Utilization and reimbursement trends of osteopathic manipulative treatment for Medicare patients: 2000–2019

Methods

OMT procedures are billed based on the number of body regions treated, ranging from 0 to 10 regions, with no more than one billed code allowed per day [7]. These codes are 98925 for 1 to 2 body regions, 98926 for 3 to 4 body regions, 98927 for 5 to 6 body regions, 98928 for 7 to 8 body regions, and 98929 for 9 to 10 body regions treated. In this retrospective study, OMT utilization data among Medicare patients from the Part B National Summary Data File on the Centers for Medicare and Medicaid Services (CMS) website for the years 2000 through 2019 was accessed [8]. The Medicare Part B National Summary Data File includes 100% of the services billed to Medicare Part B and reflect true physician reimbursement for the services provided in a given year. The Healthcare Common Procedure Coding System (HCPCS) codes 98925–98929 were utilized to identify the OMT procedures. The data evaluated included “allowed services,” or total billing volume in the calendar year, and “allowed charges”, which is the payment total disbursed by Medicare in the calendar year.

Average reimbursement per code billed was determined by dividing the allowed charges by the allowed services. The reimbursement data were adjusted for inflation utilizing the Consumer Price Index (CPI) Inflation Calculator utilizing the buying power for December 31 of each respective year relative to January 1, 2022 [9]. Service volume data were adjusted for the total number of Medicare enrollees utilizing data from cms.gov and census.gov [10, 11] to obtain the ratio of OMT codes billed per 10,000 Medicare beneficiaries (Appendix). All data were evaluated descriptively based on their frequencies and proportions.

Results

From 2000 to 2019, the total number of claims billed for OMT procedures (98925–98929) had a negative trend (Figure 1, Table 1). Proportional comparisons of 2000 to 2019 demonstrated a −24.46% change. The only increase in utilization was observed in the 5-year interval from 2000 to 2004 followed by a decrease in utilization in all other intervals.

Figure 1:

Twenty-year trend of Medicare claims of osteopathic manipulative treatment (OMT) per 10,000 beneficiaries.

When comparing each OMT procedure code individually (Figure 2, Table 2), a constant decrease in codes 98925, 98926, and 98927 (fewer number of body regions treated) with an overall decrease in code utilization was observed. These were very large decreases of −63.8%, −43.99%, and −11.82% respectively. On the other hand, an increase in codes 98928 and 98929 (larger number of body regions treated) was observed. These corresponded to a total percent increase of 46.03% and 88.91%, respectively. To further elucidate these observed changes in billing, we investigated the reimbursement trends over the same time periods. Overall, reimbursements per code for all five codes showed a proportional decrease in value through the years. The codes representing more body regions showed a smaller decrease compared to codes representing fewer body systems. Codes 98925, 98926, and 98927 decreased at a rate of −25.6%, −25.3%, and −20.7%, respectively, whereas codes 98928 and 98929 decreased at rates of −17.1% and −12.5%, respectively.

Figure 2:

Twenty-year trends of Medicare claims of individual osteopathic manipulative treatment (OMT) codes per 10,000 beneficiaries. (A) Itemized OMT codes per 10,000 beneficiaries. (B) Average reimbursement per individual OMT code.

Total average reimbursement showed similar rates of decline (Figure 3; Table 3). The adjusted sum reimbursement of combined codes 98925–98929 from 2000 to 2019 shows a decrease of −23.2%, which equates to $11.24 on average. The 5-year interval from 2010 to 2014 indicates the only noted increase in reimbursement for OMT services rendered. Years 2000 to 2009 represent the largest decrease in reimbursement per claim as well as percent change.

Figure 3:

Twenty-year trends of averaged reimbursement for all osteopathic manipulative treatment (OMT) codes.

Discussion

With the data retrieved from CMS, we compared OMT utilization and reimbursement information to identify billing trends from the last 20 years of clinical practice. With the increase in osteopathic physician representation in the total physician workforce, it is reasonable to assume that an increase in OMT utilization would be observed, but the inverse was found. Overall OMT utilization decreased. Concurrently, reimbursement from Medicare for OMT procedures decreased.

An understanding of the connection and interdependence between the body’s regions and systems guides osteopathic physicians to consider treatment of multiple body regions in response to a seemingly localized presenting complaint. Shifting toward comprehensive treatment (multiple body regions) as a strategy to maximize reimbursement may have an additional positive impact by promoting a more thorough diagnostic approach and addressing body dysfunctions that might have been previously overlooked.

Further assessment of the yearly trends in this study demonstrated a decrease in reimbursement in 2007. Although this could be related to the financial downturn and economic slowing in 2008, there was an overall increase in Medicare spending during the same time period [12–14]. This points to disparate redistribution of Medicare funds away from OMT services.

Due to the majority of OMT use being performed by primary care providers (PCPs), understanding Medicare reimbursement to primary care affords useful insight. Reid et al. [15] found that for narrow definitions of PCPs and primary care services, primary care represented 2.12% of Medicare spending, and for broad definitions represented 4.88% of spending. Given that Medicare spending on primary care services represents such a small percentage of its overall spending, and given that an enhanced focus on primary care is likely to have beneficial effects on the outcomes, quality, and cost of US healthcare [16], it is imperative that any reductions in reimbursement for valuable primary care services, including for OMT, be critically justified.

Despite an increase in reimbursement per CPT code in 2011, there remained a downward trend of reimbursement for codes observed in this study. We suspect that a major contributor to this is legislation enacted by Congress, including but not limited to both the Affordable Care Act (ACA) and Budget Control Act (BCA) of 2011. The ACA, for example, outlined adjustments in price formulas that determine the reimbursement that Medicare gives to healthcare providers. The BCA reduced Medicare fundings for its plans and payments to providers [17].

