HCFH Member Alert
HMSA''s "Complementary Care Rider"
Beginning July 1, 2001 HMSA will be offering a new "Complementary Care Rider" to Hawaii employers. For a per employee fee of 3 to 5 dollars a month HMSA will provide insurance for "Complementary Care". The Benefits include:
1) 12 to 24 visits total visits per year for chiropractic, massage therapy, and acupuncture services. The annual maximum applies as an aggregate of all these services, not 12 to 24 for each.
2) Traditional Chinese herb supplement. $500 per year, with a $10 co-pay per supplement.
3) Chiropractic, massage, and acupuncture visits will require a $10 co-pay per visit.
The massage benefit is only available if a primary care physician (or a chiropractor) writes a prescription for the massage, and the prescription "must state the medical reason for the service as well as the duration and the frequency of treatment".
In addition, services and treatments that are not medically or "clinically necessary" are not covered.
So What''s The Problem?
If a primary care physician writes such a prescription for massage therapy, it can be construed that the physician is directing the therapy, declaring it to be medically necessary, and part of the patients overall treatment plan by the physician. This places the primary care physician at great liability risk should the patient allege harm from the massage therapy, or because such therapy is alleged to have delayed or prevented diagnosis and treatment of a serious condition. The physician would have an extremely difficult time justifying the "medical necessity" of massage therapy given the scant availability of controlled clinical trials proving the benefits of massage. In addition, refusing to write a massage prescription makes the physician the "bad guy" who is denying an insurance benefit the employer paid for and the employee wants. Think of the effect on your "patient satisfaction survey" ranking!
These issues were discussed with HMSA''s Medical Director during three telephone conversations. His response (briefly stated) is that:
1) HMSA will not change the "massage prescription" requirement, although HMSA may call it something other than a prescription.
2) That the massage benefit was never meant to be an "open benefit", and that controls need to be applied. (Therefore, the physician becomes the gatekeeper/ bad guy)
3) If a physician doesn’t want to write the prescription, a chiropractor can do it. (Therefore, the physician may be forced or encouraged to refer to a chiropractor, which again, places a liability risk on the physician).
4) The document that contained the information about the Complementary Care Rider was not meant for distribution! (It was obtained by simply asking an HMSA Provider Services representative for it.)
The Coalition''s View
The Coalition does not oppose HMSA’s offering insurance for "Complementary Care". The Coalition opposes, however, HMSA linking this new insurance to a new gatekeeper requirement for primary care physicians, and creating new liability risks for HMSA’s participating providers. HMSA has repeatedly failed to provide coverage for services that meet nationally recognized standards for medical necessity, yet it is requiring primary care physicians to assume great liability in writing prescriptions, and directing care by non physician providers for services that would never fit HMSA’s own definition of medical necessity. If HMSA truly believes these services to be medically necessary, then it is unconscionable that HMSA limit their availability to the 12 or 24 "mix and match" visits per year. If these services are not viewed by HMSA as medically necessary, then the "Complimentary Care" Rider is simply a marketing ploy that we condemn.
Peter Locatelli M.D.