Never underestimate the power of an idea whose time has come. Although U.S. health care is an ailing system, there exists a simple yet profound solution to fixing many of our health care woes and it is a win-win situation for nearly everyone. The only problem? We have to get around the politics in medicine.

Overhauling Health Care
No nationwide overhaul of our health care system is likely to occur until we address the power of private interests who stand in the way of reform. Health care is in the midst of a paradigm shift. The public is redefining health and healing and this fact is a threat to bureaucracies and businesses that have grown powerful by managing illness. The new paradigm is a threat because, as we redefine health care, we demand access to new methods of healing. “Medical” care is only a small slice of “health” care. Health care includes access to all kinds of treatment options, not just conventional medicine. As the public need grows for affordable health care options, successful reform is thwarted by organizations whose people and pocketbooks are threatened by change and any reduction in public use of conventional medicine. So, while there is not one single culprit making our health care system sick, there are powerful forces preventing it from getting well.

The Elephant in the Room
Enter the Department of Health and Human Services (HHS), a government body with a budget bigger than the military, and its established relationship with the American Medical Association (AMA), a private trade organization comprised of conventional physicians created to support its members. The elephant in the room is a little-known monopoly granted by HHS to the AMA, which is controlling access to much of the U.S. health care system.

A Billing Code Monopoly
How has the HHS put a conservative MD organization in control of our access to health care? By giving it control of billing codes. The vast majority of insurance payments for health care services are based on a complex set of billing codes developed by the AMA. The AMA codes are used to track every physician transaction in health care and these codes generate data the industry uses to price health care premiums, measure costs and evaluate what constitutes effective care. When you go to see your doctor, everything that transpires in his or her office is recorded with these codes. Doctors’ offices then use these codes to bill for reimbursement from your insurance company.

Conventional or “allopathic” physicians make up fewer than 20 percent of all health care providers in this country. Conventional medicine is commonly the most expensive option. Through a contractual relationship, the AMA has been given the power to co-create all new codes alongside HHS. HHS pays nothing to the AMA for use of its codes under Medicare or Medicaid but according to a report by The Wall Street Journal, the AMA makes over $71 million each year licensing codes or selling code books to doctors’ offices, insurance companies and software vendors. HHS also agreed not to support the adoption of any competing codes as part of the contractual relationship that established this monopoly. The result is that over 2.4 million non-physician practitioners—such as advanced practice nurses, chiropractors, acupuncturists, nutritionists, midwives, mental and behavioral therapists, and integrative and alternative MDs and DOs—lack codes to bill for the care they provide. To date, while there are more than 8,000 CPT codes in existence to support conventional physician billing, there are fewer than 100 codes to support billing from the other 80 percent of practitioners. For example, chiropractors and acupuncturists have four codes each and massage therapists have only one code.

Negative Consequences of the Code Monopoly
The HHS-AMA billing code monopoly drives up the costs of health care by limiting billing to physician-directed medicine, the most expensive care option. Your insurance company then limits reimbursement to practitioners outside the medical model and to qualified non-physicians who are authorized to bill without physician oversight. This forces you to pay out of pocket for many treatments.

Codes designed by and for physicians also force other practitioners to use them improperly. For example, advanced practice nurses, who have extremely limited codes to describe their services, must instead use codes, which reflect MD care. If your doctor charges $300 per hour, while the critical care nurse charges $100 per hour, you begin to get the picture of how a lack of proper codes contributes to the astronomical cost of health care. A national lack of access to affordable and preventive care has also contributed to overuse of emergency medicine and placed an extraordinary financial burden on our hospital systems.

A lack of codes prevents us from generating data that accurately reflects the utilization of and demand for complementary, alternative and integrative care. Without a complete set of codes, we are not able to measure the effectiveness of care provided by that 80 percent of practitioners who don’t provide allopathic medicine nor can we compare the cost of their care to the cost of medical treatments, drugs and surgery.

Further, the entire insurance industry uses coded data to establish insurance benefits. Without codes to measure every type of care, the industry is basing all its conclusions on data from conventional medicine—making it unlikely that the industry will expand coverage to include non-allopathic practitioners and treatments. While you might want more options, without codes, your insurer can’t expand coverage.

As Simple as AB
In 1996, a company called ABC Coding Solutions (formerly Alternative Link) began building a new code set that provided critical information about who could do what for the 80 percent of practitioners that lacked codes. The company knew that, in addition to lacking codes, these practitioners were governed by different laws in each state. They also knew that the codes had to fit into the existing payment infrastructure of the insurance industry. Today, over 4,000 codes and 15 million references to state laws and training standards are available to the industry to enable greater access to quality care at less cost.

The ABC Solution
Although health care reform seems a daunting task, we have this simple solution right at our fingertips. By filling in coding gaps, ABC codes are capable of revolutionizing the health care industry from the inside out, in what could ultimately be a win-win situation for everyone. In empirical studies, ABC codes have reduced the cost of care by as much as 50 percent (see Alaska Medicare and New Mexico Medicaid data) while increasing access to care that would otherwise not be available.

The Politics of Medicine
Despite being granted authority from former HHS Secretary Tommy Thompson to collect data on the cost benefits of ABC codes, generating data from over 500,000 transactions at approximately half the cost of using medical codes and finally meeting every requirement the Secretary put forth—ABC codes were summarily dismissed by the current HHS Secretary, Michael Leavitt, who disallowed further use of ABC codes in electronic health care transactions after October 16th, 2006. Since then, repeated requests for a fair review have been ignored.

If we are to generate true health care reform, we must first address the politics of medicine. In order to do so, we must begin by asking the following questions:
1. How does it serve HHS to allow this monopoly to continue?
2. Just how much does this monopoly drive up the costs of health care?
3. Why is HHS allowing a conservative MD trade organization to continue to be in charge of writing codes for the entire health care industry?

To be fair, we cannot place the blame on the AMA. The codes they develop and license provide them in excess of $71 million a year in royalties. Business is business and they do an excellent job of creating codes for physicians. Who in their right mind would want to help their competitors get paid? And how could anyone legally require an organization to harm its own interests? No, the burden of blame lies with HHS and our government leaders and their refusal neutrally to assess a non-competing and critically needed code set.

Politics, Psychology and Peer Pressure
We have to look beyond the fact that HHS has a long-standing contractual, procedural, historical and financial relationship with the AMA in order to understand the reasons behind its seemingly arbitrary decision to prohibit the use of a complete set of billing codes. In fact, we must investigate the mindset of the “leaders” in health care who hold positions which give them the power to dictate health care policy.

Have our leaders ever been personally failed by or frustrated with the limitations of conventional medicine? Have these individuals ever had need of or been exposed to efficacious alternative treatments? Have the high costs and large gaps in insurance coverage ever been a burden to them? Do their careers, reputations, or positions require them to adopt a narrow mindset regarding the inclusion of integrative and Complementary and Alternative Medicine (CAM) treatments into our system? Are our leaders being psychologically or financially pressured by orthodox medical interests to prevent reform?

The answers to these questions would be enlightening indeed. The answers to these questions might help us understand why a robust and well-designed code set with the potential to reduce health care costs and increase access to options has been rejected.

Until ABC codes become an electronic standard, ABC Coding Solutions has launched an inexpensive claim filing tool that collects data on effective treatments, reduces paperwork and time and allows any practitioner to create professional paper or electronic claims while properly documenting the care they provide. This filing tool is the only one on the market that links to state statutes and legislation to assure compliance with scope of practice law and reduce billing fraud. (See http://www.eClaim.biz).