Health Center Evaluates Chiropractic

There has been conflicting research and an ongoing debate regarding the cost value of chiropractic.  At the center of the debate is the question:  Does chiropractic add to or reduce the total cost of care?  The most recent and better designed studies suggest that chiropractic care can not only reduce the immediate cost of an episode of care, but reduce the recurrence of subsequent bouts of conditions such as low back pain.  These musculoskeletal conditions are a heavy financial burden on society often requiring expensive tests to pinpoint the exact diagnosis. 
 
A 2012 study offering on-site chiropractic care versus off-site physical therapy concluded that “[These results suggest that] chiropractic services offered at on-site health centers may promote lower utilization of certain health care services, while improving musculoskeletal function.”  Additionally, patients who receive chiropractic treatment often have a more conservative, less invasive treatment profile which can significantly reduce the overall cost of treatment.
 

Value of Chiropractic Services at an On-Site Health Center.  [Link]

J Occup Environ Med. 2012 Jul 17. [Epub ahead of print]

Krause CA, Kaspin L, Gorman KM, Miller RM.
From the Cerner Healthe Clinic (Dr Krause), Kansas City, MO; Cerner LifeSciences Consulting (Dr Kaspinand and Ms Gorman), Beverly Hills, CA; and Cerner Employer Services (Dr Miller), Cerner Corporation, Beverly Hills, CA.

OBJECTIVE: Chiropractic care offered at an on-site health center could reduce the economic and clinical burden of musculoskeletal conditions.

METHODS: A retrospective claims analysis and clinical evaluation were performed to assess the influence of on-site chiropractic services on health care utilization and outcomes.

RESULTS: Patients treated off-site were significantly more likely to have physical therapy (P < 0.0001) and outpatient visits (P < 0.0001). In addition, the average total number of health care visits, radiology procedures, and musculoskeletal medication use per patient with each event were significantly higher for the off-site group (all P < 0.0001). Last, headache, neck pain, and low back pain-functional status improved significantly (all P < 0.0001).

CONCLUSIONS: These results suggest that chiropractic services offered at on-site health centers may promote lower utilization of certain health care services, while improving musculoskeletal function.

Cost of care for common back pain conditions initiated with chiropractic doctor vs medical doctor/doctor of osteopathy as first physician: experience of one Tennessee-based general health insurer.   [Link]

J Manipulative Physiol Ther. 2010 Nov-Dec;33(9):640-3. Epub 2010 Oct 18.

Liliedahl RL, Finch MD, Axene DV, Goertz CM.
Axene Health Partners, Winchester, Calif, USA.

OBJECTIVE: The primary aim of this study was to determine if there are differences in the cost of low back pain care when a patient is able to choose a course of treatment with a medical doctor (MD) versus a doctor of chiropractic (DC), given that his/her insurance provides equal access to both provider types.

METHODS: A retrospective claims analysis was performed on Blue Cross Blue Shield of Tennessee's intermediate and large group fully insured population between October 1, 2004 and September 30, 2006. The insured study population had open access to MDs and DCs through self-referral without any limit to the number of visits or differences in co-pays to these 2 provider types. Our analysis was based on episodes of care for low back pain. An episode was defined as all reimbursed care delivered between the first and the last encounter with a health care provider for low back pain. A 60 day window without an encounter was treated as a new episode. We compared paid claims and risk adjusted costs between episodes of care initiated with an MD with those initiated with a DC.

RESULTS: Paid costs for episodes of care initiated with a DC were almost 40% less than episodes initiated with an MD. Even after risk adjusting each patient's costs, we found that episodes of care initiated with a DC were 20% less expensive than episodes initiated with an MD.

CONCLUSIONS: Beneficiaries in our sampling frame had lower overall episode costs for treatment of low back pain if they initiated care with a DC, when compared to those who initiated care with an MD.

Cost and use of conservative management of lumbar disc herniation before surgical discectomy.  [Link]

Spine J. 2010 Jun;10(6):463-8. Epub 2010 Apr 1.

Daffner SD, Hymanson HJ, Wang JC.
Department of Orthopaedics, West Virginia University, Morgantown, WV 26506-9196, USA. [email protected]

BACKGROUND CONTEXT: Lumbar discectomy is one of the most common spine surgical procedures. With the exception of true emergencies (eg, cauda equina syndrome), lumbar discectomy is usually performed as an elective procedure after a prudent trial of nonoperative treatment. Although several studies have compared costs of definitive operative or nonoperative management of lumbar disc herniation, no information has been published regarding the cost of conservative care in patients who ultimately underwent surgical discectomy.

PURPOSE: The purpose of this study was to determine the financial costs (and relative distribution of those costs) associated with the nonoperative management of lumbar disc herniation in patients who ultimately failed conservative care and elected to undergo surgical discectomy.

STUDY DESIGN: This is a retrospective database review.

PATIENT SAMPLE: The sample comprises patients within the database who underwent lumbar discectomy.

OUTCOME MEASURES: The outcome measures were frequency of associated procedures and the costs of those procedures.

