issue 7

Highmark Inc. is the latest Blues plan to change the way it pays for outpatient, non-emergency physical and occupational therapy and chiropractic care, informing customers on June 19 that beginning Sept. 1, 2012, providers must get prior authorization before performing services in those areas. It also has contracted with vendor Healthways to implement the new requirements. The insurer joins a number of Blues plans from Arizona to Massachusetts that have sought out ways to control costs in this area.

Highmark says it wants to clamp down on members receiving dozens upon dozens of visits with providers performing chiropractic and related services. An analysis by Healthways of initial claims data provided by Highmark indicates a high frequency of visits overall, with a handful of members receiving more than 100 visits over the course of a calendar year, says Olson, director of clinical services for Healthways.

Highmark says the claims analysis put chiropractic care second only to cardiac care as the highest-paid service for members in some practices during the past two years. The insurer adds that in 2010, it paid more than $100 million for chiropractic-related services; in that same year, combined claims data for occupational and physical therapy cost Highmark an additional $100 million.

“Working with our vendor, we believe close to one-third of these claims may not represent optimal utilization,” says Virginia Calega, M.D., Highmark’s vice president of medical management and policy. She tells The AIS Report that Highmark is turning to prior-authorization programs for help.

“A look at the claims data revealed unwarranted variations in the delivery of care,” she says. Noting Highmark is not unique in seeking to address chiropractic and related care cost issues, Calega says the changes only came about after long discussions with vendors and other health plans seeking to address the same cost concerns.

Healthways, for instance, has worked on the problem with Blue Cross Blue Shield of Massachusetts, helping the insurer to institute a prior-authorization policy for chiropractic care. Healthways reported on its website that in 2008 the insurer established a threshold of 12 visits before requiring prior authorization for additional visits. The vendor said the Massachusetts Blues plan saw “substantial” savings and met return-on-investment goals, although it did not disclose specific figures. The insurer did not return a request for comment on the program.

The prior-authorization program applies to Highmark members in insured groups in Pennsylvania and West Virginia, as well as the plan’s individual and Medicare Advantage members in those areas. Groups that are self-insured may also participate, Highmark says, and no member will need to take special steps since providers will work directly with Healthways to obtain authorizations via an electronic health record information portal.

Calega stresses that each and every instance of provider care is not subject to prior authorization come Sept. 1; instead the prior-authorization requirement kicks in only after eight visits. “If additional visits are medically necessary, we simply want to ensure there is a proper and appropriate treatment plan in place,” she says. The insurer’s data points to the fact that nearly two-thirds of members have their chiropractic and physical therapy needs met and resolved within eight visits. “We are not doing the program to say we want to see ‘X’ number of visits. We know this is a large area of our spending and presents an opportunity for improvement,” Calega says.

Highmark Joins the Crowd

After one year of the prior-authorization program, Highmark will review in aggregate how the process is working and possibly make further changes. The Blues plan also says it is forming a provider advisory group to ensure proper care in an efficient manner. “We have really spent a lot of time sitting down with the specialty [care] societies before making this public announcement, and they gave us good feedback,” Calega says.

Highmark is not breaking new ground in this space. For example, on Jan. 1, 2011, Blue Cross Blue Shield of Arizona stopped providing its own chiropractic network for PPO members and began using the American Specialty Health network of chiropractors. The Blues plan cited time-consuming claims processing, claims not being reviewed by chiropractic specialists and chiropractors in the PPO network receiving payment for care that wasn’t a covered service, among other factors.

“Our goal was not only to bend the cost curve but to provide a higher level of service to our members who require chiropractic care by using best-in-class resources that specialize in chiropractic management. All decisions regarding medical necessity are evidence-based and chiropractors will have the opportunity for peer-to-peer review and discussion with chiropractors,” Arizona Blues spokesperson Regena Frieden tells The AIS Report.

The Blues plan says about 7% of its members use chiropractic services as part of their overall medical care. And before making the change to an outside vendor, billed charges for chiropractic care reached $68 million annually despite the small proportion of members using such services.

“These costs were unsustainable and impacted the overall costs of health care coverage for everyone,” Frieden says.

[Guest guest]

I'm not so sure that insurance companies should be footing the bill for maintenance necessarily, especially to the tune of twice per week for a year. However, when someone is injured they undoubtedly should pay and if the patient choice is chiropractic for what ails them and it's a covered service, I find preauthorization absurd and demeaning.I actually feel that they are embellishing the "over use" findings and cost of chiro care. Personally, I'd like to see the entire study or whole body of work in which they've derived these conclusions. Of course there are certain docs ultimately committing fraud, but this is so rampant as to make a change profession wide?I see it simply as bcbs cutting costs with purported justification. They are raising premiums and performing cost saving tactics all across the board. Keep in mind also that physical therapists and others are also on this list.Joe Medlin dcSent from my iPhone

Stress is one of the causes of subluxations.

Sitting, caffeine, over stimulation, lack of sleep, divorce, conflict, traffic, toxins, etc. etc. etc.

Decreasing stressors helps.

Hard to get rid of enough of them to avoid the body’s overburdened responses.

Increasing coping methods can help.

