Transcript Chiropractic - Squarespace

“Chiropractic”
Can chiropractic physicians be
better utilized as viable solutions
to help contain 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.
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4.
Drugs: Between 1998 and 2003 drug usage skyrocketed
from $59 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
Objective: To determine objective outcomes of return
to work (RTW), permanent disability, postsurgical
complications, opiate utilization, and reoperation status for
chronic low back pain subjects with lumbar fusion.
Similarly, RTW status, permanent disability, and opiate
utilization were also measured for nonsurgical controls.
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.
“A 2006 Centers for Disease Control report
demonstrated that between 1995 and 2005,
the annual number of unintentional drug
overdose deaths in the United States
more than doubled due to increasing deaths
from prescription drugs.”
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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Significant efforts to address the problem of
prescription drug abuse are currently underway.
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The Ohio Department of Health
Ohio Department of Alcohol and Drug Addiction Services
The Ohio Office of Criminal Justice Services
The Department of Job and Family Services
The Ohio Attorney General’s Office
The Ohio Medical and Pharmacy Boards
U.S. Senator Sherrod Brown: Drug Enforcement Administration and the
Centers for Medicare and Medicaid Services
Local task forces and working groups
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Legislative efforts being undertaken by the Ohio General Assembly.
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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.”
Executive Order 2010 – 4S
Establishing the Ohio Prescription Drug Abuse
Task Force
“Accordingly, I
order the
establishment of
an Ohio
Prescription Drug
Abuse Task Force
(OPDATF).”
What about BWC? 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.
Basic Chiropractic Management
vs Medical management
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Remember that “A” is just the tip of the medical
iceberg.
Chiropractic is a self-contained treatment center
where everything from diagnosis to rehab is done by
the DC.
When one visits a medical physician all services are
requested and provided ala carte, increasing the
costs dramatically while appearing that the MD only
treated the patient for 2-3 office visits.
Chiropractic: A solution for
chronic pain sufferers.
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1.
2.
Consider the alternatives: Chiropractic
is the “obvious choice”.
Options:
MD/Drugs
Orthopedic surgeon: $350 to walk thru the
door.
3.
Pain Management:
4.
Physical therapy: See next slide
Same as surgeon, plus high cost
injections and invasive procedures.
Chiropractic: A solution for
chronic pain sufferers.
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8.
EX: Larry Sent to PT by PCP for management of
chronic low back pain
Recommended:
Upper body ergometer
Client education
Home exercise program
Self care/home management
Soft tissue mobilization techniques
Stretching/flexibility activities
Therapeutic activities
Therapeutic exercises
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.
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.
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.
“Chiropractic Treatment of Workers’
Compensation Claimants in the State of Texas.”
Executive Summary. MGT of America Feb 2003.
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Workers’ compensation claims from 1996 to 2001
was conducted to determine the use and efficacy of
chiropractic care in Texas.
900,000 claims during that time period to determine
if chiropractic was cost-effective compared to medical
treatment.
They found that chiropractor treatment costs were
the lowest of all providers. Their data clearly
demonstrated that increased utilization of chiropractic
care would lead to declining costs relative to lower
back injuries.
“Chiropractic care of Florida workers' compensation claimants:
Access, costs, and administrative outcome trends from
1994 to 1999.” Folsom et al. Topics in Clinical Chiropractic 2002;
9(4): 33-53.
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1994-1999 found that the average total cost for low-back cases
treated medically was $16,998 while chiropractic care was only
$7,309.
Patients treated primarily by chiropractors were found to reach
maximum medical improvement almost 28 days sooner that if
treated medically.
Findings from this analysis of the Florida Claims and medical
files indicate that considerable cost savings and more efficient
claims resolution may be possible with greater involvement of
chiropractic treatment in specific low back cases and other
specific musculoskeletal cases.
“Managed Care Pre-approval and its Effect on the Cost of
Utah Worker Compensation Claims.” Jarvis et al. Journal
of Manipulative and Physiological Therapeutics 1997;
20(6): 372-376.
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5000 claims from 1986 and 5000 from 1989
The study compared cost for those who received chiropractic
care and those who received medical care.
From 1986 to 1989 the cost of care for chiropractic increased
12% while medical care increased 71%.
The replacement of wages increased 21% for those receiving
chiropractic care and 114% for those receiving medical care.
