[Title]

Committee: Health Policy

Complete to 11-13-08

A SUMMARY OF HOUSE BILL 5759, HOUSE BILL 6201, AND HOUSE BILLS 6407-6411 AS REPORTED FROM COMMITTEE 11-13-08

House Bill 5759 would expand the scope of practice of chiropractors to include the diagnosis and treatment of neuromuscular and skeletal disorders related to subluxations, misalignments, and joint dysfunction occurring anywhere in the body; to evaluate conditions and symptoms related to subluxations, joint dysfunction, or misalignments through physical examination, patient information, performing or ordering tests; and to use various imaging technologies.

House Bill 6201 would amend a provision that gives the Board of Chiropractic authority to promulgate rules so that the board would have rulemaking authority over the use of imaging technology by chiropractors. The bill would also require applicants for license renewal to complete, as part of the required attendance at educational conferences, an appropriate number of hours or courses in new imaging technology and extraspinal treatment.

House Bills 6407-6411 The bills would amend various insurance-related acts pertaining to reimbursement for covered benefits to specify that reimbursement or coverage would not be required for a practice of chiropractic service unless that service was included in the definition of the practice of chiropractic under Section 16401 of the Public Health Code as of January 1, 2008 (that is, the definition prior to the expansion found in House Bill 5759).

The bills are tie-barred to each other. A detailed discussion of each bill follows.

House Bill 5759

The bill would amend Part 164 of the Public Health Code (MCL 333.16401), entitled "Chiropractic," to revise the definition of "practice of chiropractic."

Proposed changes are underlined and would include the following.

· The term "practice of chiropractic" would be redefined to mean that discipline within the healing arts that deals with the human nervous system and the musculoskeletal system and their interrelationship with other body systems. Currently, the term only applies to the interrelationship between the spinal column and other body systems. (Generally speaking, a subluxation is an incomplete dislocation of a bone in a joint; spinal subluxations refer to dislocations involving the vertebrae of the spine.) “Musculoskeletal system” would be defined to mean the system of muscles, tendons, ligaments, bones, joints, and associated tissues that move the body and maintains its form.

· The practice of chiropractic would include the diagnosis of human conditions and neuromuscular and skeletal disorders related to subluxations, misalignments, and joint dysfunctions for the purpose of detecting and correcting those disorders or offering advice to seek treatment from other health professionals in order to restore and maintain health. Currently, diagnosis is restricted to determining the existence of spinal subluxations or misalignments.

· The practice of chiropractic would include the evaluation of conditions or symptoms related to misalignment, subluxations, and joint dysfunction through physical examination, the taking and reviewing of patient health information, the performance or ordering of tests, and the use of x-ray or other imaging technology. The performance or ordering of tests and the use of x-ray or other imaging technology in the practice of chiropractic is regulated by rules promulgated under Section 16423. The bill would delete a provision specifying an x-ray machine can only be used to examine patients for the purpose of locating spinal subluxations or misaligned vertebrae of the human spine.

· The practice of chiropractic would include the chiropractic adjustment of subluxations, misalignments, and joint dysfunction and the treatment of related bones and tissues for the establishment of neural integrity and structural stability.

· The practice of chiropractic would include the use of physical measures, analytical instruments, nutritional advice, rehabilitative exercise and adjustment apparatus regulated by rules promulgated under Section 16423.

The practice of chiropractic would not include the performance of any procedure that cuts or punctures the skin; the dispensing or prescribing of drugs or medicine; or, except for diagnostic purposes only, the use of x-ray.

House Bill 6201

The bill would amend Part 164 of the Public Health Code (MCL 333.16423 and 333.16431) to incorporate changes proposed by House Bill 5759 and to require the completion of courses in new imaging technology and extraspinal treatment by applicants for license renewal.

Currently, the Board of Chiropractic is required to promulgate rules to establish criteria for the approval of analytical instruments and adjustment apparatus to be used for the purpose of examining patients in locating spinal subluxations and misalignments of the human spine. Instead, House Bill 6201 would require the Department of Community Health, in consultation with the board, to promulgate rules to establish criteria for the performance and ordering of tests and the approval of analytical instruments, imaging technology, and adjustment apparatus to be used for the purpose of examining and treating patients for subluxations and misalignments that produce nerve interference or joint dysfunction.

