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2023 Namey/Burnett Preventive Medicine Writing Award second-place winner Elisabeth Arndt, DO, Ph.D. reviews and advocates for equitable reimbursement rates for osteopathic manipulation therapy.
Elisabeth Arndt, DO, PhDSponsored by the ACOFP Foundation, with winners selected by the ACOFP Health & Wellness Committee, the Namey/Burnett Preventive Medicine Writing Award honors the memory of Joseph J. Namey, DO, FACOFP, and John H. Burnett, DO, FACOFP—dedicated advocates for osteopathic medicine—and recognizes the best preventive medicine blog posts submitted by osteopathic family medicine students and residents.
“Ok so I treated 6 different body regions, making this visit a 98927, right? Unless the trapezoids count as upper extremity region, meaning it would be 7 body regions and would be a 98928 instead?” I asked my long-suffering attending, who had now patiently explained Osteopathic Manipulation Therapy (OMT) billing codes to me more times than either he or I would care to count. Since transitioning from medical school to my intern year of residency, I’ve often had cause to reflect upon the fact that I certainly “was not in Kansas anymore,” but learning about billing codes for the first time was like finally meeting the “man behind the curtain” and finding out that he speaks a completely different language that lacks any discernable form of grammatical reasoning. In other words, the U.S. Centers for Medicare & Medicaid Services (CMS) billing code reimbursement rates, and especially those for OMT procedures based upon number of body regions treated, make little sense; worse, they may actually harm patients by limiting the ability of osteopathic physicians to offer them this important modality of preventative medicine.
As the osteopathic and allopathic medical paths continue to merge together, what sets osteopathic physicians apart from other medical providers is their ability to offer their patients OMT, and multiple clinical studies have demonstrated how it is a noninvasive and effective form primary, secondary, tertiary, and even quaternary preventative medicine for a wide variety of medical issues (1). However, the current system by which osteopathic physicians are reimbursed for performing OMT undermines their ability to offer their patients this important form of preventative medicine, and it does so in several ways.
First, the current OMT reimbursement rates do not equitably reflect the value of the services provided in comparison to other common office procedures. A fully licensed and board-certified osteopathic family physician has undergone 11 years of training from college through the end of residency (2), including more than 20,000 clinical training hours (2) with at least 200 hours exclusively dedicated to learning OMT (3), passed three COMLEX Level board examinations (3), and passed both the AOA Family Medicine Cognitive and OMT Performance board examinations (4). In spite of all of this specialized training, the CMS national payment amounts for OMT procedures in the “nonfacility,” or office, are relatively low in comparison to those of other routine office billing codes as outlined in Table 1 below, many of which reimburse physicians at higher rates for less technically complex and time-consuming office procedures (5,6).
As a result of such low reimbursement rates for OMT, osteopathic physicians are disincentivized from incorporating OMT into regular office visits or, worse still, from even offering OMT to their patients altogether. According to Healy, Brockway, and Wilde’s 2021 study surveying over 1,500 osteopathic physicians about their practice of OMT, 78% reported using OMT on less than 5% of their patients, including 56% who said they do not provide OMT to any of their patients at all (7).
That percentage of osteopathic physicians who are not practicing osteopathic manipulation therapy is over double the estimated percentage reported in 2001, representing a significant decline in the practice of the very skillset that distinguishes osteopathic physicians from other medical providers (8).
Of note, in Healy et al’s study, one of the top cited barriers osteopathic physicians had in providing OMT was its low reimbursement value, with several physicians’ being quoted as saying, “I am out-of-network with insurance…It is frequently not worth billing OMT (nearly 100% of the time)” and “Reimbursement is a HUGE rate limiting step,” and lastly, “I have tried multiple times to begin using OMT as an employed practitioner. After [the] company reviews … they determine that it is not cost-effective” (7). Alternatively put, since osteopathic physicians are not being equitably reimbursed for OMT, they are not—or cannot—offer it to their patients, and the practice of OMT will likely continue to decline unless something is done to change that.
