Transcript Chiropractic - Squarespace

“Chiropractic”
Can chiropractic physicians be
better utilized as viable solutions
to help contain and lower workers’
compensation costs?
First, let’s explore the problems.
What is the financial impact of
drugs, surgery, medical errors and
pain management/PT, and
hospital-based care?
Overview:
Four main challenges and failures.
1.
2.
3.
4.
Drugs: Between 1998 and 2003 drug usage skyrocketed
from $47 million to over $139 million, with LESS claims in the
system.
Surgery: is largely out of control and ineffective.
Administrative costs: skyrocketed due to denial-minded
consultants who are often actually violating state law (fraud).
Chiropractic patients particularly hit hard.
Case Management: Too much time spent on reviewing all
cases instead of the 10% that drive the greatest costs.
Cost Drivers: Drugs, surgery,
hospital-based care/PT
Statistics: Drugs use
skyrocketed from 1998 thru
2003. $59 million to $139
million, with LESS claims in the
system, at the same time
Chiropractic care was basically
under assault regarding chronic
pain management.
Result: drug addiction, no
improvement in RTW.
http://journals.lww.com/spinejournal/pages/articleviewer.aspx?year=2009&issue=04010&article=00018&type=abstract
Surgery: Ohio BWC Data
Long-term Outcomes of Lumbar Fusion Among
Workers’ Compensation Subjects. An Historical
Cohort Study. Nguyen, Randolph et al. SPINE ©2010
Surgery: Ohio BWC Data
Results. Two years after fusion surgery:
 26% had RTW,
 67% of nonsurgical controls had RTW within 2 years from the date of injury.
 Reoperation rate was 27% for surgical patients.
 Of the lumbar fusion subjects, 36% had complications.
 Permanent disability rates were 11% for surgical cases and
 2% for nonoperative controls
 Seventeen surgical patients and 11 controls died by the end of the study
 For lumbar fusion subjects, daily opioid use increased 41% after
surgery.
 With 76% of cases continuing opioid use after surgery.
Surgery: Ohio BWC Data
Results. Two years after fusion surgery:
 Total number of days off work was more prolonged for cases compared to
controls, 1140 and 316 days, respectively
Conclusion. This Lumbar fusion for the diagnoses of
disc degeneration, disc herniation, and/or
radiculopathy in a WC setting is associated with
significant increase in disability, opiate use,
prolonged work loss, and poor RTW status.
Brand Names
Vioxx
Advil
Celebrex
Motrin
Voltaren
http://journals.lww.com/spinejournal/pages/articleviewer.aspx?year=2009&issue=04010&article=00017&type=abstract
Executive Order 2010 – 4S
Establishing the Ohio Prescription Drug Abuse
Task Force
Executive Order 2010 – 4S
Establishing the Ohio Prescription Drug Abuse
Task Force
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Prescription drug abuse is a national
public health problem.
“The Substance Abuse and Mental Health
Services Administration reported that the
number of admissions for substance
abuse treatment for prescription drugs
increased by 141% from 1998 to 2006.”
Executive Order 2010 – 4S
Establishing the Ohio Prescription Drug Abuse
Task Force
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Ohio’s prescription drug abuse problem is an
epidemic.
“In 2007, unintentional drug poisoning became the
leading cause of injury death in Ohio, surpassing
motor vehicle crashes and suicide for the first time
on record. From 1999 to 2007, Ohio’s death rate
due to unintentional drug poisonings
increased more than 300 percent. The increase
in deaths has been driven largely by prescription
drug overdoses caused by opioids (pain
medications). Prescription opioids are
associated with more overdoses than any
other prescription or illegal drug, including
cocaine and heroin.”
Executive Order 2010 – 4S
Establishing the Ohio Prescription Drug Abuse
Task Force
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Ohio needs a more coordinated, multidisciplinary, multi-jurisdictional approach to the
problem of prescription drug abuse.
“Too many Ohioans have lost their lives
or have been impacted by the
devastating effects of addiction because
of abuse and diversion of prescription
drugs.”
The Solution…
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Given the following cost-effectiveness
studies, it is clear that Chiropractic
physicians should be utilized much
earlier and in greater frequency in an
effort to lower cost, improve
RTW and prevent disability.
