alternative medicine (CAM) providers. the National Center for Complementary and Alternative Medicine. visits to alternative medicine providers: results …
MANAGERIAL
Insurance Coverage and Subsequent Utilization of Complementary and Alternative Medicine Providers
William E Lafferty, MD; Patrick T Tyree, AA; Allen S Bellas, PhD; Carolyn A Watts, PhD; Bonnie K Lind, PhD; Karen J Sherman, PhD; Daniel C Cherkin, PhD; and David E Grembowski, PhD
Background: Since 1996, Washington State law has required that private health insurance cover licensed complementary and alternative medicine CAM providers Objective: To evaluate how insured people used CAM providers and what role this played in healthcare utilization and expenditures Study Design: Cross-sectional analysis of insurance enrollees from western Washington in 2002 Methods: Analysis of insurance demographic data, claims files, benefit information, diagnoses, CAM and conventional provider utilization, and healthcare expenditures for 3 large health insurance companies Results: Among more than 600 000 enrollees, 137 made CAM claims This included 13 of enrollees with claims for acupuncture,
16 for naturopathy, 24 for massage, and 109 for chiropractic Patients enrolled in preferred provider organizations and point-of-service products were notably more likely to use CAM than those with health maintenance organization coverage The use of CAM was greater among women and among persons 31 to 50 years of age The use of chiropractic was more frequent in less populous counties The CAM provider visits usually focused on musculoskeletal complaints except for naturopathic physicians, who treated a broader array of problems The median per-visit expenditures were 3900 for CAM care and 7440 for conventional outpatient care The total expenditures per enrollee were 2589, of which 75 29 was spent on CAM Conclusions: The number of people using CAM insurance benefits was substantial; the effect on insurance expenditures was modest Because the long-term trajectory of CAM cost under thirdparty payment is unknown, utilization of these services should be followed Am J Manag Care
2006;12:397-404
therapists1 The number of CAM providers is projected to double during the next decade2 because of increased consumer demand for these services3 Clinical trials have documented the efficacy of CAM provider treatments for several medical problems such as back pain,4 osteoarthritis,5 and nausea and vomiting associated with chemotherapy6 Other studies are in progress As the number of CAM providers and the visibility of CAM services increase, the pressure on third-party payers to cover these services grows Wolsko et al7 report that many insurance products already cover chiropractic in some form A Kaiser Family Foundation employer survey in 2004 found that 87 of covered employees had chiropractic coverage, and 47 had acupuncture coverage8 The Landmark Report II on HMOs and Alternative Care reported that 67 of health maintenance organizations HMOs offer some type of alternative care9 To our knowledge, no studies to date have reported figures for population-based utilization
and the financial consequences to third-party payers of broadly covering CAM providers in their insurance products The state of Washington provides an important laboratory to assess the magnitude of economic risk when a third-party payer covers CAM providers In 1996, Washington State implemented a law mandating that all commercial health insurance companies cover the services provided by every category of licensed provider10 This law was passed in the context of a legislative environment already friendly to CAM providers
uring the last decade, the health professionals Ascend Media collectively known as complementary and alternative medicine CAM providers have been From the Department of Health Services, School of Public Health and Community recognized as mainstream sources of healthcare Medicine WEL, PTT, CAW, BKL, DEG, and Evans School of Public Affairs ASB, University of Washington; Regulation by government agencies and validation of Seattle, Wash and Center for Health Studies,
Group Health Cooperative KJS, DCC; This study was supported by grant 5 R01 AT00891 from the National Center for some CAM therapies by scientific studies have National Institutes of Health Its contents increased the credibility of CAM professionals All 50 Complementary and Alternative Medicine,do not necessarily represent the official viewsare solely the responsibility of the authors and of states now license chiropractors, and about 85 of the National Center for Complementary and Alternative Medicine Address correspondence to: William E Lafferty, MD, Department of Health states license some of the other CAM providers such as School of Public Health and Community Medicine, University of Washington, Box Services, 357660, naturopathic physicians, acupuncturists, and massage Seattle, WA 98195 E-mail: billlaf@uwashingtonedu
