Insurance coverage by indication for acupuncturist visits in the 2010-2015 Medical Expenditure Panel Survey

 

Dear Editor,

Acupuncture therapy is supported or recommended as part of comprehensive pain care by the Agency for Healthcare Research and Quality (AHRQ), the Joint Commission, the Food and Drug Administration (FDA), the Department of Health and Human Services (HHS), and the American College of Physicians.¹ Yet insurance coverage for acupuncture therapy is limited.^2,3 While the rate of insurance coverage for acupuncture therapy has increased in recent years, most costs are paid out-of-pocket and insurers tend to cover a narrow set of indications and provider types.^3,4

Here, we use the 2010–2015 Medical Expenditure Panel Survey (MEPS) to identify which indications are associated with acupuncturist visits and to estimate how insurance coverage differs across indications. Our goal is to examine how acupuncture therapy was being used in the United States between 2010 and 2015, and the extent to which insurers were reimbursing it.

Methods

Data are from the MEPS, a nationally representative survey that tracks office visits with medical providers, including acupuncturists, and measures insurance coverage for visits. The sample includes respondents aged 18+ years with private insurance, Medicare (both Medicare fee-for-service and Medicare Advantage), Medicaid, and other insurance types, including TRICARE and worker’s compensation.

First, we measured the self-reported primary indication associated with acupuncturist visits. The MEPS aggregates International Classification of Disease (ICD), 9th Edition, Clinical Modification into clinical classification codes, which were available through 2015 due to the shift to ICD-10 codes. Second, we calculated (1) the rate of insurance coverage for acupuncturist visits and (2) the share of spending paid out of pocket, which was defined as out-of-pocket costs divided by the total cost of the visit, overall and for the most frequent indications.

Results

Between 2010 and 2015, 739 respondents in the MEPS reported 4812 office visits with an acupuncturist. Of these, 4413 visits had a self-reported indication. Another 87 722 respondents did not report visiting an acupuncturist. On average, acupuncture users were older, more likely to be female, had more years of formal education, and were more likely to be Asian or White and less likely to be Black or Hispanic.

The 5 most frequent indications for acupuncturist visits were joint-related conditions, including rheumatoid arthritis, osteoarthritis, and other joint disorders (23% of acupuncturist visits cited joint-related conditions), back pain, including spondylosis and intervertebral disc disorder (18%), connective tissue disorders (6.9%), anxiety disorders (4.5%), and headaches and migraines (4.2%) (Table 1).

Table 1.

Self-reported indications for acupuncturist visits in the Medical Expenditure Panel Survey, 2010–2015.

Clinical Condition	Number of Visits	Share of Visits	Number of Respondents
Joint-related conditions, including osteoarthritis, rheumatoid arthritis, and other joint disorders	1116	23.2%	163
Back pain, including spondylosis, intervertebral disc disorders, and other back problems	855	17.8%	158
Connective tissue disorders, including peripheral enthesopathies and disorders of the muscle ligament and fascia	330	6.9%	61
Anxiety disorder	215	4.5%	25
Headache and migraines	202	4.2%	30

In total, there were 4812 acupuncturist visits among 739 unique respondents during the study period. Clinical conditions were self-reported and may not have reflected the indication that was billed for.

Source. Blewett LA, Rivera Drew JA, Griffin R, King ML, Williams KCW. IPUMS Health Surveys: Medical Expenditure Panel Survey, Version 1.1 [data set]. University of Minnesota. Accessed December 18, 2022. https://www.ipums.org/projects/ipums-health-surveys/d071.v1.1.

Overall, 43% of acupuncturist visits had some insurance coverage, although rates differed across indications (Figure 1). Rates were higher for back pain (55% of visits citing back pain had some insurance coverage) and anxiety disorders (62%). Rates were lower for joint-related conditions (43%) and connective tissue disorders (34%). The share of spending paid out of pocket ranged from 37% of spending for visits citing anxiety disorders to 73% of spending for visits citing connective tissue disorders. In terms of insurance type, 25% of visits had some private insurance coverage, 5.0% of visits had some Medicare coverage, 7.4% of visits had some Medicaid coverage, and 7.3% of visits were covered by another insurance type, including TRICARE.

Figure 1.

Share of acupuncturist visits covered by insurance and share of spending paid out-of-pocket, overall, and by self-reported indication. The share of spending paid out-of-pocket includes visits without any insurance coverage.

Discussion

According to the MEPS, Americans typically visited acupuncturists for pain care between 2010 and 2015. Joint-related conditions were the most frequent indication, followed by back pain and connective tissue disorders. We found higher rates of insurance coverage for back pain compared to joint-related conditions. Unexpectedly, the highest rate of insurance coverage was for anxiety disorders, although the number of respondents citing anxiety was small. The lowest rate of insurance coverage was for connective tissue disorders—despite evidence pointing to the effectiveness of acupuncture for conditions like fibromyalgia.⁵ As expected, lower rates of insurance coverage correlated to a larger share of spending paid out-of-pocket.

These findings are notable given the need for safe and effective pain care that avoids the liabilities of opioids. In one survey, over a third of physicians felt that reductions in opioid prescribing were having an adverse consequence for patients in pain; some noted their health care organizations were not treating pain sufficiently.⁶ Sufficient pain care is not necessarily reached by a continued reliance on opioids but rather increased access to evidence-based options, such as acupuncture therapy.

A key limitation of our study is that it predates Medicare Part B’s coverage expansion for acupuncture for chronic low back pain (cLBP) in 2020.^7,8 Still, these findings add useful context to this decision, as we show that Americans frequently used acupuncture therapy to address joint-related disorders and connective tissue disorders, at least between 2010 and 2015.

We also note that, as of August 2023, licensed acupuncturists cannot bill Medicare directly.⁹ Instead, they are required to bill through an existing Medicare biller, erecting a barrier to access. Additionally, Medicare reimburses acupuncture at a lower rate than that previously paid by the US Department of Veterans Affairs (VA), which creates a downstream effect of reduced reimbursement. The “maximum allowable rate” for the VA has become, by default, “the applicable rate” for Medicare services.¹⁰ Thus, Medicare’s decision highlights how expansions in insurance coverage can be coupled with restrictions.

This study has other limitations. While the MEPS is nationally representative, the survey resulted in fewer than 750 acupuncture users. Variables were self-reported by respondents and not verified using insurance claims or medical records. Spending measures did not disaggregate copays, coinsurance, or deductibles, and it was unclear whether respondents had additional modes of paying acupuncturists, such as health savings accounts.

Nevertheless, we are the first to measure how Americans were utilizing acupuncture therapy and how insurers were reimbursing it across indications using a nationally representative survey. A better understanding of the process by which insurers make coverage decisions about acupuncture therapy, such as the setting of reimbursement rates, restrictions on indications and provider types, and other mechanisms like prior authorization or referral requirements, could improve coverage and access to evidence-based pain care.

Funding

Dr. Candon reports support from the National Center for Complementary and Integrative Health (K01AT011776: Insurance Coverage for Acupuncture). Research reported in this publication was partially supported (J.A.D., A.N.) by the National Center for Complementary and Integrative Health (R01AT010598: Acupuncture in the Emergency Department for Acute Pain). The study sponsor had no role in the study design; collection, management, analysis, and interpretation of data; writing of the report; and the decision to submit the report for publication, including whether they will have ultimate authority over any of these activities. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Conflicts of interest: None declared.