Lindy Washburn, North Jersey Record Published 6:00 a.m. ET Aug. 22, 2019
The state’s largest insurer plans to shift oversight of its members' benefits for chiropractic care, physical therapy, occupational therapy and acupuncture to a separate company next year, in a plan that has drawn intense opposition from chiropractors and other medical providers.
Horizon Blue Cross Blue Shield of New Jersey, with 3.7 million members, says American Specialty Health, based in Indiana, will “make sure you get the care you need, when you need it.” Horizon provides coverage through the state and federal employee benefits programs, large and small private employers, Affordable Care Act plans and individual policies.
Chiropractors, physical therapists and others say Horizon's arrangement to have American Specialty review claims will interfere with their ability to provide optimal care to patients and will load them with paperwork. With the state in the midst of an opioid epidemic, they say, insurers should be making it easier to receive non-drug-based treatment for pain rather than adding potential hurdles. And they express concern about American Specialty’s reputation.
"This company routinely denies care after just 5 of the 30 visits approved in your plan," the Association of New Jersey Chiropractors has said in a "warning" on its website.
The association has generated more than 170,000 emails to legislators and Gov. Phil Murphy from chiropractic patients, its spokeswoman said. Legislators have called the state insurance commissioner to make sure that covered benefits for Horizon members are protected.
Horizon says the association has spread false information.
The state Department of Banking and Insurance is reviewing Horizon’s formal proposal for the new arrangement, to see if the material submitted is complete. Once it is, Commissioner Marlene Caride will have 60 days to decide whether to approve the plan. Horizon plans to implement the change on Jan. 1.
The conflict brings up many of the arguments first voiced in the 1990s, when managed-care companies began trying to control skyrocketing health care costs by creating networks of doctors, establishing contracted reimbursement rates, and imposing standards to decide whether treatment was necessary and would be covered.
Over the years, that approach has extended to nearly every facet of health care spending — from hospital stays to high-priced imaging services and prescription drugs. Along the way, there have been many political battles and compromises. Despite the approach, health care costs have kept climbing.
Lower back and neck pain has contributed to those rising costs, because the areas account for a huge and growing chunk of American health care spending. Only diabetes and heart disease claim a larger share of the health care dollar.
Spending for back pain — estimated at $86.7 billion in 2013 — includes surgical interventions, imaging studies and prescription drugs as well as physical health services such as chiropractic, physical therapy and acupuncture.
“Rooting out and eliminating procedures that provide no real medical benefit is fundamental to improving the overall quality, experience and cost of care for our members,” said Thomas Vincz, a Horizon spokesman. Unnecessary or redundant care is estimated to account for about 30 percent of U.S. health care spending.
Vincz cited Horizon data on claims from 2017 and 2018 that showed chiropractors in the state billed for “more than twice the volume of care compared to national benchmarks,” and physical therapists exceeded national benchmarks by as much as 140 percent for the same period. The data was reviewed by an independent national consultant, Milliman, Inc., he said.
American Specialty Health will work with care providers in its network to ensure the care they give is necessary and based on their profession’s best practices and the patient’s history, according to Horizon’s information for members. That review would occur only after the patient’s fifth visit, Vincz said, “but in more than 90 percent of cases, there is no review.”
However, representatives of the professions affected said decisions about treatment should be left in the providers’ hands.
“The appropriate amount of care should be determined by the patient’s doctor,” said Amy Boright Porchetta, executive director of the state chiropractors’ association. “It should not be determined by a third-party utilization management company … whose whole goal is to provide savings to the insurer, not the person paying the premium for the benefits.”
A Franklin Lakes physical therapist agreed. “We have a potential crisis for many patients” with Horizon coverage, said Anthony Manzella, who said he has treated many state workers and police. American Specialty “should not determine a patient’s care. A patient and doctor should make those decisions.”
The American Physical Therapy Association of New Jersey has met with Horizon several times to discuss the planned change, said Brian Mason, the association's president. Its members are concerned about the administrative burden, and that doing the paperwork for authorizations "will take away from patient care,” he said.
The president of the New Jersey Association of Acupuncture & Oriental Medicine said the benefits of acupuncture are “realized incrementally. Current research shows patients benefit from more acupuncture treatment, not less,” Jason Sargis said, noting that acupuncturists are a provider “of last hope” for many pain patients.
By imposing a review after the patient’s fifth visit, Sargis said, American Specialty is “dictating the level of care that everyone can have. It should be up to the provider to determine the course of care.”
American Specialty says it has a detailed process to develop its guidelines, and medical review decisions are based on the individual patient’s condition, not a hypothetical average patient.
It already manages physical health benefits for 140 health plans covering 36 million people — including 800,000 in New Jersey, said Lisa Freeman, a spokeswoman for American Specialty Health. It currently is approved by the state insurance department to work with Cigna and AmeriHealth, the state said.
“In the last 12 years, more than 105,000 patients have received treatment from in-network and out-of-network providers in New Jersey through our programs,” Freeman said.
The company plans to encourage Horizon members to switch from out-of-network to in-network providers because of the cost savings, she said. It will give those providers annual report cards, “peer-to-peer education and limited medical necessity review.”
In addition, a new tele-health program will enable Horizon members to have “virtual” visits with a physical therapist from the convenience of the patient’s home, she said. Members will also be able to call a nurse and use a website and mobile app for support as they care for themselves.
Opponents of the proposed plan, however, said American Specialty “has a history of standing in the way of New Jersey residents accessing conservative care such as chiropractic, physical therapy and occupational therapy” — language used in the email template recommended by the chiropractors’ association for its members to send to legislators.
They pointed to recent lawsuits against the company, including a class-action suit in Pennsylvania by chiropractors against Cigna and American Specialty. An $11.8 million settlement of that suit, agreed to in April, awaits court approval.
American Specialty said neither it nor Cigna had admitted wrongdoing.
The administrative-fee issue that was the subject of the litigation is irrelevant, Freeman said, because it is not part of the company’s agreement with Horizon. And no change in its medical-necessity review process was required.
The Jan. 1 change in management of Horizon’s physical health benefits, if approved, will not affect people with Medicare supplemental (“medigap”) policies or people on Medicaid, Horizon said. Members of other plans — including self-funded employer groups that are administered by Horizon — will be affected.