Background story: Keller family sues U.S. Department of Defense after TRICARE refuses to cover equine physical therapy.
This is an interesting case from a policy setting perspective. It highlights the struggles that providers must learn to more effectively overcome in working with health plans when confronted with the issue of advocating for their patients when coverage guidelines on the payer side are not met for treatments/services that the physician believes necessary for her/his patients.
The final outcome may very well hinge on the argument of whether or not a horse is a tool to aid in the provision of already proven physical therapy vs. a separate modality that is unproven which is the prevalent status of hippotherapy aka equine therapy. That would appear to be a decision that transcends but is nonetheless foundational to CHAMPUS regulations that seem to be guiding TRICARE’s decision to withhold coverage in spite of the ALJ decision.
The report and the complaint filed with the court for relief from TRICARE’s maintaining its decision to not cover the horse related physical therapy did not appear to address one of the likely primary considerations contributing to TRICARE’s decision. There is an additional federal regulation that requires all covered care to be proven. If the larger issue of whether or not horses are mere tools in the provision of physical therapy as opposed to being a completely stand alone treatment modality then the issue of it being considered a proven treatment is hanging as a larger looming issue.
Here is the regulation not cited in the complaint:
32 CFR Section 199.4 – Basic program benefits: (15) Unproven drugs, devices, and medical treatments or procedures. By law, CHAMPUS can only cost-share medically necessary supplies and services. Any drug, device, or medical treatment or procedure, the safety and efficacy of which have not been established, as described in this paragraph (g)(15), is unproved and cannot be cost-shared by CHAMPUS except as authorized under paragraph 199.4(e)(26) of this part.
It appears to be a primary issue of semantics – whether or not Kaitlyn is benefiting from physical therapy that uses a horse as a therapy tool or whether she is benefiting from hippotherapy aka equine therapy. Here is an article written by a PT who attempts to address the semantics issue. It’s a compelling argument.
What’s troubling however, is that as a group of health professionals, PT’s and other healthcare professionals who advocate use horses as tools in PT and OT apparently have failed as of yet to generate the credible evidence that meets the rigid requirements of health payers to accept use of horses as tools in therapy as safe and effective and / or they have failed to differentiate the use of horses as tools from the generally unaccepted modality that is hippotherapy. Regardless, they have failed to get use of horses to be an acceptable component of reimbursable healthcare under prevailing health insurance practices.
Interestingly, TRICARE does have a hippotherapy benefit under the ECHO program but for diagnoses that Kaitlyn appears not to have. Hippotherapy is not covered under TRICARE basic benefits. Hippotherapy is usually not covered under TRICARE due to the above referenced regulation that excludes non-proven / investigational care outside of TRICARE approved pilot or demonstration projects.
Other insurance payers seem to consider both physical therapy using horses and hipportherapy /equine therapy to be one and the same but stand firm on the side of it being a modality that is unproven. There appears to be mixed policies with respect to coverage across various health plans, though the vast majority cite it as unproven. Most look at it from perspective whether it is proven as effective treatment of spastic CP.
Here is a short list of health plans that deem equine therapy as not covered / investigational, though most here do not specifically address it as modality to treat scoliosis:
http://www.aetna.com/cpb/medical/data/100_199/0151.html
Click to access rehabilitative_therapies.pdf
http://www.anthem.com/medicalpolicies/anthem/va/policies/mp_pw_a050176.htm
Here is a plan where it is covered in only very limited / minimal instances – somewhat similar to TRICARE ECHO program allowance, though I think maybe less generous:
https://www.wellcare.com/WCAssets/corporate/assets/ccg/hs_ccg_hip
A decision by TRICARE to permit coverage of the CPT billing codes as reported about Kaitlyn’s care in the Dallas News blog article linked above seems at face value to be an innocuous decision in light of the fact that Katilyn’s treating healthcare providers report that the therapy using a horse is maintaining her spinal alignment and that the costs to doing so is neutral to therapy provided using other tools that are less effective.
Risk of setting a precedent for allowing arguably unproven treatment tools or modalities is a likely overriding concern that is compelling the decision not to approve coverage. It is a completely legitimate concern as it drives to the ability of health plans to assure that covered care guidelines assure safe, proven, and effective care under the benefits. It is all the more prudent in light of the ever present need to minimize the tax burden to publicly funded plans and assure valuable returns on the investment. DoD healthcare dollars are not in abundance as policy makers continue to wrestle with sequestration It is unfortunate that such considerations affect individual patients from getting treatments or services that their treating providers believe are necessary to meeting their individual healthcare needs. Such fall out is a byproduct of trying to balance the goals of operating effective health plans at a population based level while maintaining a responsibility to meeting the person centered needs of individualized care planning.
It would be ideal and most prudent if the physical and occupational therapy professional community could work to generate the evidence needed to legitimize the use of horses as a reimbursable component of their craft in whatever way the health insurance industry requires. The bottom line is that if use of horses as a tool for administering physical or occupational therapy is indeed an effective treatment to a generalizable group of patients with similar health conditions such as scoliosis and other musculoskeletal conditions, then it should be provable in commiserate methods and fashion just as other established medical standards of care are.
In the mean time, in light of the cost neutrality and apparent effectiveness of the use of horses as tools in the provision of the actual therapy treatments rendered to Kaitlyn, perhaps some authorized type of waiver can be granted or the DoD Undersecretary of Health Affairs can reverse course and abide by the ALJ ruling to let Kaitlyn resume getting the therapy using a horse so as to prevent further misalignment of her spine that her physicians fear will lead to a worsening of her health – requiring even more healthcare expenditures and hardship to Kaitlyn and her family. That can assuredly be done with minimal if any damage to the TRICARE program while the issue is worked out of whether or not the use of horses in the provision of PT and OT is proven or not regardless of the semantics of it being a tool used in generalized PT/OT or completely separate modality.
Living in America 