D
VOL 12, NO 7
THE AMERICAN JOURNAL OF MANAGED CARE
397
MANAGERIAL
because mandatory inclusion of a chiropractic benefit had been required since 198311 This study
calculates CAM utilization and expenditures for insurance companies that underwrite western Washington State health insurance Insurance benefit structures, CAM provider use, and spending for services are described for more than 600 000 private insurance enrollees in 2002 massage, and chiropractic In any given year, an enrollees health plan was defined as the product type in December of the analysis year In the tables and figures of this article, the designation of enrollee reflects the total population of covered individuals in the study sample, and claimant refers only to the persons who used any allowed service From our enrollment data, we generated variables for age and county of residence In the medical claims data, a visit was defined as 1 encounter to a specific provider per day Duplicate visits were excluded from the analysis database Provider types were divided into the following 3 categories: 1 CAM providers were defined as chiropractors, massage therapists, acupuncturists,
and naturopathic physicians; 2 conventional providers were defined as physicians including osteopaths and specialists, physical therapists, advanced registered nurse practitioners, and physician assistants; and 3 providers who did not fit into either of these categories, including occupational therapists and psychologists, were put into a third category called other as previously described15 In some analyses, naturopathic physicians, acupuncturists, and licensed massage therapists were combined and referred to as NAM providers because, unlike chiropractors, they were not reimbursed by insurance before 1997 but were covered in some form thereafter Location of service was categorized as inpatient, outpatient clinic or provider office, and outpatient other eg, emergency department, drug treatment facility, and kidney dialysis center Pharmacy files were supplied by companies B and C The pharmacy files included data on the number of prescriptions filled and aggregated annual expenditures
for each enrollees prescription drugs For companies B and C, several expenditure variables were available for each visit The amount allowed by the insurance company was chosen as the closest proxy for expense Inpatient hospital expenditures, all outpatient services, and pharmacy expenditures were included in the calculation of per capita outlays The Johns Hopkins Adjusted Clinical Groupings software, version 6,16 was used for risk adjustment to counter selection bias among the individuals who chose to use CAM providers Using this software, we constructed 2 indices of the types of diseases or disorders present and the expected resource utilization for each patient The indices are 1 expanded diagnosis clusters, which categorize International Classification of Diseases, Ninth Revision, Clinical Modification codes into 26 major disease categories for each individual and 2 resource utilization bands RUBs, which measure an individuals expected resource use and are created by grouping
adjusted
METHODS
Population and Sample This study was approved by the University of Washington Human Subjects Review Board in 2001 Three large insurance companies participated in this study Company selection was based on willingness to participate, data retrieval capacity, and market penetration in western Washington State Data for calendar year 2002 were included for all individuals 18 to 64 years of age who were continuously enrolled for 12 months in a single private health insurance plan covered by Washingtons law mandating that all commercial health insurance companies cover the services provided by every category of licensed provider Selfinsured employer plans were excluded All insurance products that we studied provided comprehensive medical coverage Insurance products were categorized as HMO, point of service POS, or preferred provider organization PPO Unknown product type and traditional or indemnity coverage accounted for fewer than 425 of enrollees, who were excluded from
the study Databases and Measures Analysis files were created for each company Company A provided an assembled analysis file that lacked expenditure information, whereas companies B and C provided separate files with data on enrollment, medical claims, utilization, and expenditures The CAM utilization data for company A were available only for their HMO product line, excluding approximately one third of their customers in POS products Enrollment data included unique encrypted enrollee identification codes, birth year, sex, residence ZIP code, product type, employer contract number, Employee Retirement Income Security Act status, and months of active enrollment Medical claims contained the unique encrypted enrollee identification codes, claim number, service date, service location, International Classification of Diseases codes,12 Current Procedural Terminology codes,13 and Healthcare Common Procedure Coding System codes14 We also received data on line-item charges and provider type