A comparison of the number of licensed osteopathic physicians to the number of OMT codes billed in that same year reveals that in the year 2000, the ratio of OMT codes billed per osteopathic physician was 8.49. Comparatively, this ratio in 2019 dropped to 2.71. This represents a −68.1% drop in the number of OMT codes billed per osteopathic physician. This could be due to the fact that not all osteopathic physicians utilize OMT in their clinical practices due to preference, lack of continuing education, inadequate facilities, and/or specialty specific limitations. Many osteopathic physicians choose to do their postgraduate education in allopathic residencies, where continued training in OMT is not uniformly available [18]. The American Osteopathic Association (AOA) had 954 eligible programs in 2014–2015. Following the implementation of the single accreditation system, 692 (72.5%) of the eligible programs achieved Accreditation Council for Graduate Medical Education (ACGME) accreditation by 2020 [19]. A decrease in the number of osteopathic programs may also contribute to decreased use and education of OMT, which might have otherwise utilized and promoted OMT more commonly in residency. This correlates with a survey study indicating that osteopathic physicians report utilizing OMT on 5% or less of their patients, and only 3%–6% of osteopathic physicians utilized it with patients over the last 20 years [20].

Although this might help explain the decrease in utilization, the overall lack of OMT usage is likely due to several factors. The decrease in compensation for OMT over the last 20 years seems to be a limiting factor for some physicians. Along with physician time restraints, these cuts in compensation represent a major barrier limiting the usage of OMT [21]. Additionally, some providers may have opted out of Medicare at the time of our analysis due to regulatory complexity, patient population characteristics, or a variety of other reasons. As of August 2022, 154 osteopathic manipulative medicine providers had opted out of Medicare. Therefore, the analysis does not capture the totality of OMT delivered by providers [22].

It is important to note that the Medicare data evaluated in this study does not provide details regarding the fee-for-service osteopathic manipulative medicine (OMM) practices. With this limitation, we are unable to tie specific billing practices to individual physicians, clinical settings, or geographic regions. It is possible that some clinics completely eliminated their use of OMT, whereas others increased theirs. Some residencies offer a specialized training curriculum of osteopathic neuromuscular medicine (ONMM) that focuses heavily on OMT use for multiple body systems. The increase in higher value codes could be from an increase in board-certified neuromuscular medicine (NMM) physicians and OMT specialists offering these comprehensive services. Further studies should be conducted to elucidate this potential relationship as well as prioritization of time by different specialty types.

We conjecture that lower remuneration for OMT has disincentivized physicians financially and contributed to the overall decline in OMT utilization among Medicare patients. In considering the upward trend of higher value code usage, however, it is possible that some physicians are increasing the comprehensiveness of their physical assessment and associated OMT. Treatment of more body regions would then justify the use of higher-level codes and would, therefore, reduce the overall financial impact of OMT reimbursement cuts for individual physicians and clinics. Further investigation should be conducted to identify if correlation exists between the increased billing codes and their associated diagnostic codes.

This study is not without significant limitations. Medicare was this study’s sole source of volume and reimbursement data. Data from providers that have opted out of Medicare and others that deliver care to privately insured patients were not included. Direct reimbursement for services is not measured here. Medicare is the single largest insurance payer in the United States, and it is important to note that its beneficiaries represent an older population whose medical needs may differ significantly from the typical patient receiving OMT. These unique demographics may influence the clinical decision making of a provider that performs OMT for Medicare beneficiaries. With 67% of all Medicare beneficiaries having two or more chronic conditions affecting their health, this population represents an increased challenge to Medicare providers [23]. Due to the complexity of their care, physicians may prioritize other examinations or treatments over OMT. Clinicians may also be limited by financial constraints when accepting or providing care to Medicare beneficiaries, and the sheer complexity of Medicare billing rules and regulations for successful OMT reimbursement may decrease a physician’s interest in offering treatment [24, 25]. This study is limited by the factors mentioned previously, and we stress that a decrease in Medicare billing of OMT may not be indicative of a decrease in OMT utilization clinically. While our results may not be wholly generalizable to the greater health system, we posit that Medicare’s outsized influence on the private insurance marketplace will influence important trends in the health economics of OMT generally [26]. Additionally, this study analyzes trends in OMT use, utilization, and reimbursement nationwide. Recognizing that substantial geographic variation exists within the nation and in both healthcare spending and use, future research should explore the effect of local factors that might lead to disparate use of and reimbursement for OMT in dissimilar regions of the United States [27].

This study’s focus on OMT does not reveal whether similar decreases in compensation from Medicare exist for nonosteopathic treatment modalities in similar primary care settings. Future research should examine these trends and be compared to the steady decline in reimbursement for OMT. The proven efficacy of OMT should prompt advocacy for sustainable and fair reimbursement [1, 28, 29]. Furthermore, it has been shown that OMT can be effective in patients of all ages, including the elderly [30]. Practical application of OMT and its educational curriculum should be evaluated to ensure that this valuable modality can be adequately utilized in practice for patients of all ages.

Conclusions

OMT is an essential tool proven to enhance patient care, and the decline in its utilization is concerning. One factor contributing to decreased utilization of OMT is the declining reimbursement by Medicare due to multiple legislative and political actions. Physicians are responding to this changing landscape by either decreasing OMT utilization altogether, or by treating more body regions to offset this decrease in reimbursement. This is likely a temporary solution because reimbursement amounts may continue to decrease. Comparisons to office visits without an associated billed procedure with their associated reimbursement trends may be required to determine if the negative trends surrounding OMT utilization and reimbursement are just one part of a much larger issue. Solutions, legislative or otherwise, could then be aptly identified and addressed.