Furthermore, for the osteopathic physicians who are practicing OMT to be reimbursed at rates commensurate for their time and skill, they must either 1) ask patients to return for a separate visit entirely dedicated to OMT—which is inconvenient for patients and decreases the effectiveness of OMT in treating acute health concerns—or 2) forgo insurance altogether and exclusively charge cash for OMT in order to justify the time spent performing these procedures. And if these are the only means by which osteopathic physicians can be equitably reimbursed for the OMT they provide, then the current inadequate reimbursement rates are unethically reinforcing socioeconomic barriers to health by placing OMT out of reach for many low-income patients who might otherwise greatly benefit from it.
What is more, the current OMT billing code system is not only unethical, but also antithetical the core principles upon which osteopathic medicine is based, namely the tenet that “The body is a unit, and the person is a unit of body, mind, and spirit” (3). As of now, the current OMT billing code system paints each patient as a sum of collective body regions of head, cervical, thoracic, rib cage, lumbar, sacral, pelvic, upper extremities, lower extremities, and abdomen/other, and then assigns a price tag to the treatment of each of them. This is in direct contradiction to the osteopathic principle that no body part or region of a patient, in either form or function, is independent of the rest of them, not to mention from their mind and spirit. For example, how could doing a thoracic inlet release on a patient to treat their severe lower extremity lymphedema count as only treating the thoracic region when it effects the lymphatic circulatory system throughout the entire body? The same argument can be made for other OMT procedures like those helping regulate the autonomic nervous system, attenuate viscerosomatic reflexes, and countless others.
Altogether, the current OMT billing code system is problematic because it does not equitably reflect the value of the OMT in comparison to other common office procedures, directly contributes to the decline in the practice of OMT, reinforces socioeconomic barriers to health, and contradicts osteopathic principles. Simply put, the current OMT reimbursement system not only undermines osteopathic physicians’ ability to offer this comprehensive form of preventative medicine, but also the entire philosophy upon which osteopathic medicine is based.
To address this problem, osteopathic physicians must advocate for policy to be changed at the national level, and one way to do this is to submit a resolution to the American College of Osteopathic Physicians (ACOFP) via the process outlined in Figure 1 below (4,9).
Figure 1. ACOFP’s Advocacy Process (4,9)
As always, the inciting factor for any change starts when one individual has an idea for how to improve the world around them. With the help of the osteopathic family physicians, residents, and medical students in the advocacy committee of their state’s affiliated ACOFP society, that individual then turns their idea into a written resolution advocating for that change. After working together to compose and edit the resolution, that state ACOFP advocacy committee then submits it to the ACOFP House of Delegates, a national committee composed of delegates from each state’s ACOFP society and osteopathic medical schools. All of the resolutions submitted for that year are then distributed amongst the House of Delegate members for review before the ACOFP Congress of Delegates, a meeting which convenes every spring during the ACOFP Annual Convention & Scientific Seminars to discuss and vote on resolutions (4). During this meeting, these resolutions are either accepted, returned to their state ACOFP affiliate association for edits for resubmission the following year, or rejected. The resolutions that are accepted then guide the ACOFP’s time, efforts, and resources to put that idea into motion and, finally, effect change at the national level (9).
In keeping with this process for the advocacy of an improved OMT reimbursement system, the Michigan Association of Osteopathic Family Physicians (MAOFP) Advocacy Committee has submitted a resolution for review at the 2023 ACOFP Congress of Delegates, petitioning the ACOFP to:
And while this resolution may get the wheels of change moving, the destination is still uncertain. We, as an entire osteopathic medicine community of every specialty, must work together to determine what OMT reimbursement system might better reflect OMT’s preventative medicine value, such as one based on the complexity or number of the medical conditions an OMT procedure addresses or the time spent performing OMT, to name a few.
No reimbursement system for OMT will ever be perfect, and changing the paradigm is rarely easy, but it is still worth striving for a billing system that better reflects OMT’s value to patients and the comprehensive primary, secondary, tertiary, and quaternary preventative medicine it can provide them. In other words, the osteopathic community must find a billing structure that is related, if not reciprocally, to the function of OMT in preventative medicine.
Special thanks to my many osteopathic family physician mentors, in particular Dr. Robert Taylor Scott and Dr. William Swords, who are endless sources of inspiration for everything an osteopathic family physician can do for their patients and community, and Dr. Rachel Allison Young, for introducing me to the world of ACOFP advocacy and all of its possibilities.
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ACOFP is a community of current and future family physicians that champions osteopathic principles and supports its members by providing resources such as education, networking and advocacy, while putting patients first.