More water, vegetables, fresh air, exercise, spinal adjustments to restore normal motion, and the company of good friends.

I can honestly tell you that if getting screamed at and flipped off in traffic for making an erroneous lane change were a 5 on a stress level of 0-10, then the stories I’ve read and seen about the Aurora shooting have caused several episodes of 5’s for me this week.

I also don’t think insurance should pay for spinal adjusting, bottled water, health club memberships, or supplements to stay well.

--

E. Abrahamson, D.C.

Chiropractic physician

Lake Oswego Chiropractic Clinic

315 Second Street

Lake Oswego, OR 97034

Website: http://www.lakeoswegochiro.com

<image.jpg>

Date: Wed, 25 Jul 2012 15:29:19 -0700

To: Pfeiffer

Cc: 'oregondcs DC'S' <oregondcs >

Subject: Re: Frustrating developments...

That's a question I have also. Wasn't there a time in chiropractic when a DC prided him or herself in fixing a person with as little treatment as necessary? It's funny that in many chiro circles you are seen as a great DC if your patients are coming in to see you 100 visits per year. Are those people REALLY getting the most bang for the healthcare buck with all that adjusting? The chiropractic story seems to have become "the body is self-healing and self-regulating as long as you get adjusted 1-2 x per week for the rest of your life". I don't think there is any evidence to support this concept however. Maybe someone can enlighten me?

Jamey Dyson, DC

HOW MANY DC’S HAVE PATIENTS NEEDING WEEKLY TREATMENTS IF PEROPER MANIPULATION IS PERFORMED????????????

BOB

W. Pfeiffer, D.C., D.A.B.C.O.

Lee Pfeiffer, R.N., B.S.

46 N.E. Mt. Hebron Dr. (no USPS mail)

P.O. Box 606

Pendleton, OR 97801

drbob@...

leernbs@...

All people smile in the same language

From: oregondcs [mailto:oregondcs ] On Behalf Of Jamey Dyson

Sent: Wednesday, July 25, 2012 12:54 PM

To: oregondcs DC'S

Subject: Frustrating developments...

Featured Health Business Daily <http://aishealth.com/enews/businessnews> Story, July 24, 2012

Blues Plans Limit Chiropractic Care, Citing Excessive Costs, Spiking Utilization

Reprinted from THE AIS REPORT ON BLUE CROSS AND BLUE SHIELD PLANS <http://aishealth.com/marketplace/ais-report-blue-cross-and-blue-shield-plans> , a hard-hitting independent monthly newsletter on new products, market share, strategies, conversions, financing, profitability and strategic alliances of BC/BS plans. (Not affiliated with the Blue Cross and Blue Shield Association or its member companies.)

By Connole, Editor - July 2012 - Volume 11 Issue 7

Highmark Inc. is the latest Blues plan to change the way it pays for outpatient, non-emergency physical and occupational therapy and chiropractic care, informing customers on June 19 that beginning Sept. 1, 2012, providers must get prior authorization before performing services in those areas. It also has contracted with vendor Healthways to implement the new requirements. The insurer joins a number of Blues plans from Arizona to Massachusetts that have sought out ways to control costs in this area.

Highmark says it wants to clamp down on members receiving dozens upon dozens of visits with providers performing chiropractic and related services. An analysis by Healthways of initial claims data provided by Highmark indicates a high frequency of visits overall, with a handful of members receiving more than 100 visits over the course of a calendar year, says Olson, director of clinical services for Healthways.

Highmark says the claims analysis put chiropractic care second only to cardiac care as the highest-paid service for members in some practices during the past two years. The insurer adds that in 2010, it paid more than $100 million for chiropractic-related services; in that same year, combined claims data for occupational and physical therapy cost Highmark an additional $100 million.

“Working with our vendor, we believe close to one-third of these claims may not represent optimal utilization,†says Virginia Calega, M.D., Highmark’s vice president of medical management and policy. She tells The AIS Report that Highmark is turning to prior-authorization programs for help.

“A look at the claims data revealed unwarranted variations in the delivery of care,†she says. Noting Highmark is not unique in seeking to address chiropractic and related care cost issues, Calega says the changes only came about after long discussions with vendors and other health plans seeking to address the same cost concerns.

Healthways, for instance, has worked on the problem with Blue Cross Blue Shield of Massachusetts, helping the insurer to institute a prior-authorization policy for chiropractic care. Healthways reported on its website that in 2008 the insurer established a threshold of 12 visits before requiring prior authorization for additional visits. The vendor said the Massachusetts Blues plan saw “substantial†savings and met return-on-investment goals, although it did not disclose specific figures. The insurer did not return a request for comment on the program.

The prior-authorization program applies to Highmark members in insured groups in Pennsylvania and West Virginia, as well as the plan’s individual and Medicare Advantage members in those areas. Groups that are self-insured may also participate, Highmark says, and no member will need to take special steps since providers will work directly with Healthways to obtain authorizations via an electronic health record information portal.