including specific codes for acupuncture, naturopathy,
398
THE AMERICAN JOURNAL OF MANAGED CARE
JULY 2006
Insurance Coverage and Complementary and Alternative Medicine Providers
clinical grouping codes for individuals with similar levels of expected resource use Lower RUBs include individuals with less expected resource use, and higher RUBs include those with greater expected resource use Predictors of CAM use were modeled using logistic regression analysis Predictors included in the model were age group, sex, insurance product type, county population, disease types present using indicators for the 26 expanded diagnosis cluster categories, and indicators for expected resource use using indicators for the 5 RUB categories These predictors were then entered in a linear regression model This model included more than 500 000 observations; therefore, using linear regression analysis provides valid estimates even though the outcome variable is dichotomous17 National Health Interview
Survey NHIS18 data from the 2002 supplemental survey on CAM use was used to provide a US comparison with our western Washington State experience To approximate the selection criteria used for our local data, adults aged 18-64 years with private insurance were selected from the NHIS sample, and then 3 of the NHIS databases samadult, personsx, and althealt were linked together for our analysis As with the analysis of Washington State data, US CAM utilization was defined as the use of a chiropractor, massage therapist, acupuncturist, or naturopathic physician in the last 12 months care providers recommendation Massage for fibromyalgia was originally included but was excluded in 1998 By 2002, companies B and C had extended the CAM benefit to all product lines, using cost sharing similar to that of conventional medical services Massage was treated like a rehabilitation benefit, with visit limits and primary care provider referral requirements
Population and Sample
The 3 companies that
participated covered approximately 75 of western Washington States private insurance market More than 600 000 enrollees met the study inclusion criteria Table 1 summarizes the characteristics of the study population and the prevalence of CAM claims Subjects were 533 female, 570 were older than 40 years, and 731 lived in counties with a population greater than 400 000 Health maintenance organization coverage was the most common 411, followed by PPO coverage 385, and POS coverage 204 The study population was composed of 249 low utilizers RUBs 0-1 and 120 high utilizers RUBs 4-5 The percentage of enrollees with claims was 834 Overall, 137 of enrollees made CAM claims as follows: 13 of enrollees had claims for acupuncture, 16 for naturopathy, 24 for massage, and 109 for chiropractic United States survey data from privately insured people in 2002 showed that 12 used acupuncture, 03 used naturopathy, 65 used massage, and 84 used chiropractic18 As in Washington State, US CAM use was greater
for enrollees in PPO 163 and POS 168 products than in HMOs 109 Prevalence and Predictors of CAM Provider Use Table 2 summarizes the predictors of CAM use Significant predictors included female sex and age 31 to 50 years Enrollees in insurance products that offered greater consumer choice eg, PPO and POS products vs HMOs showed greater utilization of CAM The single greatest predictor of CAM use was expected resource consumption based on the RUB index Persons in RUB 4 or 5 expected high utilizers of medical care were more than 11 times more likely to use CAM than persons in RUB 1 The use of CAM was lowest in urban areas because of lower rates of chiropractic use in urban counties than in rural counties CAM Utilization and Total Medical Expenditures Table 3 gives the visit-level utilization of CAM and conventional services for companies A, B, and C Expenditure data were available for companies B and C only Chiropractic, naturopathy, acupuncture, and massage CAM accounted for 176 of
outpatient
RESULTS
CAM Benefit Structures Since 1983, all private health insurance companies in Washington State were required to have a chiropractic benefit11 The law mandating that all commercial health insurance companies cover the services provided by every category of licensed provider was implemented in 1996 and required that private health insurance companies include access to all categories of licensed providers in private insurance products10 In 2000, the ability to self-refer for chiropractic care was also mandated19 The history of these benefits has been extensively described20 Company A created a list of medical conditions for which the scientific data provided strongest support for CAM use, including chronic pain syndromes for acupuncture, back pain for massage, and selected medical conditions for naturopathy Enrollees were required to obtain a referral from a primary care physician except chiropractic, for which enrollees could self-refer for the first 10 visits, and
