The point here is that the only two places that the phrase "maintenance therapy" is used in the Medicare Policy Manual, are in the sections relating to Chiropractic and rehabilitative services, both of which are services that a Chiropractor may provide. No other type of provider mentioned in the Medicare Policy Manual has this restriction placed upon them.

So how does Medicare, and more broadly, the insurance industry as a whole handle reimbursement for treatment plans that use pharmaceutical methods of care?

Drug Therapy: Is it Maintenance Care?

Well, let's first look at some common pharmaceutical methods of treatment (drug therapy) and see which category they would fall into.

According to the Merck Manual 17th edition, there are generally four classes of drugs that actually correct the problem for which they are prescribed. These are: antibiotics² (antibacterials), antifungals³, and antivirals⁴. Certain chemotherapeutic agents may also fit into this classification as well⁵. So how does this work? If someone takes an antibiotic, the drug kills the infection and "corrects" the problem. Same can be said about the case of antifungals. Antivirals are used to drive the virus into dormancy and therefore correct the problem according to the definition above. Lastly, certain chemotherapeutic agents kill cancerous cells, which is the reason why they are prescribed. All of the drugs classes that have been mentioned thus far either kill or eliminate the source of the problem for which they were prescribed, and therefore fit the definition of active or corrective care.

But what about some of the most popular drugs that are prescribed today? Drugs such as: those that lower cholesterol, blood pressure, blood sugar, and drugs designed to ease asthma symptoms. Each of these drugs maintain, or prevent deterioration of a chronic condition. In other words if the patient stops taking them, the signs and symptoms come back. The condition has not been corrected, and therefore these drugs, by definition, have to be classified as MAINTENANCE DRUGS! Remember that contained within the definition of maintenance therapy is the term "Once the clinical status has remained stable for a given condition, without expectation of additional objective clinical improvements, further treatment is considered maintenance therapy."

In other words if we look at a condition such as type II diabetes, pharmaceuticals are prescribed to lower the patient blood glucose levels. Once the optimum level is reached, the drugs are prescribed continually to maintain blood glucose levels within a normal range. The treatment that was prescribed was never intended to correct the problem, but merely lower blood serum glucose levels and keep them at that level. Once the patient stops taking the drug, the serum glucose levels go back up. Nothing was corrected, and the underlying problem still remains.

OK, now that I have your attention, what about vaccines? Which category do they fall into? Well, by definition, vaccines "seek to prevent disease", and therefore fall into the maintenance drug category. At this point if you're not hopping mad you should be.

We as a profession have bought this stupid policy that insurance companies do not paying for maintenance care for too long. Almost all health plans pay for the maintenance drug classes mentioned above, some on a 90 day refill basis and most on a 30 day. But none pay for Chiropractic adjustments on similar maintenance schedule, even though a properly delivered Chiropractic adjustment removes the subluxation for which it was given. Paying for one type of therapy on a monthly basis and not another reflects outright discrimination against the Chiropractic profession.

What Can Be Done?

So what can be done? Well in the past, not a whole lot. Remember that at the heart of this issue is Medicare, and because Medicare is a federal law and not an insurance company, it literally takes an act of Congress to change it. Additionally, with this discriminatory language being written into the federal code, there was little hope of ever getting private insurance companies to change their policies regarding non-reimbursement for Chiropractic maintenance therapy.

However, with the Supreme Court of the United States (SCOTUS) upholding of the Patient Protection and Affordable Care Act (PPACA), we have hope. The PPACA contains a nondiscrimination section, (section 2706) also known as the Harkin amendment that changes the rules of the game and gives us the firepower to correct this issue like we have never been able to do before.