Why?
Chiropractic: A solution for
chronic pain sufferers.
Consider the alternatives: Chiropractic is the
“obvious choice”.
Options:
1.
MD/Drugs…ineffective, and costly.
2.
Orthopedic surgeon: $350 to walk thru the door.
3.
Pain Management:
4.
Physical therapy…excessive treatment and costs.
Same as surgeon, plus high cost
injections and invasive procedures.
Chiropractic: A solution for
chronic pain sufferers.
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OR, one can visit a DC:
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Spinal manipulation and one therapy:
$65
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Instead of allowing this low cost treatment,
the system often spends thousands of dollars
in denial/appeals, hearing, IMEs, etc.
Result: Forces patients into medical directed
care: higher costs, invasive and dangerous,
less effective.
Guidelines: All recommend DC care
for both acute and chronic pain.
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Council on Chiropractic Guidelines and
Practice Parameters (CCGPP): Acute
and chronic spine pain
Official Disability Guidelines (ODG)
American College of Physicians and
American Pain Society
Diagnosis and Treatment of Low Back Pain: A Joint Clinical
Practice Guideline from the American College of Physicians
and the American Pain Society 2 October 2007 | Volume
147 Issue 7 | Pages 478-491
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Recommendation 7: For patients who do not improve with
self-care options, clinicians should consider the addition of
nonpharmacologic therapy with proven benefits—for acute low
back pain, spinal manipulation; for chronic or subacute low
back pain, intensive interdisciplinary rehabilitation,
exercise therapy, acupuncture, massage therapy, spinal
manipulation, yoga, cognitive-behavioral therapy, or
progressive relaxation (weak recommendation, moderatequality)
Official Disability Guidelines
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Recommended for chronic pain if
caused by musculoskeletal conditions,
and manipulation is specifically
recommended as an option in the Low
Back Chapter and the Neck Chapter.
Official Disability Guidelines
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“The latest project completed by the Council on Chiropractic
Guidelines and Practice Parameters (CCGPP) addresses
chiropractic management of the chronic pain patient. The
CCGPP guideline provides clear case management suggestions
and dosing recommendations when confronted with the patient
suffering ongoing chronic pain after treatments that exceed
ODG recommendations. Chiropractic management may be more
beneficial, safer, and rendered at much lower costs, compared
to narcotics or invasive medical procedures to control chronic
pain. (Farabaugh, 2010)”
The elephant in the room…
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What are the goals of care provided by
DCs once a patient has reached a
plateau in care (MTB)?
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Minimize lost time on the job
Support patient's current level of function/ADL
Pain control/relief to tolerance
Minimize further disability
Minimize exacerbation frequency and severity
Maximize patient satisfaction
Reduce and/or minimize reliance on medication
Cost Effectiveness Studies
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A quick view of several of the most
recent studies.
Health maintenance care in work-related low back pain and its association with
disability recurrence. Cifuentes M, Willetts J, Wasiak R. J Occup Environ Med. 2011
Apr;53(4):396-404.
OBJECTIVES:
To compare occurrence of repeated disability episodes across types of
health care providers who treat claimants with new episodes of workrelated low back pain (LBP).
CONCLUSIONS:
In work-related nonspecific LBP, the use of health maintenance care
provided by physical therapist or physician services was
associated with a higher disability recurrence than in
chiropractic services or no treatment.
The Chiropractic Hospital-based Interventions Research Outcomes (CHIRO) study: a
randomized controlled trial on the effectiveness of clinical practice guidelines in the
medical and chiropractic management of patients with acute mechanical low back
pain. Bishop et al. Spine J. 2010 Dec;10(12):1055-64.
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CONCLUSIONS: This is the first reported randomized
controlled trial comparing full CPG-based treatment, including
spinal manipulative therapy administered by chiropractors, to
family physician-directed UC in the treatment of patients with
AM-LBP.
Compared to family physician-directed UC, full CPG-based
treatment including CSMT is associated with significantly greater
improvement in condition-specific functioning.
Does maintained Spinal manipulation therapy for chronic non-specific low
back pain result in better long term outcome? Senna et al. Rheumatology
and Rehabilitation Department, Mansoura Faculty of Medicine, Mansoura
University. Spine (Phila Pa 1976). 2011 Jan 17.