some visit limits were established by type of service Visit limits could be increased based on the primary
VOL 12, NO 7
THE AMERICAN JOURNAL OF MANAGED CARE
399
MANAGERIAL
Table 1 Population Demographics and Complementary and Alternative Medicine CAM Provider Claims
Enrollees With Claims by Provider Type, All Enrollees, No 605 368 282 969 322 399 260 516 344 852 of Total Population 1000 467 533 430 570 77 192 731 411 204 385 Any Claim 834 758 901 797 862 839 844 831 847 799 839 Naturopathic Massage Physician Therapist 16 07 24 15 17 09 13 18 08 24 21 24 12 35 24 25 27 26 24 11 26 38
Demographic All enrollees Sex Male Female Age, y 18-40 41-64
CAM 137 108 162 124 146 174 164 126 95 134 183
NAM 46 24 66 42 50 42 45 47 25 51 67
Chiropractor 109 94 123 99 117 152 141 97 78 101 147
Acupuncturist 13 08 18 10 16 12 12 14 09 11 19
County population, in 1000s 46 538 100 100-400 400 Insurance product Health maintenance organization Point of service Preferred provider organization
116 427 442 403 249 036 123 428 232 904
Resource utilization band 0 No claims 100 505 1 2 3 4 5 50 228 115 371 265 455 58 906 13 884
166 83 191 439 97 23
– 1000 1000 1000 1000 1000
– 13 99 185 291 333
– 07 19 63 119 128
– 06 85 146 230 274
– 01 05 17 36 48
– 03 07 22 39 42
– 03 08 33 69 68
Chiropractors, naturopathic physicians, acupuncturists, and massage therapists Naturopathic physicians, acupuncturists, and massage therapists From diagnostic information contained in the claims data excludes 1019 claimants whose diagnostic information was insufficient to create a resource utilization band All other values in the All Enrollees column reflect data received in the enrollment file
provider visits and 29 of the total medical expenditures The CAM expenditures were dwarfed by the high cost of conventional care The median per-visit expenditures were 3900 for CAM care and 7440 for conventional outpatient care Inpatient hospital expenditures were 216 and prescription drugs
were 231 of the total medical expenditures The 12 of the insured population in RUBs 4 and 5 were responsible for 335 of CAM, 410 of outpatient conventional, and 497 of total expenditures
Medical Problems Treated by CAM Providers
Table 4 lists provider diagnoses for companies B and C Musculoskeletal pain was the most common diagno-
sis from a CAM visit, accounting for 993 of visits to chiropractors, 927 of visits to massage therapists, 727 of visits to acupuncturists, and 307 of visits to naturopathic physicians Musculoskeletal pain was also the top diagnosis for conventional providers, representing 210 of visits Female reproductive diagnoses were the next most frequent reasons for naturopathic physician visits, accounting for 182 of all visits, almost half of which 3512 visits were for menopause treatment Neurologic problems such as headache accounted for 179 of visits to acupuncturists, 132 of visits to naturopathic physicians, 87 of visits to massage therapists, 62 of chiropractic
visits, and 52 of visits to conventional providers
400
THE AMERICAN JOURNAL OF MANAGED CARE
JULY 2006
Insurance Coverage and Complementary and Alternative Medicine Providers
CONCLUSIONS
Our study addresses important questions about CAM use by people with priOdds Ratio vate insurance who have a CAM benefit Predictor 95 Confidence Interval SE Our cohort had fewer people with claims Female sex 123 121-126 001 for massage, a similar proportion with Age, y claims for acupuncture, and a greater 18-30 100 — proportion with claims for naturopathy 31-40 138 134-141 002 and chiropractic than was seen among 41-50 123 119-126 002 privately insured adults who took part in 18 We believe that the 51-64 098 095-101 002 the 2002 NHIS requirement for a provider referral reCounty population, in 1000s 100 100 — duced the claims for massage in our pop100-400 106 103-110 002 ulation A survey of our cohort like the 400 069 067-071 001 NHIS would undoubtedly reveal additional use outside of
insurance billing Our Insurance product Health maintenance organization 100 — study also shows that a small proportion Point of service 169 165-174 002 of the population uses acupuncture, even Preferred provider organization 235 230-240 002 when it is covered by insurance, and that chiropractic is the most commonly used Resource utilization band form of CAM among the privately insured 1 100 — in the United States and in Washington 2 527 485-573 022 State, with 83 and 109 use, respec3 748 689-812 031 tively The 5 times greater prevalence in 4 1149 1054-1252 050 the use of naturopathy among our in5 1435 1305-1578 070 sured cohort compared with national surveys is likely a regional phenomenon P 16 P 001 for all others All values are adjusted for expanded diagnosis cluster category Western Washingtons 422 actively and insurance company SE indicates the standard error of the estimated odds ratio licensed naturopathic physicians written communication, Roland Wilbur, Washington State