Calega stresses that each and every instance of provider care is not subject to prior authorization come Sept. 1; instead the prior-authorization requirement kicks in only after eight visits. “If additional visits are medically necessary, we simply want to ensure there is a proper and appropriate treatment plan in place,†she says. The insurer’s data points to the fact that nearly two-thirds of members have their chiropractic and physical therapy needs met and resolved within eight visits. “We are not doing the program to say we want to see ‘X’ number of visits. We know this is a large area of our spending and presents an opportunity for improvement,†Calega says.

Highmark Joins the Crowd

After one year of the prior-authorization program, Highmark will review in aggregate how the process is working and possibly make further changes. The Blues plan also says it is forming a provider advisory group to ensure proper care in an efficient manner. “We have really spent a lot of time sitting down with the specialty [care] societies before making this public announcement, and they gave us good feedback,†Calega says.

Highmark is not breaking new ground in this space. For example, on Jan. 1, 2011, Blue Cross Blue Shield of Arizona stopped providing its own chiropractic network for PPO members and began using the American Specialty Health network of chiropractors. The Blues plan cited time-consuming claims processing, claims not being reviewed by chiropractic specialists and chiropractors in the PPO network receiving payment for care that wasn’t a covered service, among other factors.

“Our goal was not only to bend the cost curve but to provide a higher level of service to our members who require chiropractic care by using best-in-class resources that specialize in chiropractic management. All decisions regarding medical necessity are evidence-based and chiropractors will have the opportunity for peer-to-peer review and discussion with chiropractors,†Arizona Blues spokesperson Regena Frieden tells The AIS Report.

The Blues plan says about 7% of its members use chiropractic services as part of their overall medical care. And before making the change to an outside vendor, billed charges for chiropractic care reached $68 million annually despite the small proportion of members using such services.

“These costs were unsustainable and impacted the overall costs of health care coverage for everyone,†Frieden says.

[Guest guest]

Good that you don’t think that “insurance companies should be footing the bill for maintenance”, since you would need to send in the Dx. Of subluxation only which wouldn’t get paid.

People are taking pharmaceuticals on a maintenance dose for years with no attempt to try the myriad alternative behaviors. 2 wrongs not = 1 right, etc.

--

E. Abrahamson, D.C.

Chiropractic physician

Lake Oswego Chiropractic Clinic

315 Second Street

Lake Oswego, OR 97034

Website: http://www.lakeoswegochiro.com

Date: Wed, 25 Jul 2012 18:13:33 -0700

To: Abrahamson

Cc: Jamey Dyson , oregondcs DC'S <oregondcs >

Subject: Re: Frustrating developments...

I'm not so sure that insurance companies should be footing the bill for maintenance necessarily, especially to the tune of twice per week for a year. However, when someone is injured they undoubtedly should pay and if the patient choice is chiropractic for what ails them and it's a covered service, I find preauthorization absurd and demeaning.

I actually feel that they are embellishing the " over use " findings and cost of chiro care. Personally, I'd like to see the entire study or whole body of work in which they've derived these conclusions. Of course there are certain docs ultimately committing fraud, but this is so rampant as to make a change profession wide?

I see it simply as bcbs cutting costs with purported justification. They are raising premiums and performing cost saving tactics all across the board. Keep in mind also that physical therapists and others are also on this list.

Joe Medlin dc

Sent from my iPhone

Stress is one of the causes of subluxations.

Sitting, caffeine, over stimulation, lack of sleep, divorce, conflict, traffic, toxins, etc. etc. etc.

Decreasing stressors helps.

Hard to get rid of enough of them to avoid the body’s overburdened responses.

Increasing coping methods can help.

More water, vegetables, fresh air, exercise, spinal adjustments to restore normal motion, and the company of good friends.

I can honestly tell you that if getting screamed at and flipped off in traffic for making an erroneous lane change were a 5 on a stress level of 0-10, then the stories I’ve read and seen about the Aurora shooting have caused several episodes of 5’s for me this week.

I also don’t think insurance should pay for spinal adjusting, bottled water, health club memberships, or supplements to stay well.

--

E. Abrahamson, D.C.

Chiropractic physician

Lake Oswego Chiropractic Clinic

315 Second Street

Lake Oswego, OR 97034

Website: http://www.lakeoswegochiro.com

<image.jpg>

Date: Wed, 25 Jul 2012 15:29:19 -0700

To: Pfeiffer

Cc: 'oregondcs DC'S' <oregondcs >

Subject: Re: Frustrating developments...

That's a question I have also. Wasn't there a time in chiropractic when a DC prided him or herself in fixing a person with as little treatment as necessary? It's funny that in many chiro circles you are seen as a great DC if your patients are coming in to see you 100 visits per year. Are those people REALLY getting the most bang for the healthcare buck with all that adjusting? The chiropractic story seems to have become " the body is self-healing and self-regulating as long as you get adjusted 1-2 x per week for the rest of your life " . I don't think there is any evidence to support this concept however. Maybe someone can enlighten me?

Jamey Dyson, DC

HOW MANY DC’S HAVE PATIENTS NEEDING WEEKLY TREATMENTS IF PEROPER MANIPULATION IS PERFORMED????????????

BOB

W. Pfeiffer, D.C., D.A.B.C.O.

Lee Pfeiffer, R.N., B.S.

