Acupuncture and The Insurance Issue: An Inside Look

This post was from Dr. Lisa Nash, a chiropractor in Vermont. It was taken from PerennialMedicine, a listserve on Yahoo for acupuncturists and those who are in a larger conversation about healthcare, as opposed to "fix-it" medicine. Dr. Nash has graciously permitted a reprint of her words.


Dear friends,

I am a chiropractor and so a member of a profession which has gone from being excluded from the insurance game to being a player within the last thirty-some years. While chiropractic and Chinese medicine differ in many important regards, I think some aspects of my profession's experience are likely relevant to you as you--individually and collectively--consider how you want to engage with the insurance industry.

Industry--there's the key word. Insurance is an industry, born of an industrial paradigm and keyed to the sensibilities of an industrial society. While those sensibilities are changing a bit as we move from an industrial to an "information" age, the basic assumptions are not radically transforming. Insurance is wedded to, inextricable from, a view of the body as a thing (an old fashioned machine or a computer, take your pick), and to a view of illness and injury as technical problems to be "fixed" or "solved" in the most expedient way possible.

Everything about the process of dealing with insurance hammers this point home. One must reduce the living patient--a unique spark of Divine creativity manifest here on Earth--to a set of numbers otherwise known as diagnostic codes. One must likewise reduce one's experience of and work with this person to a set of procedure codes, and one must make sure that one's notes justify the numbers one has chosen in both cases. This is not optional. If one is going to play the insurance game, one must play by these rules. Sure, people bend them all the time, but to do so compromises one's integrity in ways that are subtle but pervasive and powerful, and also puts one's financial security--the very security most of us are seeking when we choose to bill insurance--at risk. Here in Vermont, insurance companies have taken to auditing chiropractors' notes and demanding that the chiropractors repay the insurance companies--to the tune of tens of thousands of dollars--if there is any sign of discrepancy between the diagnosis and procedure codes and the chiropractor's notes.

The real issue is not the hassle of dealing with insurance--this is truly a technical problem which is easily managed in a variety of ways. The deeper question is whether the insurance paradigm is commensurable with the paradigm of Chinese medicine, and if not, what engaging with the insurance industry will do to your soul, as individual practitioners and as a community of healers.

Americans are prone to believe that we as individuals or minorities can engage with these vast collective entities and transform them from within. We tend to consistently over-estimate the power of the individual and to underestimate the power of the collective. Looking at the history of chiropractic's enfoldment by insurance, I would say that the collective entity has had far more effect upon us than we have had upon it.

Before the 1970's, chiropractors served a small minority of their communities but were greatly trusted and often beloved within those communities. Most were low-tech, high-touch family doctors, similar in tone, although not in method, to the allopathic family doctors of earlier generations. The trust and love were, I believe, rooted in part in the fact that chiropractors lived close to the economic standards of the (often working class) communities they served.

Since the 1970's, many chiropractors have gotten quite wealthy, but because the insurance paradigm defines us as musculoskeletal specialists, we are increasingly working as--and rightly viewed by the public--as such. Here in Vermont and in some other, mostly rural or poor urban, communities some chiropractors still play a wider role, one more in keeping with our profession's historical roots and beliefs, but we are the exception, not the rule. Meanwhile, I do not see that the insurance industry has become significantly more receptive to the understanding of the soma, health, and healing that was traditionally embedded within chiropractic thought and practice.

While chiropractors have undoubtedly gained a certain measure of credibility among allopaths in the years since we gained insurance recognition, we still serve a tiny minority of the public (less than 10%), and I would say that we have sacrificed some of the love and trust we historically enjoyed within the communities we served. Engagement with insurance has also deepened existing divides within the profession. The schism between those who want to play the allopathic game, with its relentless and exclusive demand for "scientific validation" and "evidence-based medicine" and those who insist that illness, health and healing are fundamentally mysterious and cannot be wholly encompassed within a Western mechanistic, reductionist scientific paradigm is probably irreconcilable.

Chinese medicine is rooted in a much more powerfully articulated tradition than modern chiropractic, a tradition that insists on mystery, even poetry, as necessary aspects of the dance of healing. This tradition is a powerful ally, but I question if even it is strong enough to withstand the daily assaults offered by engagement with the dominant mechanistic/reductionist paradigm so fully embodied in insurance. You, your traditions, your practices, will be changed by such engagement, and you will not have as much choice about the form such changes take as you might like to think.

I do not say there is a right or wrong answer here. I do think full consciousness of the risks as well as benefits of dealing with insurance is necessary. The allure of greater accessibility and income is great, but so are the potential losses. Caveat emptor.

love,
Lisa