Hawaii has a long-standing tradition of insurance coverage for injured workers and those involved in automobile accidents that includes acupuncture, chiropractic, naturopathy and massage therapy. More than 70 percent of workers’ injuries and the majority of complaints among those involved in motor vehicle accidents are musculoskeletal in nature. These services can offer substantial support toward the resolution of such pain and suffering in combination with or, at times, instead of modern medical care. Tens of thousands of research studies have been done to evaluate clinical outcomes from such care options, and responsible guidelines can be derived from this information. All four of these professions have Hawaii state boards that provide licensure and monitor scope of practice.

Personal injury protection (PIP) insurance, which pays for medical care after a motor vehicle accident, underwent substantial reform in the state Legislature during the late ’90s. In part, based on perceptions of abuse by the chiropractic profession, a bill was passed mandating that for all PIP policies the total maximum combined number of visits offered by acupuncture, chiropractic and naturopathy be capped at 30. The bill further mandated that all PIP carriers pay a maximum of $75 per visit for all three professions. No provisions were made for cost-of-living increases. What police officer, what teacher, what office worker would continue to work for 12 to 15 years without any cost-of-living increase, let alone additional compensation for longevity and performance?

In the meantime the acupuncture profession has gone from a minimum of three years to four years of training required to obtain a license, and more acupuncturists have been awarded doctoral degrees, notwithstanding certain concerns regarding the quality of some of the doctoral programs. Largely, under the leadership of Chrisoula, a leading chiropractic physician association, utilization among the chiropractic profession has become more measured.

Finally, naturopathic physicians, who complete four years of premed and four years of naturopathic school, have essentially achieved primary care status in Hawaii based on bills passed two years ago. Concerns do remain as to their broad latitude with prescriptive rights and the choice of formulary.

In summary, all three professions have come a long way since PIP reform began in the mid- to late ’90s.

Now is the time to revisit and update the position taken by the Hawaii Legislature so many years ago. No profession, product or service should be legally capped at a fixed reimbursement rate ad infinitum and sustain what amounts to shrinking fees as inflation advances. Furthermore, it is no more justified to cap acupuncture, chiropractic and naturopathy at a total combined maximum of 30 visits than it would be to cap medical visits, physical therapy or massage, which are also covered under PIP but stand outside the 30-visit cap. All care under PIP should simply be held to the requirement that it is reasonably appropriate and necessary.

Integrative medicine, founded on the principle of team-based care, has been shown to work. In turn, coordinated dialogue among leadership of relevant health professions and concerned legislators has the potential to bring about much-needed change in PIP coverage.

Ira Zunin, M.D., M.P.H., M.B.A., is medical director of Manakai o Malama Integrative Healthcare Group and Rehabilitation Center and CEO of Global Advisory Services Inc. Please submit your questions to info@manakaiomalama.com.