46 N.E. Mt. Hebron Dr. (no USPS mail)

P.O. Box 606

Pendleton, OR 97801

drbob@...

leernbs@...

All people smile in the same language

From: oregondcs [mailto:oregondcs ] On Behalf Of Jamey Dyson

Sent: Wednesday, July 25, 2012 12:54 PM

To: oregondcs DC'S

Subject: Frustrating developments...

Featured Health Business Daily <http://aishealth.com/enews/businessnews> Story, July 24, 2012

Blues Plans Limit Chiropractic Care, Citing Excessive Costs, Spiking Utilization

Reprinted from THE AIS REPORT ON BLUE CROSS AND BLUE SHIELD PLANS <http://aishealth.com/marketplace/ais-report-blue-cross-and-blue-shield-plans> , a hard-hitting independent monthly newsletter on new products, market share, strategies, conversions, financing, profitability and strategic alliances of BC/BS plans. (Not affiliated with the Blue Cross and Blue Shield Association or its member companies.)

By Connole, Editor - July 2012 - Volume 11 Issue 7

Highmark Inc. is the latest Blues plan to change the way it pays for outpatient, non-emergency physical and occupational therapy and chiropractic care, informing customers on June 19 that beginning Sept. 1, 2012, providers must get prior authorization before performing services in those areas. It also has contracted with vendor Healthways to implement the new requirements. The insurer joins a number of Blues plans from Arizona to Massachusetts that have sought out ways to control costs in this area.

Highmark says it wants to clamp down on members receiving dozens upon dozens of visits with providers performing chiropractic and related services. An analysis by Healthways of initial claims data provided by Highmark indicates a high frequency of visits overall, with a handful of members receiving more than 100 visits over the course of a calendar year, says Olson, director of clinical services for Healthways.

Highmark says the claims analysis put chiropractic care second only to cardiac care as the highest-paid service for members in some practices during the past two years. The insurer adds that in 2010, it paid more than $100 million for chiropractic-related services; in that same year, combined claims data for occupational and physical therapy cost Highmark an additional $100 million.

“Working with our vendor, we believe close to one-third of these claims may not represent optimal utilization,” says Virginia Calega, M.D., Highmark’s vice president of medical management and policy. She tells The AIS Report that Highmark is turning to prior-authorization programs for help.

“A look at the claims data revealed unwarranted variations in the delivery of care,” she says. Noting Highmark is not unique in seeking to address chiropractic and related care cost issues, Calega says the changes only came about after long discussions with vendors and other health plans seeking to address the same cost concerns.

Healthways, for instance, has worked on the problem with Blue Cross Blue Shield of Massachusetts, helping the insurer to institute a prior-authorization policy for chiropractic care. Healthways reported on its website that in 2008 the insurer established a threshold of 12 visits before requiring prior authorization for additional visits. The vendor said the Massachusetts Blues plan saw “substantial” savings and met return-on-investment goals, although it did not disclose specific figures. The insurer did not return a request for comment on the program.

The prior-authorization program applies to Highmark members in insured groups in Pennsylvania and West Virginia, as well as the plan’s individual and Medicare Advantage members in those areas. Groups that are self-insured may also participate, Highmark says, and no member will need to take special steps since providers will work directly with Healthways to obtain authorizations via an electronic health record information portal.

Calega stresses that each and every instance of provider care is not subject to prior authorization come Sept. 1; instead the prior-authorization requirement kicks in only after eight visits. “If additional visits are medically necessary, we simply want to ensure there is a proper and appropriate treatment plan in place,” she says. The insurer’s data points to the fact that nearly two-thirds of members have their chiropractic and physical therapy needs met and resolved within eight visits. “We are not doing the program to say we want to see ‘X’ number of visits. We know this is a large area of our spending and presents an opportunity for improvement,” Calega says.

Highmark Joins the Crowd

After one year of the prior-authorization program, Highmark will review in aggregate how the process is working and possibly make further changes. The Blues plan also says it is forming a provider advisory group to ensure proper care in an efficient manner. “We have really spent a lot of time sitting down with the specialty [care] societies before making this public announcement, and they gave us good feedback,” Calega says.

Highmark is not breaking new ground in this space. For example, on Jan. 1, 2011, Blue Cross Blue Shield of Arizona stopped providing its own chiropractic network for PPO members and began using the American Specialty Health network of chiropractors. The Blues plan cited time-consuming claims processing, claims not being reviewed by chiropractic specialists and chiropractors in the PPO network receiving payment for care that wasn’t a covered service, among other factors.

“Our goal was not only to bend the cost curve but to provide a higher level of service to our members who require chiropractic care by using best-in-class resources that specialize in chiropractic management. All decisions regarding medical necessity are evidence-based and chiropractors will have the opportunity for peer-to-peer review and discussion with chiropractors,” Arizona Blues spokesperson Regena Frieden tells The AIS Report.

The Blues plan says about 7% of its members use chiropractic services as part of their overall medical care. And before making the change to an outside vendor, billed charges for chiropractic care reached $68 million annually despite the small proportion of members using such services.

“These costs were unsustainable and impacted the overall costs of health care coverage for everyone,” Frieden says.