“Preliminary Findings of Analysis of Chiropractic Utilization in the
Workers‘ Compensation System of New South Wales, Australia.”
Tuchin et al. JMPT 1995; 18(8): 503-511.
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1289 cases reviewed
30% had back problems.
12% employed chiropractic care for spinal injury workers’
compensation claims.
The total payments for all cases using chiropractic and physiotherapy
care were $25.2 million, which was 2.4% of the total payments.
When 20 claims were chosen at random the average chiropractic cost
of care was $299.65, while the average medical cost was $647.20.
A trend in data collected indicated that when greater than 60% of total
cost of treatment came from chiropractic care the number of days
missed from work was 9.5. When less than 60% of total cost of
treatment came from chiropractic care the number of days missed from
work was 50.3.
“Mechanical Low Back Pain: A Comparison of Medical and
Chiropractic Management within the Victorian Workcare
Scheme.” Ebrall PS. Chiropractic Journal of Australia 1992;
22(2): 47-53.
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This study reviewed claims made in a twelve-month period
involving work related mechanical low-back pain. Management
by chiropractic care and medical care were compared.
39% of claims reviewed for individuals visiting chiropractors
required compensation days while,
78% of claims for those visiting medical doctors required
compensation days.
The average number of compensation days needed for those
visiting chiropractors was 6.26 days and 25.56 days for those
visiting medical practitioners.
“Cost Per Case Comparison of Back Injury Claims of Chiropractic
Versus Medical Management for Conditions With Identical
Diagnostic Codes” Jarvis et al. Journal of Occupational Medicine
1991; 33(8): 847-852.
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This workers’ compensation study conducted in Utah compared the
cost of chiropractic care to the costs of medical care for conditions with
identical diagnostic codes.
The study indicated that costs were significantly higher for medical
claims than for chiropractic claims.
The sample consisted of 3062 claims or 40.6% of the 7551 estimated
back injury claims from the 1986 Workers' Compensation Fund of Utah.
For the total data set, cost for care was significantly more for medical
claims, and compensation costs were 10-fold less for chiropractic
claims.
“Disabling Low Back Oregon Workers' Compensation
Claims. Part II: Time Loss.” Nyiendo et al. JMPT. 1991;
14(4): 231-239.
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This report focused on time lost for individuals who visited DCs versus those
who visited MDs for treatment of low back pain.
Median missed days of work for individuals with similar severity of injury was
9.0 days for those visiting DCs and 11.5 for individuals visiting MDs.
Individuals visiting chiropractors more often returned to work having missed one
week or less of work days.
There was no difference in time lost for individuals visiting DCs and MDs with no
previous history of low back pain.
For claimants with a history of chronic low back problems, the median time loss
days for MD cases was 34.5 days, compared to 9 days for DC cases. It is
suggested that chiropractors are better able to manage injured workers with a
history of chronic low back problems and to return them more quickly to
productive employment.
"Disability Low Back Oregon Workers' Compensation Claims. Part
I: Methodology and Clinical Categorization of Chiropractic and
Medical Cases.“Nyiendo et al. JMPt. 1991; 14(3): 177-184.
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This study examined 201 randomly selected workers‘
compensation cases that involved low back injuries
that were disabling.
The study found individuals who visited DCs less
often initially had more trips to the hospital for their
injuries than those visiting MDs.
"A Comparison of Chiropractic, Medical and Osteopathic Care for
Work-Related Sprains/Strains." Johnson et al. JMPT1989; 12(5):
335-344.
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This study analyzed data on Iowa state record from individuals in Iowa who filed claims for
back or neck injuries in 1984.
The study compared benefits and the cost of care received by individuals from MDs, DCs
and DOs.
There was a focus on individuals who missed days of work and were compensated because
of their injuries.
Individuals who visited DCs missed on average at least 2.3 days less than individuals who
visited MDs and 3.8 days less than individuals who saw DOs.
Less money was dispersed as employment compensation on average for individuals who
visited DCs.
On average, the disability compensation paid to workers for those who visited DCs was
$263.66, $617.85 for those who visited MDs, and was $1565.05 for those who visited DOs.
"An Analysis of Florida Workers‘ Compensation Medical Claims for
Back-Related Injuries." Wolk et al. J ACA1988; 27(7): 50-59.
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This study is an analysis of worker's compensation claims in Florida
from June through December of 1987.
All of the claims analyzed were related to back injuries. The greater
purpose of this study was to compare the cost of osteopathic, medical
and chiropractic doctors.
The cost of drugs was not included in the analysis.
The results of the study lead to the finding that individuals who had
compensable injuries and were treated by chiropractors often times
