Alternative link: creating a reimbursement system for alternative medicine; Payment codes will foster the future growth of alternative medicine and the natural products industry.

Complementary and alternative medicine (CAM) has grown rapidly over the last decade, in tandem with the growth of the natural products industry. But the further expansion of CAM and natural therapeutics has been hindered by a lack of insurance reimbursement for the vast majority of its services and goods, including nutrition counseling and dietary supplements. There are clear and promising signs, however, that insurers, federal agencies, and even the American Medical Association (AMA), are looking for ways to address that roadblock. An effective solution to the problem could be a major boon for the natural products industry.

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Creating Alternative Link

Reimbursement for conventional medicine as practiced by the nation's 700,000-plus MDs and DOs is governed by the Current Procedural Terminology (CPT) codes, which describe all of the various services, operations and therapies used by physicians for which reimbursement is deemed appropriate. The CPT codes are a proprietary property of the AMA, and defined by a closed-door committee jointly run by the AMA and the Center for Medicare and Medicaid Services. CPT codes form the bedrock of the nation's health insurance payment system, and are used for all Medicare, Medicaid, indemnity and HMO transactions.

The overwhelming majority of practices in the realm of holistic/alternative medicine are not included in the current CPT coding system. Wide-spread insurance reimbursement for CAM cannot become a reality until there are well-defined reimbursement codes to describe these services. Clearly, and perhaps not surprisingly, the CPT editorial committee has not kept pace with the public's demand for greater access to holistic health services.

Alternative Link, a company based in Albuquerque, NM, has attempted to address the absence of appropriate CAM codes by creating a comprehensive set of more than 4000 5-letter codes to describe nearly every healing modality practiced by alternative healthcare providers. Roughly analogous to the 5-digit CPT system, Alternative Link's "Alternative Billing Concept (ABC)" codes cover the 80% of healthcare practitioner--nurses, massage therapists, chiropractors, naturopaths, acupuncturists, nutritionists, medical herbalists and others--not currently covered by CPT.

The ABC code system is linked to a powerful database called Health Intel, which among other things defines the legal scope of practice for various CAM professionals according to the individual laws of the 50 states.

According to Synthia Molina, Alternative Link's CEO, the absence of codes for holistic health services has created many roadblocks to integrative healthcare. Without specific codes, it is nearly impossible to do the kind of outcomes research that could determine the precise role of natural therapeutics in management of common diseases. Many alternative practitioners, including MDs who practice holistic modalities, have tried to obtain reimbursement by using a handful of non-specific codes in the CPT system. But this frequently throws claims into manual review, creating administrative hassles.

Ms. Molina explained that from a health insurer's perspective, if it can't be coded, it doesn't really exist. Introduction of new codes into the CPT system is an arduous process, even within conventional medicine. "Historically, the AMA and the Department of Health and Human Services (HHS) have created prevalence requirements: You have to prove something is widely used before the CPT committee will even consider creating a reimbursement code for it. But everyone, healthcare plans and physicians alike, wants to know that there is an established code and payment mechanism before they start to utilize a new modality or service. It is something of a Catch 22," said Ms. Molina.

The ABC codes are the fruit of more than 10 years' work by Melinna Giannini, formerly an insurance administrator, and her colleagues. Ms. Giannini realized the need for a new coding system when she required treatment for a serious kidney disease. She realized then that insurers were willing to spend tens of thousands of dollars on costly, high-tech acute care, but almost nothing on prevention-oriented natural medicine and self-care. She understood that from an administrative viewpoint, insurers had no mechanism for dealing with preventive medicine, even if they saw the value in it.

She set about developing a code set based on a five-character system like CPT, but using letters rather than numbers. Each ABC code defines a specific service and also the type of practitioner delivering it.

The Next Steps

Over the last few years, Alternative Link has had ongoing meetings with high-ranking officials within HHS in an effort to bring the ABC system into the nation's Medicare/Medicaid program. Ms. Molina reports that the ABC codes have strong support from a number of policymakers in Washington, D.C., including HHS Secretary Tommy Thompson and Rep. Frank Pallone (D-NJ).

Last year, Secretary Thompson committed to an evaluation of ABC as a freestanding and independent coding system with an eye toward possible incorporation into Medicare and Medicaid at some future date. This led to a pilot project involving clinics around the country that will use the codes in electronic claims transactions. HHS will be able to assess how well the codes work in real world practice.