[Guest guest]

This isn't just about greedy chiros over-treating. What about the insurers? Do they just blindly pay for 100 visits/year? Really? What are the diagnoses? Where are the utilization guidelines? Am I being cynical in believing the insurers were really asleep at the wheel (doubtful) or were they just trying to give our profession enough rope to hang ourselves? "See, you just can't trust those Chiropractors!" Seitz, DC Tuality Physicians 730-D SE Oak St Hillsboro, OR 97123 (503)640-3724CC: drjdyson1@...; drbob@...; oregondcs To: drscott@...From: spinetree@...Date: Wed, 25 Jul 2012 18:13:33 -0700Subject: Re: Frustrating developments...

I'm not so sure that insurance companies should be footing the bill for maintenance necessarily, especially to the tune of twice per week for a year. However, when someone is injured they undoubtedly should pay and if the patient choice is chiropractic for what ails them and it's a covered service, I find preauthorization absurd and demeaning.I actually feel that they are embellishing the "over use" findings and cost of chiro care. Personally, I'd like to see the entire study or whole body of work in which they've derived these conclusions. Of course there are certain docs ultimately committing fraud, but this is so rampant as to make a change profession wide?I see it simply as bcbs cutting costs with purported justification. They are raising premiums and performing cost saving tactics all across the board. Keep in mind also that physical therapists and others are also on this list.Joe Medlin dcSent from my iPhone

Stress is one of the causes of subluxations.

Sitting, caffeine, over stimulation, lack of sleep, divorce, conflict, traffic, toxins, etc. etc. etc.

Decreasing stressors helps.

Hard to get rid of enough of them to avoid the body’s overburdened responses.

Increasing coping methods can help.

More water, vegetables, fresh air, exercise, spinal adjustments to restore normal motion, and the company of good friends.

I can honestly tell you that if getting screamed at and flipped off in traffic for making an erroneous lane change were a 5 on a stress level of 0-10, then the stories I’ve read and seen about the Aurora shooting have caused several episodes of 5’s for me this week.

I also don’t think insurance should pay for spinal adjusting, bottled water, health club memberships, or supplements to stay well.

--

E. Abrahamson, D.C.

Chiropractic physician

Lake Oswego Chiropractic Clinic

315 Second Street

Lake Oswego, OR 97034

Website: http://www.lakeoswegochiro.com

<image.jpg>

Date: Wed, 25 Jul 2012 15:29:19 -0700

To: Pfeiffer

Cc: 'oregondcs DC'S' <oregondcs >

Subject: Re: Frustrating developments...

That's a question I have also. Wasn't there a time in chiropractic when a DC prided him or herself in fixing a person with as little treatment as necessary? It's funny that in many chiro circles you are seen as a great DC if your patients are coming in to see you 100 visits per year. Are those people REALLY getting the most bang for the healthcare buck with all that adjusting? The chiropractic story seems to have become "the body is self-healing and self-regulating as long as you get adjusted 1-2 x per week for the rest of your life". I don't think there is any evidence to support this concept however. Maybe someone can enlighten me?

Jamey Dyson, DC

HOW MANY DC’S HAVE PATIENTS NEEDING WEEKLY TREATMENTS IF PEROPER MANIPULATION IS PERFORMED????????????

BOB

W. Pfeiffer, D.C., D.A.B.C.O.

Lee Pfeiffer, R.N., B.S.

46 N.E. Mt. Hebron Dr. (no USPS mail)

P.O. Box 606

Pendleton, OR 97801

drbob@...

leernbs@...

All people smile in the same language

From: oregondcs [mailto:oregondcs ] On Behalf Of Jamey Dyson

Sent: Wednesday, July 25, 2012 12:54 PM

To: oregondcs DC'S

Subject: Frustrating developments...

Featured Health Business Daily <http://aishealth.com/enews/businessnews> Story, July 24, 2012

Blues Plans Limit Chiropractic Care, Citing Excessive Costs, Spiking Utilization

Reprinted from THE AIS REPORT ON BLUE CROSS AND BLUE SHIELD PLANS <http://aishealth.com/marketplace/ais-report-blue-cross-and-blue-shield-plans> , a hard-hitting independent monthly newsletter on new products, market share, strategies, conversions, financing, profitability and strategic alliances of BC/BS plans. (Not affiliated with the Blue Cross and Blue Shield Association or its member companies.)

By Connole, Editor - July 2012 - Volume 11 Issue 7

Highmark Inc. is the latest Blues plan to change the way it pays for outpatient, non-emergency physical and occupational therapy and chiropractic care, informing customers on June 19 that beginning Sept. 1, 2012, providers must get prior authorization before performing services in those areas. It also has contracted with vendor Healthways to implement the new requirements. The insurer joins a number of Blues plans from Arizona to Massachusetts that have sought out ways to control costs in this area.

Highmark says it wants to clamp down on members receiving dozens upon dozens of visits with providers performing chiropractic and related services. An analysis by Healthways of initial claims data provided by Highmark indicates a high frequency of visits overall, with a handful of members receiving more than 100 visits over the course of a calendar year, says Olson, director of clinical services for Healthways.