were not forced to be hospitalized. It also revealed that chiropractic
care is a "relatively cost-effective approach to the management of
work-related injuries."
Branson, Richard. “Cost Comparison of Chiropractic and Medical
Treatment of Common Musculoskeletal Disorders: A Review of the
Literature after 1980.” Topics in Clinical Chiropractic 1999; 6(2):
57-68.
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A cost comparisons study between DC-provided care
and care provided by general and specialist MDs for
individuals with musculoskeletal conditions found that
the majority of retrospective studies had positive
results for chiropractic care.
Manga, Pran. "Enhanced chiropractic coverage under OHIP
(Ontario Health Insurance Plan) as a means for reducing health
care costs, attaining better health outcomes and achieving
equitable access to health services." Report to the Ontario
Ministry of Health, 1998.
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Greater chiropractic coverage under OHIP would
result in a greater number of individuals visiting
chiropractors and going more often. The study shows
that despite increased visits to DCs, this would result
in net savings in both direct and indirect costs.
Direct savings for Ontario's healthcare system could
be as much as $770 million and at the very least
$380 million.
Stano, Miron. "A Comparison of Health Care Costs
for Chiropractic and Medical patients." Journal of
Manipulative and Physiological Therapeutics 1993;
16(5): 291-299.
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Comparison of cost for patients who received chiropractic care
for neuromusculoskeletal problems to those who received
medical and osteopathic care. One quarter of patients analyzed
were treated by chiropractors. These patients had lower health
care costs.
"Total cost differences on the order of $1000 over the two year
period were found in the total sample of patients as well as in
sub-samples of patients with specific disorders."
Lower costs are attributed to lower inpatient utilization.
Dean, David; Schmidt, Robert. "A comparison of
the cost of chiropractors versus Alternative Medical
Practitioners." Richmond, VA: Virginia Chiropractic
Association, 1992.
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This study is an assessment of the difference
in cost of treatment between chiropractors
and other practitioners in dealing with
individuals who have similar back-related
problems.
Chiropractic care had a lower cost option for
many back ailments.
“The Selection Effects of the Inclusion of a Chiropractic
Benefit on the Patient Population of a Managed Health Care
Organization.” Nelson et al. JMPT 2005 Mar-Apr;28(3):164-9.
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The data of 1.7 million subscribers over four years
indicated that the employer groups with chiropractic
coverage had a younger population and significantly
lower rates of common chronic diseases than
subscribers who had access only to medical care for
neuro-musculoskeletal complaints.
The employers who chose the chiropractic rider had a
patient population with a more favorable risk profile,
thereby decreasing the health care costs of the
health plan.
“Primary Care - Cost Effectiveness of Physiotherapy, Manual Therapy and
General Practitioner Care for Neck pain: Economic Evaluation Alongside a
Randomized Controlled Trial.” Korthals-de Bos et al. British Medical Journal
2003; 326: 911.
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The clinical outcome measures showed that manual
therapy resulted in faster recovery than
physiotherapy and general practitioner care. While
achieving this superior outcome, the total costs of
the manual therapy-treated patients were about one
third of the costs of physiotherapy or general
practitioner care.
Treatment- and Cost-Effectiveness of Early Intervention For Acute
Low-Back Pain Patients: A One-Year Prospective Study Gatchel et
al. Journal of Occupational Rehabilitation, Vol. 13, No. 1, March 2003 ( C° 2003)
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The results of this study clearly demonstrate the
treatment- and cost-effectiveness of an early
intervention program for ALBP patients.
The other major contribution of the present study
was the clear demonstration that appropriate early
intervention can successfully prevent the
development of chronic lowback pain disability.
The cost of providing medical and surgical treatment
for low-back pain is staggering.
Treatment- and Cost-Effectiveness of Early Intervention For Acute
Low-Back Pain Patients: A One-Year Prospective Study (cont’d)
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It is now agreed that, except under the
circumstances of obvious structural pathology
amenable to surgical intervention, conservative care
is the initial treatment of choice for low-back pain.
“Integration and Reimbursement of Complementary and Alternative
Medicine by Managed Care and Insurance Providers: 2000 Update and
Cohort Analysis.” Pelletier et al. Alternative Therapies in Health and
Medicine 2002; 8(1): 38-48.
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Market demand is one of the primary motivators for
offering coverage of CAM, with consumer interest
similarly cited as a key factor.
Emphasis on what is validated by sound clinical and
cost outcomes research rather than what is
considered “alternative” versus “conventional” will be
critical for reducing excessive medical utilization and
containing rising medical care costs.