Department of Health, Information Services, February 2003 represent tions such as menopause account for some of these approximately 31 of all naturopathic physicians gender-specific differences Chiropractic use was sublicensed nationally1 Even with these differences stantially more common in smaller counties than in noted, the prevalence of CAM use among our claims major urban centers This affirms the important role data is similar to that among the NHIS data 137 vs that chiropractors have historically played in rural pri13418 Although we do not know why this is true, it mary care, where access to conventional providers is suggests that insurance coverage of licensed CAM more limited23 Some benefit structures are probably more CAM-friendly than others; requiring a gatekeepers providers does not lead to runaway utilization 7,21 recommendation as opposed to self-referral may be the As shown in previous population-based surveys, we found that CAM use is greater among certain groups
biggest disincentive to insurance-financed CAM use In than among others The insured proportions that fall addition, people will likely self-select into different prodinto these different categories will be a factor determin- ucts based on their expected need for medical services ing the prevalence of CAM use For example, patients For this reason, we were not surprised that CAM use was who have high expected resource utilization based on greater in PPOs than it was in HMO product lines We did not expect to find that CAM care would risk-adjustment schemes use more CAM than people account for such a small proportion of insurance expenwho use less healthcare Other investigations using provider visits as a measure of utilization have had sim- ditures The data from the 1997 survey by Eisenberg et ilar results22 Although women were only slightly more al24 estimated that CAM professional expenditures likely to use chiropractic than men, they were more were between 212 billion and 327 billion,
or about than twice as likely to use naturopathy, massage, and 19 to 30 of the total 1997 healthcare expenditures acupuncture The treatment of specific medical condi- Our estimate that CAM providers accounted for 29 of
Table 2 Predictors of Complementary and Alternative Medicine Provider Use
VOL 12, NO 7
THE AMERICAN JOURNAL OF MANAGED CARE
401
MANAGERIAL
First, because the typical CAM patients emphasis is on the treatment of musculoskeletal pain, the scopes of practice for many CAM providers overlap This suggests that other CAM services such as massage Variable Value and acupuncture may compete with the previously covered CAM service of chiroOutpatient provider visits and expenditures per enrollee Acupuncture practic care Second, although naturopathVisits 52 542 13 ic physicians, and to a lesser extent Visits per user, median 652 acupuncturists, have broader scopes of Expenditures per enrollee, 6 02 practice, these services are used by a small Naturopathy fraction of the
population Third, CAM Visits 41 106 10 providers in our study practice a less expenVisits per user, median 425 sive form of medicine They provide virtualExpenditures per enrollee, 9 03 ly no inpatient services, and they rarely use Massage expensive diagnostic tools such as imaging Visits 116 453 30 technology25 Visits per user, median 788 Expenditures per enrollee, 18 07 Our study has several limitations First, we measured utilization and expenditure, NAM Visits 210 101 53 not efficacy and value Although we found Visits per user, median 752 that CAMs proportion of the insurance dolExpenditures per enrollee, 33 13 lar is small, 29 of more than 1 billion is Chiropractic still a great deal of money Randomized conVisits 481 553 122 trolled investigations performed for specific Visits per user, median 727 CAM interventions show that CAM like conExpenditures per enrollee, 41 16 ventional care is not effective for all of the CAM conditions it is used to treat eg, acupuncVisits 691 654