The federal government is also pushing the AMA to address the issue of codes for holistic healthcare. Last year, the National Committee on Vital and Health Statistics (NCVHS)--a public advisory committee to HHS Secretary Thompson--advised AMA to meet with Alternative Link to see if the ABC codes could be harmonized with the existing CPT system. HHS asked the CPT editorial committee to either work with Alternative Link or develop a comparable set of codes themselves.

Although representatives of Alternative Link have met with members of the CPT editorial committee several times, and the correspondence is ongoing, Ms. Molina said that it appears that AMA is more inclined to pursue the second option.

In recent months, AMA has brought a number of non-MD healthcare professionals into the CPT code-making process. The Health Care Professionals Advisory Committee (HCPAC) is composed of 20 non-MD or DO health professionals assembled to advise the CPT Editorial Panel on codes for non-conventional care. Most of the major licensed CAM professions, including chiropractors, acupuncturists and massage therapists are represented. And most recently, Bruce Milliman, ND, joined HCPAC, as a representative of the American Association of Naturopathic Physicians.

The CPT committee appears to be negotiating in good faith with members of HCPAC on the development of meaningful codes. The timeline for establishment of a full coding set, however, is another question. Alternative Link's Ms. Molina doesn't expect that AMA will move very quickly.

"One of their (AMA's) prime sources of revenue is the licensing fees for their codes and coding manuals," Ms. Molina said. "The existence of codes in integrative medicine could displace services provided by their membership." She said Alternative Link would welcome the opportunity to integrate their codes and the Health Intel database with the existing CPT system, making for a comprehensive platform for reimbursement. But she's not counting on it.

At the conclusion of the ABC codes pilot project, HHS may ultimately determine that this coding set is a legitimate, well-wrought system that should be adopted by healthcare payors. It remains to be seen whether the AMA's CPT committee will ultimately choose to work with Alternative Link, or to continue with the endeavor of creating CAM codes on its own.

While Alternative Link certainly has its fans within the ranks of alternative medicine, it also has its critics. Leaders of some CAM professional trade organizations hold that Alternative Link worked too independently in creation of their code set, and did not build a strong enough consensus between the various professions. The ABC codes have support from many professional associations, but they have not yet had buy in from several major organizations, including the American Chiropractic Association, the American Association of Naturopathic Physicians, as well as several of the organizations representing licensed acupuncturists.

The Future

The development of reimbursement codes is founded on the notion that insurance reimbursement for alternative medicine is a good idea. Again, not everyone who practices natural medicine would agree. Given the ways third-party reimbursement systems have turned conventional medicine into a Kafka-esque nightmare of bureaucratic hassles and administrative rigmarole, there are many practitioners of holistic health modalities who are extremely wary.

Alternative Link's Ms. Molina acknowledged the dangers, but she and many other advocates for insurance reimbursement believe it is necessary in order to broaden access to holistic health services, and to pave the way for CAM to truly take its rightful place in the landscape of American medicine. She added that while it is true that third party reimbursement could shake the way many CAM professionals work, it will have equally seismic effects on conventional medicine, as conventional doctors realize that they must contend with the real value that holistic and preventive medicine can bring to the healthcare equation.

Establishment of a solid coding set--whether from Alternative Link, the AMA's CPT committee, or a joint effort from both--is only one step in the direction of insurance reimbursement. Ms. Molina stressed that even in the realm of conventional medicine, it is difficult to persuade insurers to cover a new drug or treatment option. It will be all the more difficult to obtain coverage for holistic practices that come from "outside" the mainstream.

At the same time, health insurance plans--and the large corporations that pay their premiums--are desperate for new strategies to rein in healthcare costs. The preventive, patient-oriented, health maintenance orientation of holistic healthcare modalities certainly has a lot more traction with insurers than it might have 10 or 15 years ago.

Insurance coverage of CAM would certainly foster wider use of these approaches, and this would likely prove to be beneficial not only for the health of our nation, but for the health of the natural products industry as well.

RELATED ARTICLE: This article in a nutshell:

* Creating alternative link

* The next steps

* The future

By Erik Goldman

Editor-in-Chief

Holistic Primary Care--News For Health & Healing

New York, NY

About the author:

Erik Goldman is editor-and-chief of Holistic Primary Care, New York, N.Y. He can be reached at 212-406-8957; Fax: [phone]; E-mail: [e-mail].