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From the Townsend Letter
August / September 2013

Pathways to Healing
Affordable Care Act Offers Incentives for Prevention
by Elaine Zablocki
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Jud RichlandThe Affordable Care Act is moving the health-care system in the direction of increased preventive care. "The act includes several provisions that incentivize a much greater emphasis on prevention than has historically been part of our health-care system," says Jud Richland, MPH, MPA, CEO of the American Association of Naturopathic Physicians. He has specialized expertise on this subject, since he was previously the president of the Partnership for Prevention. "Perhaps the single most important thing in this respect is that the act requires insurers to cover all preventive services that are recommended by the U.S. Preventive Services Task Force, without any cost sharing by the patient." In other words, these preventive services will be available without copayments and deductibles.

These provisions mean that the act requires coverage of screening services and immunizations such as mammograms and flu shots, and also counseling services on subjects such as reducing cardiovascular risk, smoking cessation, and improved diet. "The Affordable Care Act in general promotes preventive care," Richland says. "There is much greater emphasis aligning payment systems with improved health outcomes, and on multidisciplinary integration of services."

Naturopathic Physicians Are Key Providers Under Health-Care Reform
Naturopathic physicians are currently licensed in 16 states plus the District of Columbia, Puerto Rico, and the US Virgin Islands. In addition, the Colorado legislature has approved ND licensure, and the legislation is on the governor's desk awaiting his signature. What does the Affordable Care Act mean for naturopathic physicians?

Erica ObergAs we discussed in the June issue of the Townsend Letter, the Affordable Care Act will be implemented state by state. "Some of the CAM disciplines face a special challenge when they offer services such as acupuncture that often haven't been included in insurance packages previously, even when there is strong evidence in support of these services," says Erica Oberg, ND, MPH, director of the Center for Health Policy & Leadership at Bastyr University. "For naturopathic medicine the issue is a bit different, since naturopathic physicians are primary care providers. The services NDs offer are the same primary care office-based services that are offered by primary care physicians, nurse practitioners, and other primary care providers."

Because of this, it's essential for naturopathic physicians to step forward and educate policy makers about the role of NDs. "Since we are dealing with primary care shortages in most parts of the country, benefits managers need to understand that low-cost, prevention-oriented providers will be a valuable addition to the primary care workforce," Oberg says.

HHS Guidance Propels the Discussion Forward
Recently, the Department of Health and Human Services released guidance for the states on its interpretation of the law, and this guidance basically restates the antidiscrimination prohibitions in Section 2706 (discussed in the Townsend Letter, June and July issues.) "Basically, the HHS guidance reconfirms that health insurers can't discriminate against any licensed provider who delivers services that are already covered by the insurer," Richland says. "I believe in general this is positive guidance. It will be particularly important for naturopathic physicians, since they deliver many services that MDs also deliver."

Some NDs currently have many patients who pay out of pocket for their services, and these practitioners may not be particularly interested in accepting health insurance. "However, it may be especially valuable for younger NDs who do not have a full-fledged thriving practice and want to integrate themselves into the health-care system," Richland says. "Most importantly, these changes will offer many patients greater access to NDs, especially for those who previously were not able to afford this form of care."

Certain states are taking the lead on this issue, while others face special challenges. Washington State has had an "every category of provider" law on the books for almost 20 years, a law which is very similar to the nondiscrimination provisions of the Affordable Care Act. Over the past several years, NDs have successfully been included in all insurance plans in Vermont, including Medicaid and Medicare coverage. "Vermont NDs are accepted as part of the primary care workforce, and they've agreed to be evaluated by the same metrics as other primary care providers," Oberg says. "Vermont is functioning as a laboratory, and we'll be able to compare outcomes. We expect that naturopathic physicians offering primary care are going to do extremely well on quality-of-care metrics such as preventive screenings and patient satisfaction."

In contrast, California faces an unusual situation in which various administrative boards are responsible for different aspects of health care: managed care, Medicare, Medicaid and so on. "It is going to be quite challenging in California to find out whether we can get an essential benefits package that is congruent across all of the different populations of insured patients, because they are all administered separately," Oberg says. "Kaiser has been selected as the benchmark plan for the state, but it operates as a managed care organization, which uses a staff model with employed physicians and capitated payments. It remains unclear how this will be translated into guidance for a standard PPO plan, or a Medicaid or Medicare plan, which operate as fee-for-service plans. More realistic models may be found in the examples set forth by Washington and Vermont."

Laura Farr"There is a tremendous amount of confusion about Section 2706 implementation," says Laura Farr, executive director of the Oregon Association of Naturopathic Physicians (OANP). "People tend to look at naturopathic, chiropractic, and acupuncture as a kind of benefit, rather than looking at them as types of providers. This is a really important distinction because under Section 2706 it is very clear that you cannot discriminate against various types of licensed providers."

OANP representatives have met with Oregon's insurance commissioner, Lou Savage. "He understands Section 2706 and seems to be firmly committed to ensuring that insurance plans do not discriminate against licensed providers," Farr reports. She recommends that Oregon patients who value services of various providers write directly to the insurance commissioner and "give him the support he needs to uphold the law. If there is an instance where a patient feels their provider has been discriminated against by the insurance plan, they should file a complaint to the insurance division. We are doing this right now; we are creating a paper trail to document current problems."

In many other locations, NDs and their patients have organized letter-writing campaigns supporting access to all provider types. However, the effort is uneven. "In some states NDs have already organized themselves so that they can present a strong and united front to decision-makers at the state level who are determining how 2706 gets implemented," Richland says. "But in other localities state associations are not as well developed. NDs who are not so used to dealing with the political process need to educate themselves about how important decisions made by governmental agencies could affect the way they are able to practice."

Oberg emphasizes the value of patients who choose to participate in the current debate over the future of health care. "Since these decisions are being worked out on a state-by-state level, patients who are seeing NDs should let state legislators know how much they value their naturopathic doctors," she says. "They could share their viewpoint through letters to the editor, and through other community discussions about health care, such as the Covered California town hall meetings taking place throughout that state during the summer. Patients can share our own experiences, that primary care focused on prevention and health promotion really does improve our personal health."

For information on recently released guidance from HHS on Section 2706, go to:
For federal and state information and advocacy tools, go to:
To learn more about advocacy in Oregon, and how to send a letter to the Oregon Insurance Commissioner, go to:
For more information specifically for massage therapists, contact Vivian Madison-Mahoney, massage insurance billing consultant and CE provider, at or
The Integrative Healthcare Policy Consortium (IHPC) has set up an action network to alert people to new developments related to the Affordable Care Act and integrative health care. To sign up for e-mail alerts, go to

Massage Therapists Starting to Organize
Vivian Madison-Mahoney was the first person in the country to successfully bill insurance for massage services. Since 1990 she has been teaching massage therapists how to "successfully, ethically, and legally bill for insurance in the cases where it's possible," she says.

Madison-Mahoney is acting as massage therapy advocacy coordinator for the Integrated Healthcare Policy Consortium. However, she notes that the massage profession tends to attract a high proportion of people who are somewhat relaxed. "At this time massage therapists are not as organized and active on this issue as some of the other professions," she says. However, she invites those who are ready to step forward and become more involved to contact her for pointers on appropriate steps that are most needed at this time. See the Resources section for more details.

Elaine Zablocki has been a freelance health-care journalist for more than 20 years. She was the editor of Alternative Medicine Business News and CHRF News Files. She writes regularly for many health-care publications.


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