Smith, M; Stano, M. "Costs and Recurrences of Chiropractic and
Medical Episodes of Low Back Care.“ JMPT. 1997; 20(1): 5-12.
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Those who visited chiropractors paid a
lower cost and were also more satisfied
with the care given. Because of this, the
study suggests that chiropractic care should
be given careful attention by employers when
using gate-keeper strategies.
Stano M, Smith M “Chiropractic and Medical Costs
of Low Back Care.” Medical Care 1996; 34(3): 191204.
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The mean total payment when DCs
were the first providers was $518,
whereas the mean payment for cases in
which an MD was the first provider was
$1,020.
Stano, Miron. "The Economic Role of Chiropractic Further Analysis of
Relative Insurance Costs for Low Back Care." Journal of the
Neuromusculoskeletal System 1995; 3(3): 139-144.
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This retrospective study of 7077 patients compared costs of
care for treatment of common low back conditions when a
chiropractor was the first provider versus when an MD was the
first provider. Total payments for inpatient procedures were
higher for MD initiated treatment and especially episodes that
lasted longer than a single day. Outpatient payments were
much higher for MD initiated treatments as well. Payments were
nearly twice as great for the medically initiated cases and their
outpatient payments were nearly 50% higher.
Their statistical estimates indicate that the costs of care
for common low back disorders using a chiropractor as
first-contact provider are substantially lower than
episodes in which a medical physician is the firstcontact provider.
THE DEPARTMENT OF DEFENSE:
CHIROPRACTIC HEALTH CARE DEMONSTRATION
PROGRAM
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March 3, 2000.
This report is provided to the Committees on Armed
Services and the full Congress pursuant to Section 731
of Public Law 103-337 and Section 739 of Public Law
105-85 by the following Doctor of Chiropractic members
of the CHCDP Oversight Advisory Committee: George A.
Goodman, D.C. Ronald Evans, D.C. Rick McMichael, D.C.
Richard Beacham, D.C. Peter Ferguson, D.C. Reed B.
Phillips, Ph.D., D.C.
CHIROPRACTIC HEALTH CARE DEMONSTRATION
PROGRAM (cont’d)
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Finding #1: The results of the CHCDP clearly demonstrate that
it is feasible to integrate chiropractic care into the military
health care system. Perceptions and attitudes towards
chiropractic care improved over time
Finding #2: Levels of patient satisfaction with chiropractic care
during the CHCDP were high and significantly better than those
reported for traditional medical care
Finding #3: Findings from the CHCDP indicate that personnel
who utilized chiropractic care for the treatment of lower back
pain experienced superior patient outcomes compared to
patients who received more traditional types of care
CHIROPRACTIC HEALTH CARE DEMONSTRATION
PROGRAM (cont’d)
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Finding #4: Results from the CHCDP highlight the implications
for enhanced readiness that arise from the use of chiropractic
care. Additionally, enhanced readiness may also lead to
increased retention of military personnel
Finding #5: Findings from the CHCDP indicate that spinal
maladies remain a big problem for the military. Further, the
Demonstration illustrates the inadequacy of the current care
system to address this problem.
CHIROPRACTIC HEALTH CARE DEMONSTRATION
PROGRAM (cont’d)
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Therefore, we conclude that full integration of chiropractic care
into the MHS is fully justified and both feasible and advisable;
will not have a negative effect on either aggregate MHS
health care costs or medical manpower levels currently in
effect; and will significantly enhance health care for the men
and women of the Armed Forces.
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.
Mosley, Cohen, DC, Arnold, MD. American Journal of
Managed Care 1996;2:280-282.
Retrospective study of patients at an independent
physician model HMO in Louisiana evaluating cost of
care for acute low back pain or neck pain for patients
who sought chiropractic care or other treatment. Also
looked at surgical rates, use of diagnostic imaging (MR
and CT) and patient satisfaction on claims paid Oct. 1,
1994 – Oct. 1, 1995.
Mosley, Cohen, DC, Arnold, MD. American Journal of
Managed Care 1996;2:280-282.
Results: Cost of care for BP and NP was substantially lower for DC
patients than non-DC patients.
Use of prescription drugs and
diagnostic imaging were significantly greater in non-DC group
whereas surgical rates and patient satisfaction were nearly identical.
Conclusion: DC care outcomes are equal to those of non-DC care at
substantially lower costs. MD patients got 2x as many prescriptions.
Study demonstrates that DC services were well integrated in an HMO
and has proven satisfactory to patients and providers as well as costeffective for BP and NP. The system offered self-referral for DC
services.
Mosley, Cohen, DC, Arnold, MD. American Journal of
Managed Care 1996;2:280-282.
If half of the patients treated by traditional care received DC
care, annual savings would have exceeded $215,000. We
recommend its wider application by the managed care
industry and physician community. [Emphasis Added.]
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).
*
*
*
*
*
*
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.