Highmark says the claims analysis put chiropractic care second only to cardiac care as the highest-paid service for members in some practices during the past two years. The insurer adds that in 2010, it paid more than $100 million for chiropractic-related services; in that same year, combined claims data for occupational and physical therapy cost Highmark an additional $100 million.

“Working with our vendor, we believe close to one-third of these claims may not represent optimal utilization,” says Virginia Calega, M.D., Highmark’s vice president of medical management and policy. She tells The AIS Report that Highmark is turning to prior-authorization programs for help.

“A look at the claims data revealed unwarranted variations in the delivery of care,” she says. Noting Highmark is not unique in seeking to address chiropractic and related care cost issues, Calega says the changes only came about after long discussions with vendors and other health plans seeking to address the same cost concerns.

Healthways, for instance, has worked on the problem with Blue Cross Blue Shield of Massachusetts, helping the insurer to institute a prior-authorization policy for chiropractic care. Healthways reported on its website that in 2008 the insurer established a threshold of 12 visits before requiring prior authorization for additional visits. The vendor said the Massachusetts Blues plan saw “substantial” savings and met return-on-investment goals, although it did not disclose specific figures. The insurer did not return a request for comment on the program.

The prior-authorization program applies to Highmark members in insured groups in Pennsylvania and West Virginia, as well as the plan’s individual and Medicare Advantage members in those areas. Groups that are self-insured may also participate, Highmark says, and no member will need to take special steps since providers will work directly with Healthways to obtain authorizations via an electronic health record information portal.

Calega stresses that each and every instance of provider care is not subject to prior authorization come Sept. 1; instead the prior-authorization requirement kicks in only after eight visits. “If additional visits are medically necessary, we simply want to ensure there is a proper and appropriate treatment plan in place,” she says. The insurer’s data points to the fact that nearly two-thirds of members have their chiropractic and physical therapy needs met and resolved within eight visits. “We are not doing the program to say we want to see ‘X’ number of visits. We know this is a large area of our spending and presents an opportunity for improvement,” Calega says.

Highmark Joins the Crowd

After one year of the prior-authorization program, Highmark will review in aggregate how the process is working and possibly make further changes. The Blues plan also says it is forming a provider advisory group to ensure proper care in an efficient manner. “We have really spent a lot of time sitting down with the specialty [care] societies before making this public announcement, and they gave us good feedback,” Calega says.

Highmark is not breaking new ground in this space. For example, on Jan. 1, 2011, Blue Cross Blue Shield of Arizona stopped providing its own chiropractic network for PPO members and began using the American Specialty Health network of chiropractors. The Blues plan cited time-consuming claims processing, claims not being reviewed by chiropractic specialists and chiropractors in the PPO network receiving payment for care that wasn’t a covered service, among other factors.

“Our goal was not only to bend the cost curve but to provide a higher level of service to our members who require chiropractic care by using best-in-class resources that specialize in chiropractic management. All decisions regarding medical necessity are evidence-based and chiropractors will have the opportunity for peer-to-peer review and discussion with chiropractors,” Arizona Blues spokesperson Regena Frieden tells The AIS Report.

The Blues plan says about 7% of its members use chiropractic services as part of their overall medical care. And before making the change to an outside vendor, billed charges for chiropractic care reached $68 million annually despite the small proportion of members using such services.

“These costs were unsustainable and impacted the overall costs of health care coverage for everyone,” Frieden says.

[Guest guest]

Yeah ... I have trouble beleiving their figures as well. Only 7% of their subscribers use our services and they acknowledged the offenders are only a portion of that amount yet their overall billing was 68 mill? hmmmmmm How is going after the few not a more appropriate answer? skSunny Kierstyn, RN DC Fibromyalgia Care Center of Oregon 2677 Willakenzie Road, 7CEugene, Oregon, 97401541- 654-0850; Fx; 541- 654-0834www.drsunnykierstyn.com To: drjdyson1@...; oregondcs From: drbob@...Date: Wed, 25 Jul 2012 14:34:10 -0700Subject: RE: Frustrating developments...