176 ture for fibromyalgia26 Even so, many Visits per user, median 835 patients commonly integrate CAM and conExpenditures per enrollee, 75 29 ventional care,27,28 and the extent to which Conventional provider this should be encouraged is unclear Visits 3 246 793 824 Second, the value to the healthcare conVisits per user, median 677 Expenditures per enrollee, 686 265 sumer of integrating CAM services into health insurance benefits is still debated in Additional expenditure data Outpatient other 671 259 Washington State The movement toward 560 216 Inpatient expenditures per enrollee forms of consumer-directed healthcare will 598 231 Prescription drug expenditures per enrollee, test the consumers commitment to CAM Total expenditures per enrollee, 2589 1000 services In theory, the economical nature of CAM interventions may be attractive to patients with high-deductible insurance poliData are given as number percentage of total expenditures unless otherwise indicated Expenditures are
based on companies B and C only cies and private medical savings accounts Naturopathic physicians, acupuncturists, and massage therapists Studies on CAM cost sharing, cost-effectiveChiropractors, naturopathic physicians, acupuncturists, and massage therapists ness, and medical quality are warranted Third, although the samples for this study are large, the population and benefits are always select the 2002 private insurance expenditures is similar to these earlier national survey data Payers have resisted The exclusion of Medicaid and Medicare recipients, the covering CAM providers in part because of a fear that uninsured, and self-insured companies means that our coverage would result in large, steadily increasing, and data may be incomparable to some large populationunpredictable expenditures for CAM services, not unlike based national surveys Although we believe that our the history of prescription drug coverage Our study per- 4 provider categories capture almost all professional
formed 6 years after the mandated inclusion of CAM CAM services 965 based on NHIS population-based benefits in Washington State suggests that this is not use estimates, at least 11 additional provider groups going to be the case We hypothesize several reasons have been included in national surveys21
Table 3 Complementary and Alternative Medicine CAM and Conventional Outpatient Provider Visits and Expenditure Data per Enrollee in 2002
402
THE AMERICAN JOURNAL OF MANAGED CARE
JULY 2006
Insurance Coverage and Complementary and Alternative Medicine Providers
Table 4 Diagnoses Assigned by Conventional or Complementary and Alternative Medicine Providers
Expanded Diagnosis Cluster Category
Musculoskeletal Administrative, general examination Cardiovascular Female reproductive General surgery Skin Respiratory Allergy Neurologic eg, headache Psychosocial Ear, nose, and throat eg, otitis media, chronic pharyngitis Endocrine Gastrointestinal or hepatic General signs and symptoms Malignancy
Genitourinary Eye Hematologic Infections Visits that included an unassigned diagnosis
Conventional Provider n 2 733 912
210 151 90 86 82 75 65 53 52 48 44 44 42 37 35 28 26 11 06 96
Acupuncturist n 41 655
727 — 09 43 24 10 22 22 179 20 19 05 21 34 — – — – — 42
Massage Practitioner n 120 111
927 — – — – — – — 87 05 — – — 08 — – — – — 36
Naturopathic Physician n 40 847
307 74 81 182 49 96 62 95 132 47 60 112 122 98 12 24 06 39 25 147
Chiropractor n 435 781
993 — – — – — – — 62 — – — – — – — – — – 76
Data are given as percentage of visits to that provider type with that diagnosis limited to diagnoses that account for at least 2 of visits to any provider type [diagnoses are not mutually exclusive and do not sum to 100], excluding company A and including all visits inpatient, outpatient clinic or provider office, outpatient other, and allowed and not allowed at which a provider assigned a diagnosis The n values represent the number of visits
to that provider type These differ from the visit values in Table 3, in which the data are restricted to allowed outpatient clinic or provider office visits and are based on the experience of all 3 companies Dashes indicate categories representing less than 05 of visits Conditions that often lead to a surgical procedure performed by a conventional provider and not elsewhere classifiable eg, hemorrhoids, appendicitis, and hernia
Our study is of national significance as insurance companies in the United States respond to consumer demand for an integrated CAM benefit3 The Washington State law mandating CAM provider coverage in private commercial insurance products creates a window through which consumer behavior under various CAM and conventional benefit structures can be monitored and the effect on healthcare expenditures measured Despite the increase in CAM provider use and a mandatory requirement in Washington State to include CAM providers in insurance, the overall percentage of
insurance expenditures for CAM remains small 6 years after passage of the requirement At this time, CAM coverage minimally contributes to increasing healthcare expenditures and health insurance premiums in Washington State Future studies should evaluate the trajectory of CAM expenditures and the role of CAM in the health-