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Subjects and Methods. 60 patients with chronic, nonspecific LBP
lasting at least 6 months were randomized to receive either (1)
12 treatments of sham SMT over a one-month period, (2) 12
treatments, consisting of SMT over a one-month period, but no
treatments for the subsequent nine months, or (3) 12
treatments over a one-month period, along with "maintenance
spinal manipulation" every two weeks for the following nine
months.
Does maintained Spinal manipulation therapy for chronic non-specific low
back pain result in better long term outcome? (Cont’d)
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Conclusion. SMT is effective for the treatment of chronic non
specific LBP. To obtain long-term benefit, this study suggests
maintenance spinal manipulations after the initial
intensive manipulative therapy.
Blue Cross/Blue Shield: Wellmark Announces Results of
Physical Medicine Pilot on Quality. 2009
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The Wellmark Blue Cross and Blue Shield 2008
pilot was a quality improvement program for
Iowa and South Dakota physical medicine
providers.
A total of 238 chiropractors, physical
therapists, and occupational therapists
participated in the pilot, submitting
information on the care provided to 5500
Wellmark members with musculoskeletal
disorders.
Blue Cross/Blue Shield: Wellmark Announces Results of
Physical Medicine Pilot on Quality. 2009
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The comparison showed that those who received
chiropractic or physical therapy care were less likely
to have surgery and experienced lower total health
care costs.
Mercer/Harvard Study 2009
by Choudhray and Milstein
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Do Chiropractic Physician Services for
Treatment of Low Back and Neck Pain
Improve the Value of Health Benefits
Plans. An Evidence-based Assessment
of Incremental Impact of Population
and Total Health Care Spending
Mercer/Harvard Study (cont’d)
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Effectiveness: Chiropractic care is more effective
than other modalities for treating low back and neck
pain.
Cost Effectiveness: When considering the
effectiveness and cost together DC care for low back
and neck pain is highly cost effective, and
represents a good value in comparison to medical
physician care and to widely accepted costeffectiveness thresholds.
Mercer/Harvard Study (cont’d)
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The addition of DC coverage for the treatment of LB
and neck pain at prices typically payable in the US
employer-sponsored health benefits plans will likely
increase value-for-dollar by improving clinical
outcomes and either reducing total spending
(neck pain) or increase total spending (LB) by a
smaller percentage than clinical outcomes improve.
Mercer/Harvard Study (cont’d)
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Interventions with cost-effectiveness ratios between
$50,000 and $100,000 per QALY (quality adjusted life
years) are generally considered to be cost effective.
DC care….$1837!!
When combined with exercise chiropractic physician
care is also very cost effective compared to exercise
alone.
CLINICAL AND COST OUTCOMES OF AN INTEGRATIVE
MEDICINE IPA
Sarnat, Winterstein JMPT June 2004
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Results: Analysis of clinical and cost outcomes on 21,743 member
months over a 4-year period demonstrated decreases of
43.0% in hospital admissions
58.4% hospital days
43.2% outpatient surgeries and procedures
51.8% pharmaceutical cost reductions when
compared with normative conventional
medicine IPA
CLINICAL UTILIZATION AND COST OUTCOMES FROM AN
INTEGRATIVE MEDICINE INDEPENDENT PHYSICIAN
ASSOCIATION: AN ADDITIONAL 3-YEAR UPDATE
Sarnat, Winterstein, Cambron JMPT May 2007
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Results: Clinical and cost utilization based on 70274 membermonths over a 7-year period demonstrated decreases of
60.2% in-hospital admissions
59.0% hospital days
62.0% outpatient surgeries and procedures,
and
85% pharmaceutical costs
when compared with conventional medicine IPA performance
for the same health maintenance organization product in the
same geography and time frame.
Sarnat/Winterstein Study…Conclusion
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AMI’s primary care chiropractors are showing
the world what the profession has always
believed since its inception:
Chiropractic has an ability to impact a
person’s health in a very profound manner.
