As a small-business operator, Julie Silver, an acupuncture specialist and owner of West Bloomfield Township-based Acupuncture Healthcare Associates of Michigan, also works in the growing health care field of complementary and alternative medicine.
Like most similar providers, Silver's patients mostly pay out of pocket for services because few health insurers cover acupuncture.
"We are seeing more people use their health savings accounts to pay," said Silver, noting that her practice has grown 10 percent to 15 percent every year and is up to 100 patients per week.
Samuel Gray and Roy Picard, chiropractors who run separate small clinics in Waterford Township and Shelby Township, respectively, said 30 percent to 40 percent of their revenue comes from cash or through health savings accounts.
"We are going through an incredible growth spurt," said Picard, who may hire another chiropractor this year. He also employs a medical biller, two receptionists and leases space to a massage therapist.
Picard, who opened his practice in 1991, said he became interested in chiropractic neurology, nutrition, functional endocrinology and applied kinesiology in 2003.
"We tie everything we do to the nerve and brain system to optimize brain and nerve function," Picard said. "Only about 20 percent of what we do is traditional chiropractic."
Like most small employers, Gray, who owns Summit Chiropractic, said one challenge is paying employee health care costs.
"We have had a 10 to 20 percent increase" in premiums the past few years, said Gray, who covers four full-time employees.
"It has been a challenge to keep it as a benefit to employees," Gray said. "They are paying more in co-pays and deductibles and we are looking into health savings accounts."
But Gray said rising co-payments also affect his revenue, as patients sometimes think twice about coming in.
"When co-pays go up to $40 from $20, some patients wait until it gets serious. We are holding steady, but most everybody is down 10 to 15 percent," Gray said.
Chiropractic care has become more accepted by mainstream medicine in recent years, primarily because it is licensed in most states, including Michigan, and covered by insurance.
But employers and health insurers in Southeast Michigan have been slow to embrace complementary and alternative medicine, say employee benefit professionals and owners of complementary and alternative medicine clinics.
Some 38 percent of U.S. adults -- more than 44 percent for those ages 50-59 -- use at least one complementary or alternative medicine, or CAM, service each year, according to a 2008 report from the National Institutes of Health's National Center for Complementary and Alternative Medicine, available at www.nccam.nih.gov.
Nationally, Americans spent nearly $34 billion in 2007 on CAM products and visits, accounting for 11.2 percent of all out-of-pocket spending on health care and 1.5 percent of total health care expenditures.
Most people use alternative and integrative medicine for musculoskeletal problems, including back, neck or joint pain. But people also are seeking alternative medicine for stress reduction, relaxation, general wellness and for dietary and nutritional counseling, said Ramon Nunez, who practices acupuncture and Chinese medicine at the Waterford Center for Integrative Medicine.
"We have people who use complementary and alternative medicine to supplement conventional medicine," said Nunez, who also is a consultant with Southfield-based Henry Ford Center for Integrative Wellness.
Jerry Konal, health and benefits practice leader at Mercer's Detroit office, said companies in Michigan might be cutting back on alternative medicine coverage to reduce health care expenses.
"I don't think Michigan lags behind other states in general, but you will tend to see initiatives in health care working their way in from the coasts," Konal said.
Most employer benefit packages offer chiropractic care and to a lesser extent acupuncture, he said. Like most health care services, alternative medicine is covered after the deductible is met. There usually is a yearly limit on the number of visits up to about 30, he said.
In Mercer's 2009 national health plan survey, the percentage of alternative medicine services offered by employers increased with the size of the companies. For example, 68 percent of companies with 10-49 employees offered chiropractic benefits compared with 95 percent of companies with 20,000 or more employees.
The top surveyed alternative medicine services were chiropractic (covered by 72 percent of all companies), acupuncture/acupressure (24 percent), massage therapy (19 percent), homeopathy (11 percent) and biofeedback (6 percent), Mercer said.
While most states mandate chiropractic care insurance coverage, only 12 states mandate coverage for acupuncture services and only four require it for naturopathy services.
But mandating complementary and alternative medicine coverage doesn't always make it widely available.
Last year, the Lansing-based Michigan Association of Chiropractors sued Blue Cross Blue Shield of Michigan for limiting coverage and payment of chiropractic services.
The lawsuit, which is being heard by Ingham County Circuit Court Judge Paula Manderfield, alleges Blue Cross has engaged in discriminatory conduct against chiropractors that includes: Offering members a limited chiropractic network; requiring patients to seek a primary care referral for services; and not paying for some services permitted by Michigan law.
Blue Cross declined to comment.
Picard said Blue Cross and other health insurers are becoming more restrictive in the numbers of visits and types of treatments they cover.
Still, Picard said, he has been working more often with physicians, including primary care doctors, neurologists and oncologists.
"Patients will ask their doctor to send me blood work to see if there is anything we can do to help them," Picard said. "The doctors call me and we build rapport with them through the blood work discussion."
Picard said discussions with medical doctors help to rule out problems and avoid duplicative tests and services.
For example, Picard said he often consults with physicians on the treatment of patients with pain or other medical problems associated with nerve damage from peripheral neuropathy.
"We are seeing patients who couldn't walk that well before, couldn't drive, and they are seeing the results of our treatment," Picard said.
Gray said most of his patients come in for back pain.
"Most (spinal) disc cases will respond to treatment," Gray said. "We had a new patient who is undergoing chemotherapy and her physician referred her to a chiropractor for low back pain radiating to her legs."
In May, the state of Michigan began to send voluntary registration applications for acupuncture and massage specialists. State law requires physician referral for acupuncture services.
"Registration is the first step to licensure. This is a good message to insurers that members want it," Silver said. "This sets a scope of practice and creates legitimacy for our practices."
Silver said most medical doctors accept acupuncture for a variety of treatments.
Kristine Dowell, executive director of the Michigan Association of Chiropractors, said she hopes chiropractic and other alternative medicine treatments will become part of the essential benefit plans that will be offered by the state health insurance exchanges in 2014.
"We are pushing this at the national level to make musculoskeletal care a part of the essential benefits because of the strong wellness component," Dowell said. "Everybody who is licensed to perform services should be allowed. This could really allow chiropractic care to take off."
While the Michigan State Medical Society has opposed scope of practice expansion of chiropractors and other alternative medicine providers, Colin Ford, the medical society's state legislative director, said opposition is limited to services that doctors consider to be the practice of medicine.
"We look at it on a case-by-case basis," Ford said. "It is one thing to go to a massage therapist to get some relief; it is another thing if they say, "stop taking your diabetes medicine.' "
Ford said many medical doctors are working with alternative medicine providers to ensure therapies are complementary.
But Ford said the medical community is opposed to a bill in the Legislature this year that would allow non-licensed alternative medicine providers to practice their full scope of services.
Modeled after a 2002 state law in California, the Michigan Health Freedom Act would allow naturopathic physicians, herbalists, denturists, homeopathic doctors and other alternative medicine providers to freely practice under the state's medical practice act.