HOW MANY DC’S HAVE PATIENTS NEEDING WEEKLY TREATMENTS IF PEROPER MANIPULATION IS PERFORMED???????????? BOB W. Pfeiffer, D.C., D.A.B.C.O.Lee Pfeiffer, R.N., B.S.46 N.E. Mt. Hebron Dr. (no USPS mail)P.O. Box 606 Pendleton, OR 97801drbob@...leernbs@... All people smile in the same language From: oregondcs [mailto:oregondcs ] On Behalf Of Jamey DysonSent: Wednesday, July 25, 2012 12:54 PMTo: oregondcs DC'SSubject: Frustrating developments... Featured Health Business Daily Story, July 24, 2012Blues Plans Limit Chiropractic Care, Citing Excessive Costs, Spiking UtilizationReprinted from THE AIS REPORT ON BLUE CROSS AND BLUE SHIELD PLANS, a hard-hitting independent monthly newsletter on new products, market share, strategies, conversions, financing, profitability and strategic alliances of BC/BS plans. (Not affiliated with the Blue Cross and Blue Shield Association or its member companies.)By Connole, Editor - July 2012 - Volume 11 Issue 7 Highmark Inc. is the latest Blues plan to change the way it pays for outpatient, non-emergency physical and occupational therapy and chiropractic care, informing customers on June 19 that beginning Sept. 1, 2012, providers must get prior authorization before performing services in those areas. It also has contracted with vendor Healthways to implement the new requirements. The insurer joins a number of Blues plans from Arizona to Massachusetts that have sought out ways to control costs in this area.Highmark says it wants to clamp down on members receiving dozens upon dozens of visits with providers performing chiropractic and related services. An analysis by Healthways of initial claims data provided by Highmark indicates a high frequency of visits overall, with a handful of members receiving more than 100 visits over the course of a calendar year, says Olson, director of clinical services for Healthways.Highmark says the claims analysis put chiropractic care second only to cardiac care as the highest-paid service for members in some practices during the past two years. The insurer adds that in 2010, it paid more than $100 million for chiropractic-related services; in that same year, combined claims data for occupational and physical therapy cost Highmark an additional $100 million.“Working with our vendor, we believe close to one-third of these claims may not represent optimal utilization,” says Virginia Calega, M.D., Highmark’s vice president of medical management and policy. She tells The AIS Report that Highmark is turning to prior-authorization programs for help.“A look at the claims data revealed unwarranted variations in the delivery of care,” she says. Noting Highmark is not unique in seeking to address chiropractic and related care cost issues, Calega says the changes only came about after long discussions with vendors and other health plans seeking to address the same cost concerns.Healthways, for instance, has worked on the problem with Blue Cross Blue Shield of Massachusetts, helping the insurer to institute a prior-authorization policy for chiropractic care. Healthways reported on its website that in 2008 the insurer established a threshold of 12 visits before requiring prior authorization for additional visits. The vendor said the Massachusetts Blues plan saw “substantial” savings and met return-on-investment goals, although it did not disclose specific figures. The insurer did not return a request for comment on the program.The prior-authorization program applies to Highmark members in insured groups in Pennsylvania and West Virginia, as well as the plan’s individual and Medicare Advantage members in those areas. Groups that are self-insured may also participate, Highmark says, and no member will need to take special steps since providers will work directly with Healthways to obtain authorizations via an electronic health record information portal.Calega stresses that each and every instance of provider care is not subject to prior authorization come Sept. 1; instead the prior-authorization requirement kicks in only after eight visits. “If additional visits are medically necessary, we simply want to ensure there is a proper and appropriate treatment plan in place,” she says. The insurer’s data points to the fact that nearly two-thirds of members have their chiropractic and physical therapy needs met and resolved within eight visits. “We are not doing the program to say we want to see ‘X’ number of visits. We know this is a large area of our spending and presents an opportunity for improvement,” Calega says.Highmark Joins the CrowdAfter one year of the prior-authorization program, Highmark will review in aggregate how the process is working and possibly make further changes. The Blues plan also says it is forming a provider advisory group to ensure proper care in an efficient manner. “We have really spent a lot of time sitting down with the specialty [care] societies before making this public announcement, and they gave us good feedback,” Calega says.Highmark is not breaking new ground in this space. For example, on Jan. 1, 2011, Blue Cross Blue Shield of Arizona stopped providing its own chiropractic network for PPO members and began using the American Specialty Health network of chiropractors. The Blues plan cited time-consuming claims processing, claims not being reviewed by chiropractic specialists and chiropractors in the PPO network receiving payment for care that wasn’t a covered service, among other factors.“Our goal was not only to bend the cost curve but to provide a higher level of service to our members who require chiropractic care by using best-in-class resources that specialize in chiropractic management. All decisions regarding medical necessity are evidence-based and chiropractors will have the opportunity for peer-to-peer review and discussion with chiropractors,” Arizona Blues spokesperson Regena Frieden tells The AIS Report.The Blues plan says about 7% of its members use chiropractic services as part of their overall medical care. And before making the change to an outside vendor, billed charges for chiropractic care reached $68 million annually despite the small proportion of members using such services.“These costs were unsustainable and impacted the overall costs of health care coverage for everyone,” Frieden says.

[Guest guest]

I agree that the numbers are probably exaggerated, as this is an article coming from the health insurance company. To contain costs, they could have simply put a cap on visits per year and $ per visit. But instead, they are subcontracting chiro care and PT to Healthways, which I assume is like ASHN. It makes me wonder what kind of financial relationship exists when insurance companies get into those types of relationships. If this trend continues across the country, then we all need to prepare for cash practice, IMHO.Jamey Dyson, DC

Yeah ... I have trouble beleiving their figures as well. Only 7% of their subscribers use our services and they acknowledged the offenders are only a portion of that amount yet their overall billing was 68 mill? hmmmmmm How is going after the few not a more appropriate answer? skSunny Kierstyn, RN DC Fibromyalgia Care Center of Oregon 2677 Willakenzie Road, 7CEugene, Oregon, 97401541- 654-0850; Fx; 541- 654-0834www.drsunnykierstyn.com To: drjdyson1@...; oregondcs From: drbob@...Date: Wed, 25 Jul 2012 14:34:10 -0700Subject: RE: Frustrating developments...