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.
United Kingdom back pain, exercise, and manipulation,
randomized trial: Cost-Effectiveness of physical treatments for
back pain in primary care. UK BEAM Trial Team. BMJ Online First, Nov. 29, 2004
Researchers examined the cost-effectiveness of adding SMT,
exercise, or both to the usual “best care” practice for back pain.
(Best care: based on the country’s national acute back pain guidelines)
Conclusion: SMT would be “a cost-effective addition to ‘best care’
for back pain in general practice,” and that, “manipulation alone
probably gives better value for money than manipulation
followed by exercise.”
“The cost-effectiveness of both manipulation and combined
treatment may be better than we have reported.”
The Cost Effectiveness of Chiropractic for Back
and Neck Pain




Estimates and pattern of direct health care expenditures among
individuals with back pain in the US. Luo, Pietrobon, Sun, et al.
Spine 2004;29:79-86
Medical Data International. Market and Technology Reports. US
Markets for Pain Management Products, Report RP-821922,
June 1999.
Effects of a managed chiropractic benefit on the use of specific
diagnostic and therapeutic procedures in the treatment of low
back and neck pain. Nelson, Metz, et al., JMPT, October
2005;28:564-569.
Cost effectiveness of medical and chiropractic care for acute
and chronic low back pain. JMPT October 2005;28:555-563
The Cost Effectiveness of Chiropractic for Back
and Neck Pain (cont’d)


Compared to medical care, DC care appears to offer benefits
identical or superior to those provided by medical care, while
reducing many of the costs and extraneous procedures
associated with the medical approach to back and neck pain
treatment.
Office costs higher for DC care (acute and chronic), but
factoring in referrals and imaging by MDs, TOTAL costs the
differences were much lower.

Chiropractic treatment appeared much more effective.

Chiropractic patients reported greater satisfaction.
The Cost Effectiveness of Chiropractic for Back
and Neck Pain (cont’d)



At 12 months, the cost-effectiveness of DC care for chronic
LBP patients appeared even more evident.
“Chiropractic patients with chronic LBP showed an advantage
over medical patients in pain, disability, and satisfaction
outcomes without additional costs.”
“Chronic pain and disability outcomes were clinically important
in the short term and of lesser magnitude in the long
term…with their mission to increase value and respond to
patient preferences, health care organizations and policy makers
need to re-evaluate the appropriateness of chiropractic as a
treatment option for LBP.”
The Cost Effectiveness of Chiropractic for Back
and Neck Pain (cont’d)


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Rates of surgery
Advanced imaging
Inpatient care
Plain-film radiography
(13.7% lower)
(20.3% lower)
(24.8% lower)
(2.2% lower)
When the claims data was analyzed, the researchers found that
“the rates of surgery, advanced imaging, inpatient care,
and plain-film radiographs were all lower in the cohort
with chiropractic coverage” compared to plans that didn’t
offer a chiropractic benefit.
The Cost Effectiveness of Chiropractic for Back
and Neck Pain (cont’d)