The criteria established must be substantially equivalent to nationally recognized standards in the profession for the performance and ordering of tests and the use and operation of the instruments, imaging technology, and apparatus. The bill would also allow the board to approve types and makes of imaging technology and adjustment apparatus that meet these criteria (in addition to analytical instruments as currently allowed) and would prohibit an individual from performing or ordering tests or using imaging technology that does not meet nationally recognized standards or that are not approved by the board (this prohibition currently applies to analytical instruments and adjustment apparatus).

Currently, the board may require a licensee seeking renewal of a license to provide documentation that he or she attended – in the two years immediately preceding the application for renewal – not less than two approved two-day educational conferences in subjects related to the practice of chiropractic and designed to further educate licensees and which include an appropriate number of hours or courses in pain and symptom management.

The bill would require the department, in consultation with the board, to promulgate rules requiring each applicant for license renewal to complete as part of the educational conferences an appropriate number of hours or courses in new imaging technology and extraspinal treatment.

House Bills 6407-6411

The bills would amend various insurance-related acts pertaining to reimbursement for covered benefits to specify that reimbursement or coverage would not be required for a practice of chiropractic service unless that service was included in the definition of the practice of chiropractic under Section 16401 of the Public Health Code as of January 1, 2008 (that is, the definition prior to the expansion found in House Bill 5759).

House Bill 6407 and 6408 would amend the Insurance Code (MCL 500.3107b and 500.3107b et al., respectively) to apply to insurance claims under the no-fault act, individual and group disability insurers, commercial health insurers, and health maintenance organizations (HMOs).

House Bill 6409 would amend the Nonprofit Health Care Corporation Reform Act (MCL 550.1502a) to apply to Blue Cross Blue Shield of Michigan.

House Bill 6410 would amend the Prudent Purchaser Act (MCL 550.53) to apply to prudent purchaser agreements.

House Bill 6411 would amend the Worker’s Disability Compensation Act (MCL 418.315) to apply to employer-reimbursable charges.

FISCAL IMPACT:

A fiscal analysis is in progress.

BACKGROUND INFORMATION:

Michigan remains one of the most restrictive states in regard to the scope of practice for chiropractors. Chiropractors maintain that under state law, they cannot practice to the full level of their training and education; for instance, treating subluxations in areas of the body other than the spine and using ultrasound and other newer technologies to treat patients. House Bills 5759 and 6201 would allow chiropractors to treat other areas of the body related to subluxations, misalignments, and joint dysfunction. In addition, as allowed under departmental rules, chiropractors could also use imaging technology and perform and order tests. House Bill 6407-6411 would make reimbursement by health insurers for the new services optional. The use of chiropractic is known to increase access to care and lower health care costs. These benefits would be realized in greater numbers if the scope of practice was redefined to incorporate those treatments and services chiropractors are trained to provide.

Opponents of the legislation maintain that there is no current emergency driving quick adoption of the bills and the complex nature of the changes requires a deeper look. For instance, though the committee substitutes for House Bill 5759 and 6201 tighten up the diagnoses that chiropractors would be authorized to perform, concerns remain with the expansion to cover neuromuscular and skeletal disorders. Even though the treatment must be in connection with subluxations and joint dysfunctions, the concern is that the change could allow chiropractors to treat Parkinson’s disease. Further, the change in the current prohibition against invasive procedures to instead prohibit procedures that puncture the skin could allow chiropractors to perform prostate exams, among other things. Whenever a scope of practice for a health profession is added or significantly revised, a thorough vetting is necessary to avoid unintended consequences that could negatively impact the public’s health and safety.

POSITIONS:

The Michigan Association of Chiropractors supports HB 5759 and HB 6201. (11-13-08)

Among those indicating opposition to the bills on 11-13-08 were the following:

Michigan Association of Health Plans – HB 5759 and HB 6201

Michigan Chapter Academy of Pediatrics – All bills

American College of Cardiology – HB 5759 and HB 6201

Michigan State Medical Society – HB 5759 and HB 6201

Michigan Radiological Society – HB 5759 and HB 6201

Insurance Institute of Michigan – HB 5759 and HB 6201

Michigan AFL-CIO – HB 5759 and HB 6201

Department of Community Health – HB 5759

Michigan Physical Therapy Association – HB 5759

Michigan Orthopedic Society – HB 5759

Michigan Osteopathic Association – HB 5759 and HB 6201

Economic Alliance of Michigan – HB 5759

Office of Financial and Insurance Regulation – HB 6407-6410

AAA Michigan indicated support for House Bill 6407.

Legislative Analyst: Susan Stutzky

Fiscal Analyst: Susan Frey

■ This analysis was prepared by nonpartisan House staff for use by House members in their deliberations, and does not constitute an official statement of legislative intent.