care marketplace, especially whether CAM therapies actually substitute for more expensive conventional care Only then can the total impact of CAM integration on healthcare utilization be measured
Acknowledgment
We thank Yuki Duran, MLS, for her assistance with references
REFERENCES
1 Eisenberg DM, Cohen MH, Hrbek A, Grayzel J, Van Rompay MI, Cooper RA Credentialing complementary and alternative medical providers Ann Intern Med 2002;137:965-973 2 Cooper RA, Laud P, Dietrich CL Current and projected workforce of nonphysician clinicians JAMA 1998;280:788-794 3 Pelletier KR, Astin JA Integration and reimbursement of complementary and alternative medicine by managed care
and insurance providers: 2000 update and cohort analysis Altern Ther Health Med 2002;8:38-39, 42, 44 passim 4 Cherkin DC, Eisenberg D, Sherman KJ, et al Randomized trial comparing traditional Chinese medical acupuncture, therapeutic massage, and self-care education for chronic low back pain Arch Intern Med 2001;161:1081-1088
VOL 12, NO 7
THE AMERICAN JOURNAL OF MANAGED CARE
403
MANAGERIAL
5 Berman BM, Lao L, Langenberg P, Lee WL, Gilpin AM, Hochberg MC Effectiveness of acupuncture as adjunctive therapy in osteoarthritis of the knee: a randomized, controlled trial Ann Intern Med 2004;141:901-910 6 Weiger WA, Smith M, Boon H, Richardson MA, Kaptchuk TJ, Eisenberg DM Advising patients who seek complementary and alternative medical therapies for cancer Ann Intern Med 2002;137:889-903 7 Wolsko PM, Eisenberg DM, Davis RB, Ettner SL, Phillips RS Insurance coverage, medical conditions, and visits to alternative medicine providers: results of a national survey Arch Intern Med
2002;162:281-287 8 Claxton G, Gabel J, Gil I, et al Employer Health Benefits: 2004 Annual Survey Menlo Park, Calif: Kaiser Family Foundation and the Health Research and Educational Trust; September 2004 9 Landmark Healthcare, Inc The Landmark Report II on HMOs and Alternative Care Sacramento, Calif: Landmark Healthcare Inc; 1999 10 Health Plan Requirements Wash Rev Code 4843045 1995 11 Chiropractic Care, Coverage Required, Exceptions Wash Rev Code 4844310 1983 12 International Classification of Diseases, Ninth Revision, Clinical Modification Washington, DC: Public Health Service, US Dept of Health and Human Services; 1988 13 American Medical Association Current Procedural Terminology Chicago, Ill: American Medical Association; 2002 14 American Medical Association Healthcare Common Procedure Coding System Chicago, Ill: American Medical Association; 2002 15 Tyree PT, Lind BK, Lafferty WE Challenges of using medical insurance claims data for utilization analysis Am J Med Qual In press 16
Johns Hopkins Adjusted Clinical Groupings Case-Mix System [computer program] Version 6 Baltimore, Md: Johns Hopkins University; 2003 17 Lumley T, Diehr P, Emerson S, Chen L The importance of the normality assumption in large public health data sets Annu Rev Public Health 2002;23:151-169 18 National Center for Health Statistics National Health Interview Survey NHIS: Questionnaires, Datasets, and Related Documentation 1997-2006 Hyattsville, Md: National Center for Health Statistics Available at: http://www cdcgov/nchs/about/major/nhis/quest_data_related_1997_forwardhtm Accessed June 15, 2006 19 Access to appropriate health services–Enrollee options–Rules Wash Rev Code 48-43515 2000 20 Watts CA, Lafferty WE, Baden AC The effect of mandating complementary and alternative medicine services on insurance benefits in Washington State J Altern Complement Med 2004;10:1001-1008 21 Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL Unconventional medicine in the United
States: prevalence, costs, and patterns of use N Engl J Med 1993;328:246-252 22 Druss BG, Rosenheck RA Association between use of unconventional therapies and conventional medical services JAMA 1999;282:651-656 23 Smith M, Carber L Chiropractic health care in health professional shortage areas in the United States Am J Public Health 2002;92:2001-2009 24 Eisenberg DM, Davis RB, Ettner SL, et al Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey JAMA 1998;280:1569-1575 25 Lind BK, Lafferty WE, Tyree PT, Sherman KJ, Deyo RA, Cherkin DC The role of alternative medical providers for the outpatient treatment of insured patients with back pain Spine 2005;30:1454-1459 26 Assefi NP, Sherman KJ, Jacobsen C, Goldberg J, Smith WR, Buchwald D A randomized clinical trial of acupuncture compared with sham acupuncture in fibromyalgia Ann Intern Med 2005;143:10-19 27 Lind BK, Lafferty WE, Tyree PT, Diehr PK, Grembowski DE Use of complementary and
alternative medicine providers by fibromyalgia patients under insurance coverage Arthritis Care Res In press 28 Lafferty WE, Bellas A, Corage Baden A, Tyree PT, Standish LJ, Patterson R The use of complementary and alternative medical providers by insured cancer patients in Washington State Cancer 2004;100:1522-1530
404
THE AMERICAN JOURNAL OF MANAGED CARE
JULY 2006
Source:ishim.net