Rates of surgery
Advanced imaging
Inpatient care
Plain-film radiography
(32.1%
(37.2%
(40.1%
(23.1%
lower)
lower)
lower)
lower)
On a per episode basis the results were even more dramatic.
“Among employer groups with chiropractic coverage compared with those
without such coverage, there is a significant reduction in the use of
high-cost and invasive procedures for the treatment of LBP and neck
pain. The presumed mechanism of this effect is the substitution of
chiropractic care for medical care for the treatment of back and neck
pain. The resultant chiropractic care is far less likely to lead to the use
of these invasive procedures.”
Research…
oldies but goodies!
A review of past literature.
RAND Study
Shekelle, et al. “The Appropriateness of Spinal Manipulation for
Low Back Pain: Indication and Ratings by a Multidisciplinary
Expert Panel.” 1991; RAND/UCLA Monograph No. R-4025/2CCR/FCER.
“Spinal manipulation is the most commonly used conservative treatment
for back pain supported by the most research evidence of effectiveness
in terms of early results and long-term effectiveness.”
2/3 of patient visits were to chiropractic providers for a total cost
of $2.4 billion in 1988. Conversely, 1/3 of the visits for back
pain were to medical providers (MD) for a total cost of $8
billion.
94% of manipulation is performed by doctors of chiropractic.
AHCPR
Acute Low Back Problems in Adults: Assessment and Treatment
Proven Initial Care: Patient education, patient comfort
(NSAIDs), and SPINAL MANIPULATION.
Unproven Therapies: Traction, physical modalities
(massage, diathermy, US, cutaneous laser,
biofeedback, TENS, acupuncture, trigger point
injections, facet injections, steroid or lidocaine
injections, shoe lifts, exercise machines, stretching.
Harmful treatment: Best Rest.
Utah Study
Jarvis, et al. Cost per Case Comparison of Back Injury Claims of
Chiropractic Versus Medical Management for Conditions with
Identical Diagnostic Codes. Journal of Occupational Medicine.
1991; Vol. 33, No. 8, Aug., pp. 847-851.
In 3,062 separate cases:

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Chiropractic care took an active
approach with 8 times more visits.
Medical care took a passive approach
prescribing medication and rest.
Utah Study
(cont’d)
Conclusion:

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
Chiropractic care was 73% more cost-effective per
case.
The average distribution cost per office visit was 67%
less for chiropractic than for the medical office visit.
Patients seeing doctors of chiropractic were able to
return to work 10 times sooner than those under
medical care.
For the total data set, cost for care was significantly
more for medical claims—Compensation costs were
ten-fold less for chiropractic claims.
Australian Study
Ebrall. Mechanical Low Back Pain: A Comparison of Medical and
Chiropractic Management Within the Victorian WorkCare Scheme.
Chiropractic Journal of Australia. 1992; Vol. 22, No. 2, June pp.
47-53
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Compensation days with Chiropractic management
are ¼ the days of claims with medical management.
The “occurrence of chronicity” was greater with
medical management (6 fold greater progression to
chronicity-11.6% to 1.9%).
Cost of claims: $2,038 Medical/$963 Chiropractic.
Average compensation payment is 4 times greater
with medical management.
Australian Study
(cont’d)
Conclusion: Financial and social savings could
be maximized by:


Increased participation rate by DCs in the WorkCare.
Increased early referral from medical doctors to
Chiropractic doctors.
British Study
Meade, et al. Low Back Pain of Mechanical Origin. Randomized
Comparison of Chiropractic and Hospital Outpatient Treatment.
BMJ. 1990; Vol. 303, No. 6737. June pp. 1431-1437

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10 year multicenter trial.
Conclusion:

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Chiropractic treatment was significantly more effective,
particularly with patients with chronic and severe pain.
Results were long-term throughout the two-year follow up
period.
The potential economic, resources, and policy implications of
the results were extensive.
Patients treated by Chiropractors…almost certainly
fared considerably better and maintained their
improvement for at least two years.
Canadian Study
Manga et al. The Effectiveness and Cost Effectiveness of
Chiropractic Management of Low-Back Pain. Manga Report to
Ontario Ministry of Health. August, 1993.
Conclusions: The “Constellation of evidence” demonstrates:

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The treatment effectiveness and cost effectiveness of
Chiropractic care.
The untested, questionable, or harmful nature of
many current medical therapies.
The economic efficiency of Chiropractic care versus
medical care.
The safety of Chiropractic.
Higher patient satisfaction.
Canadian Study
Manga (cont’d)
Summary:
There should be a shift in policy to encourage the
utilization of chiropractic services for most patients
with back pain…
A very good case can be made for making chiropractors
the gatekeepers for management of low-back pain
the worker’ compensation system.
Virginia Study
Schifrin. Mandated Health Insurance Coverage for Chiropractic
Treatment: An Economic Assessment with Implications for the
Commonwealth of Virginia. January, 1992
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“By every test of cost-effectiveness, the general
weight of evidence shows that Chiropractic provides
important therapeutic benefits at economical costs.”
“These benefits are achieved with minimal, even
negligible, impact on the costs of health insurance.”
“Chiropractic services are widely used and
appreciated by a growing segment of Americans.”
2nd Virginia Study
Dean, et al. “A Comparison of the Cost of Chiropractors versus
Alternative Medical Practitioners.” Virginia Chiropractic
Association. January 1992.
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“Chiropractors see their patients more frequently but
have lower overall costs for most of the conditions
considered.”
“Chiropractic care requires fewer referrals for
specialists and outside procedures.”
“If Chiropractic care is insured to the same extent as
other specialties, it may result in a decrease in overall
treatment costs for neuro-musculoskeletal
conditions.”
Medstat Project
Stano et al. MEDSTAT Data Base Review. The Journal of
American Health Policy. 1992; Vol. 2 #6.
Conclusions:


Plans which have limited or no chiropractic coverage
have the highest total costs per patient.
Broader coverage of chiropractic services results in
dramatically lower health care cost as follows:
35% lower hospital admission rates.
42% lower inpatient payments.
23% lower total health care costs.
US General Accounting Office
“Access to Health Insurance: State Efforts to Assist Small
Business.” GAO-92-90; May 1992; pg. 33

“Mandates determined not to add significantly to the
cost of health insurance include services for in-vitro
fertilization, acupuncture, and cleft palate, as well as
services provided by Chiropractors and home health
nurses. It is these low cost mandates, however that
are often cited by the business community as
examples of the added wasteful expense mandates
cause for business.”
Journal of American Health Policy
Stano et al. “The Growing Role of Chiropractic in Health Care
Delivery.” Journal of American Health Policy. 1992 Nov-Dec. pp.
39-45.

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“Plans which do not cover Chiropractic have the
highest payments per patient.”
“Increased availability of demonstrated cost-effective
alternatives would increase access and would reduce
costs.”
Journal of Family Practice
Cherkin et al. “Family Physicians, Chiropractors, and Back Pain.”
The Journal of Family Practice. 1992; Vol. 35, No. 5, pp. 551-555

Chiropractic doctors are well-trained
and well-accepted by both patients and
insurers.
Western Journal of Medicine
Cherkin et al. “Patient Evaluation of Low Back Pain Care from
Family Physicians and Chiropractors.” Western Journal of
Medicine. 1989; Vol. 150, No. 3, March pp. 351-355.
Conclusion:
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Chiropractic doctors were highly rated compared to
medical doctors in critical patient care areas for the
treatment of low back pain.
Patients gave DCs a 3:1 advantage in five important
areas of patient satisfaction.
Chiropractic patients reported quicker recoveries.
British Medical Journal
Smith. “Where is the Wisdom? The Poverty of Medical Evidence.”
BMJ. 1991; Vol. 303, October pp. 798-799.
“Only about 15% of medical
interventions are supported by valid
medical evidence…Many treatments
have never been assessed at all.”
Topic: Bed Rest
Waddell. A New Clinical Model for the Treatment of Low-Back
Pain. Spine. 1987;12:632-644

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Little scientific or clinical evidence supports the value
of bed rest.
Only four controlled studies
Bed rest is the most harmful treatment ever devised
and a potent cause of iatrogenic disease.
Topic: Bed Rest
AHCPR. Lee. Publication No. 95-0643; December 1994, pp. 2.
Extended bed rest could be harmful. Resting in bed
for more than 4 days can weaken muscles and bones
and delay recovery.
HPP……A look back.
Presented by:
Dr. Ronald J. Farabaugh
Patient: Thomas L.
•
MOI: 125# Ladder fell 32 ft. onto LB as he was
bent over 90 degrees.
•
DX: Hospital ER dx…………contusion
•
•
Review of x-rays: possible fx. Conferenced with
radiologist who agreed and suggested CT of LB
and abdomen (due to blood in rectum). MCO
denied it since dx was only “contusion”.
6 PCPs refused to take a WC case. Why?
Positive attributes


Quicker FROI.
Acute care fairly efficient.
Note: However, as of 2010 even acute care has been
plagued by hassle-factors caused by bad consultants
and MCOs.
Negatives:
#1 Lack of historical design
knowledge.