Muse: Utilization, Costs, and Effects of Chiropractic
Care on Medicare Program Costs. 2001
The Muse study compared the most recently available
CMC Medicare cost and utilization data for those
beneficiaries that received chiropractic care versus
those beneficiaries that only received traditional
medical care. The Muse study found that the
global per capita Medicare expenditures for
chiropractic patients were significantly lower
than the same costs for non-chiropractic
patients.
Muse Study\Medicare
(cont’d)
The Muse study concluded,
"Chiropractic care significantly reduces per
beneficiary costs to the Medicare program. The
results of the study suggests that chiropractic
services could play a role in reducing costs
Medicare reform and/or a new prescription
drug benefit."
Comparative Analysis of Individuals With and Without Chiropractic Coverage
Patient Characteristics, Utilization, and Costs. Legorreta, Metz, Nelson, Ray, Chernicoff,
DiNubile, MD Arch Intern Med. 2004;164:1985-1992.
Methods: A 4-year retrospective claims data analysis comparing more than 700,000 health
plan members with an additional chiropractic coverage benefit and 1 million members of
the same health plan without the chiropractic benefit.
Results: Members with chiropractic insurance coverage, compared with those without
coverage, had lower annual total health care expenditures ($1463 vs $1671 per member
per year, P<.001).
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Less total annual health care costs at the health plan level.
Lower utilization (per 1000 episodes) of plain radiographs
Less low back surgery
Less hospitalizations
Less magnetic resonance imaging.
Lower average back pain episode–related costs ($289 vs $399, P<.001).
“Chiropractic Care: is it substitution care or add-on care in
corporate medical plans?” Metz, et al. J. Occupational
Environmental Medicine. 2004;46:847-855.
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The results “indicate that patients use chiropractic care as a
direct substitute for medical care.”
4 year study: 1997-2001
Not a survey….used actual claims data.
1,394,070 patients; 174,209 were DC pts; 332,548 were
medical pts; 887,313 were medical pts w/o DC coverage.
Results: nearly half chose DC care when offered a choice.
“Within a MC setting, the inclusion of a DC benefit does not
increase the overall rates of pt. complaints….pts appear to be
directly substituting DC care for medical care”.
“An Evaluation of Medical and Chiropractic Provider Utilization and Costs:
Treating Injured Workers in North Carolina JMPT September 2004 • Volume
27 • Number 7 Phelan et al.
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Objective: To examine utilization, treatment costs, lost workdays, and
compensation paid workers with musculoskeletal injuries treated by
medical doctors (MDs) and doctors of chiropractic (DCs).
Design: Retrospective review of 96,627 claims between 1975 and
1994.
Results Average cost of treatment, hospitalization, and compensation
payments were higher for patients treated by MDs than for patients
treated by DCs. Average number of lost workdays for patients treated
by MDs was higher than for those treated by DCs. Combined care
patients generated higher costs than patients treated by MDs or DCs
alone.
“An Evaluation of Medical and Chiropractic Provider Utilization
and Costs: Treating Injured Workers in North Carolina (cont’d)
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Conclusion: These data, with the acknowledged
limitations of an insurance database, indicate
lower treatment costs,
less workdays lost,
lower compensation payments, and
lower utilization of ancillary medical services for
patients treated by DCs.
Despite the lower cost of chiropractic management, the
use of chiropractic services in North Carolina appears
very low.
State Specific Workers
Compensation Studies
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NOTE: In the past managed care leaders (usually
medical physicians) would flippantly dismiss the
studies on DC cost effectiveness, but usually simply
due to medical bias.
However, given the out-of-control drug and medical
costs, the time has come to consider real solutions to
these main cost drivers and accept that one cannot
discount such a large volume of studies all pointing in
the same direction….that being chiropractic IS cost
effective, safe, and supported by a large volume of
literature.
State Specific Workers
Compensation Studies
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There are dozens of studies from all over the US, in
fact all over the world which report the same overall
theme….
Chiropractic physicians can help lower costs, return
patients to work and prevent disability much more
efficiently than other forms of treatment.
Bottom line: Chiropractic should be encouraged and
promoted as an important part of integrated care,
especially for complicated and chronic work-related
injuries.
Copyright Protection Statement
The material in this packet is under copyright
protection and may not be reproduced in any format
without the expressed written consent of Dr. Ronald
J. Farabaugh.
© Copyright. 2011. All Rights Reserved.