HOW MANY DC’S HAVE PATIENTS NEEDING WEEKLY TREATMENTS IF PEROPER MANIPULATION IS PERFORMED???????????? BOB W. Pfeiffer, D.C., D.A.B.C.O.Lee Pfeiffer, R.N., B.S.46 N.E. Mt. Hebron Dr. (no USPS mail)P.O. Box 606 Pendleton, OR 97801drbob@...leernbs@... All people smile in the same language From: oregondcs [mailto:oregondcs ] On Behalf Of Jamey DysonSent: Wednesday, July 25, 2012 12:54 PMTo: oregondcs DC'SSubject: Frustrating developments... Featured Health Business Daily Story, July 24, 2012Blues Plans Limit Chiropractic Care, Citing Excessive Costs, Spiking UtilizationReprinted from THE AIS REPORT ON BLUE CROSS AND BLUE SHIELD PLANS, a hard-hitting independent monthly newsletter on new products, market share, strategies, conversions, financing, profitability and strategic alliances of BC/BS plans. (Not affiliated with the Blue Cross and Blue Shield Association or its member companies.)By Connole, Editor - July 2012 - Volume 11 Issue 7 Highmark Inc. is the latest Blues plan to change the way it pays for outpatient, non-emergency physical and occupational therapy and chiropractic care, informing customers on June 19 that beginning Sept. 1, 2012, providers must get prior authorization before performing services in those areas. It also has contracted with vendor Healthways to implement the new requirements. The insurer joins a number of Blues plans from Arizona to Massachusetts that have sought out ways to control costs in this area.Highmark says it wants to clamp down on members receiving dozens upon dozens of visits with providers performing chiropractic and related services. An analysis by Healthways of initial claims data provided by Highmark indicates a high frequency of visits overall, with a handful of members receiving more than 100 visits over the course of a calendar year, says Olson, director of clinical services for Healthways.Highmark says the claims analysis put chiropractic care second only to cardiac care as the highest-paid service for members in some practices during the past two years. The insurer adds that in 2010, it paid more than $100 million for chiropractic-related services; in that same year, combined claims data for occupational and physical therapy cost Highmark an additional $100 million.“Working with our vendor, we believe close to one-third of these claims may not represent optimal utilization,” says Virginia Calega, M.D., Highmark’s vice president of medical management and policy. She tells The AIS Report that Highmark is turning to prior-authorization programs for help.“A look at the claims data revealed unwarranted variations in the delivery of care,” she says. Noting Highmark is not unique in seeking to address chiropractic and related care cost issues, Calega says the changes only came about after long discussions with vendors and other health plans seeking to address the same cost concerns.Healthways, for instance, has worked on the problem with Blue Cross Blue Shield of Massachusetts, helping the insurer to institute a prior-authorization policy for chiropractic care. Healthways reported on its website that in 2008 the insurer established a threshold of 12 visits before requiring prior authorization for additional visits. The vendor said the Massachusetts Blues plan saw “substantial” savings and met return-on-investment goals, although it did not disclose specific figures. The insurer did not return a request for comment on the program.The prior-authorization program applies to Highmark members in insured groups in Pennsylvania and West Virginia, as well as the plan’s individual and Medicare Advantage members in those areas. Groups that are self-insured may also participate, Highmark says, and no member will need to take special steps since providers will work directly with Healthways to obtain authorizations via an electronic health record information portal.Calega stresses that each and every instance of provider care is not subject to prior authorization come Sept. 1; instead the prior-authorization requirement kicks in only after eight visits. “If additional visits are medically necessary, we simply want to ensure there is a proper and appropriate treatment plan in place,” she says. The insurer’s data points to the fact that nearly two-thirds of members have their chiropractic and physical therapy needs met and resolved within eight visits. “We are not doing the program to say we want to see ‘X’ number of visits. We know this is a large area of our spending and presents an opportunity for improvement,” Calega says.Highmark Joins the CrowdAfter one year of the prior-authorization program, Highmark will review in aggregate how the process is working and possibly make further changes. The Blues plan also says it is forming a provider advisory group to ensure proper care in an efficient manner. “We have really spent a lot of time sitting down with the specialty [care] societies before making this public announcement, and they gave us good feedback,” Calega says.Highmark is not breaking new ground in this space. For example, on Jan. 1, 2011, Blue Cross Blue Shield of Arizona stopped providing its own chiropractic network for PPO members and began using the American Specialty Health network of chiropractors. The Blues plan cited time-consuming claims processing, claims not being reviewed by chiropractic specialists and chiropractors in the PPO network receiving payment for care that wasn’t a covered service, among other factors.“Our goal was not only to bend the cost curve but to provide a higher level of service to our members who require chiropractic care by using best-in-class resources that specialize in chiropractic management. All decisions regarding medical necessity are evidence-based and chiropractors will have the opportunity for peer-to-peer review and discussion with chiropractors,” Arizona Blues spokesperson Regena Frieden tells The AIS Report.The Blues plan says about 7% of its members use chiropractic services as part of their overall medical care. And before making the change to an outside vendor, billed charges for chiropractic care reached $68 million annually despite the small proportion of members using such services.“These costs were unsustainable and impacted the overall costs of health care coverage for everyone,” Frieden says.