System was designed to be data
driven..............not fee
reduction/network driven.
“Best in Class”

System was designed on "best in
class"..........in every area.
Inappropriate use of system
resources.

The system wastes massive amounts of
money "overseeing" 100% of the cases
instead of dedicating resources to the
10-20% of doctors and
paraprofessionals who really need
oversight.
Guidelines
•
•
•
Bad consultants, case managers, etc. treat
guidelines as “cookbooks” for care, instead
of a “compass” for care.
Proper use includes: clinical decisionmaking, patient values, documentation,
response to care, risk stratification, etc.
Flexible
Desperate need: Chronic care
guideline

We continue to suffer from a lack of a
chronic care guideline applicable to all
professions.
Chronic care/permanency
•
•
•
Acute care management is not too bad, but the
system falls apart once a patient progresses to
a chronic state.
The problem is multifaceted, but two primary
groups, bad consultants and outlying
physicians, are a huge part of the problem.
Result: huge escalation in the major cost
drivers within the system.
Bad Consultants/IMEs
•
Consultants..........the #1 cancer affecting
this system. They need to be held
accountable.
•
Lead to wasteful administrative and legal
costs.
•
Routinely see the same consultant denying
care in the same case, time after time.
Silent PPOs



Silent PPOs..........the #2 cancer
beginning to affect the system.
If you reduce fees even further, even
more doctors will abandon this system.
Silent PPOs inappropriately reduce fees
with the physician receiving of benefit
in return.
Conflicts of Interest
•
1.
2.
3.
4.
MAJOR conflicts of interests:
MCO medical directors being involved in forming BWC policy
MCOs owing their own occ med centers and voc rehab
centers, etc.
Cozy relationship between MCOs and TPA.
Ex., Consultants: “Ohio Society of Chiropractic
Physicians”….mission statement to “protect
employers……………..”
Steerage


Steerage remains a major problem.
Many MCOs and employers are literally
lying to employees on a daily basis.
Difficulty in multidisciplinary tx
allowance.
•
•
Lack of historical knowledge. The current
MCO administrators and case managers seem
unaware of the fight that took place allowing
multidisciplinary treatment without a hassle.
Too many MCO case managers still think that
only ONE type of physician can be treating
vs. allowing concurrent tx by multiple
physicians.
Lack of Partnership
•
•
•
Lack of "partnership". Too many MCOs think they are
directing care and return to work efforts, and continue to
hassle the treating POR instead of working cooperatively
with them.
One attorney recently sent me a letter instructing me NOT
to speak with the patient’s employer anymore………Pt.
quote: “She wanted me going to another doctor.”
Result: several more weeks of disability vs. working to
get patient back to work.
Documentation: hassle
factors

MCO/TPAs created hassle factors have
lead a great many primary care doctors
to abandon WC altogether.
Accountability of all parties

Lack of ability of BWC to decertify bad
docs, bad MCOs, and bad
consultants. Again, data should be
used more effectively.
Summary/Solutions
•
While it may sound harsh, the MCO
system has been a massive failure
compared to the design, even
though there have been a few bright
spots (early report of injury, etc.).
Summary/Solutions
•
The MCOs still use old-fashion case
management that has been proven not to
work effectively. We spent billions on a
system that allow costs to run
away.........ie., drugs and hospital based
care, while at the same time hassled to
death the physicians who possess logical
solutions to the main cost drivers in the
system.
Summary/Solutions
•
All medical professions, the BWC, MCOs,
TPAs, and employers need to become
more patient-centered, and work to rid
this system of gross abusers, while
bringing the mild to moderate outliers into
line with accepted treatment parameters
and common sense case management.
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.