MATERIALS AND METHODS: A search was conducted using a commercially available online database of insurance records of orthopedic patients to identify all patients within the database undergoing lumbar discectomy between 2004 and 2006. Patients were identified by American Medical Association Current Procedural Terminology code. The associated charge codes for the 90-day period before the surgery were reviewed and categorized as outpatient physician visits, imaging studies, physical therapy, injection, chiropractic manipulation, medication charges, preoperative studies, or miscellaneous charges. The frequency of each code and the percentage of patients for whom that code was submitted to the insurance companies were noted, as were the associated charges.

RESULTS: In total, 30,709 patients in the database met eligibility criteria. A total of $105,799,925 was charged during the 90 days preoperatively, an average of $3,445 per patient. Average charge for discectomy procedure was $7,841. Charges for injection procedures totaled $16,211,246 or 32% of total charges, diagnostic imaging $15,648,769 (31%), outpatient visits $6,552,135 (13%), physical therapy visits $5,723,644 (11%), chiropractic manipulation $1,177,406 (2%), preoperative studies $426,976 (0.8%), medications $263,039 (0.5%), and miscellaneous charges $1,177,371 (2%).

CONCLUSIONS: Charges for preoperative care of patients with lumbar disc herniation are substantial and are split almost evenly between diagnostic charges (outpatient visits, imaging, laboratory studies, and miscellaneous) and therapeutic charges (injections, physical therapy, chiropractic manipulation, and medications). Although a large number of patients will ultimately require surgical intervention, given that many patients will improve with nonoperative therapy, a trial of conservative management is appropriate. Additional studies to identify patients who may ultimately fail nonoperative treatment and would benefit from early discectomy would be beneficial.

Comparative analysis of individuals with and without chiropractic coverage: patient characteristics, utilization, and costs.  [Link]

Arch Intern Med. 2004 Oct 11;164(18):1985-92.

Legorreta AP, Metz RD, Nelson CF, Ray S, Chernicoff HO, Dinubile NA.
Department of Health Services, UCLA School of Public Health, Los Angeles, Calif, USA. [email protected]

BACKGROUND: Back pain accounts for more than $100 billion in annual US health care costs and is the second leading cause of physician visits and hospitalizations. This study ascertains the effect of systematic access to chiropractic care on the overall and neuromusculoskeletal-specific consumption of health care resources within a large managed-care system.

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). Having chiropractic coverage was associated with a 1.6% decrease (P = .001) in total annual health care costs at the health plan level. Back pain patients with chiropractic coverage, compared with those without coverage, had lower utilization (per 1000 episodes) of plain radiographs (17.5 vs 22.7, P<.001), low back surgery (3.3 vs 4.8, P<.001), hospitalizations (9.3 vs 15.6, P<.001), and magnetic resonance imaging (43.2 vs 68.9, P<.001). Patients with chiropractic coverage, compared with those without coverage, also had lower average back pain episode-related costs ($289 vs $399, P<.001).

CONCLUSIONS: Access to managed chiropractic care may reduce overall health care expenditures through several effects, including (1) positive risk selection; (2) substitution of chiropractic for traditional medical care, particularly for spine conditions; (3) more conservative, less invasive treatment profiles; and (4) lower health service costs associated with managed chiropractic care. Systematic access to managed chiropractic care not only may prove to be clinically beneficial but also may reduce overall health care costs.

Economic case for the integration of chiropractic services into the health care system.  [Link]

J Manipulative Physiol Ther. 2000 Feb;23(2):118-22.

Manga P.
Masters Program in Health Administration, University of Ottawa, Ontario, Canada.

The role and position of chiropractic care in the health care system must be transformed from being alternative and separate to alternative and mainstream. This transformation requires that chiropractic services become integrated in the many health care delivery organizations that collectively constitute the health care system. There is solid and impressive economic and related justification for the desired integration. Chiropractic care is a cost-effective alternative to the management of neuromusculoskeletal conditions by other professions. It is also safer and increasingly accepted by the public, as reflected in the growing use and high patient retention rates. There is much and repeated evidence that patients prefer chiropractic care over other forms of care for the more common musculoskeletal conditions. The public interest will be well served by this transformation. Musculoskeletal disorders and injuries are the second and third most costly categories of health problems in economic burden-of-illness studies. They rank first as a cause in the prevalence of chronic health problems and long-term disability and rank at the top for activity limitations and short-term disability. They rank first as a reason for consultation with a health professional and second as a reason for the use of prescription and nonprescription drugs. These conditions are more prevalent among the poor, lower-middle income groups, and the elderly, yet those are precisely the groups that make the least use of chiropractic care for reasons of inadequate insurance coverage. The integration of chiropractic care into the health care system should serve to reduce health care costs, improve accessibility to needed care, and improve health outcomes.

Maintenance care: health promotion services administered to US chiropractic patients aged 65 and older, part II.  [Link]

J Manipulative Physiol Ther. 2000 Jan;23(1):10-9.

Rupert RL, Manello D, Sandefur R.
Logan Chiropractic College, St Louis, MO, USA.

OBJECTIVE: Health promotion and prevention services provided by the chiropractic profession historically have been referred to as maintenance care (MC). The primary objective of this investigation was to obtain information regarding multiple health issues of patients age 65 years and over who have had a long-term regimen of chiropractic health promotion and preventive care. The study also sought to explore the nature of the interventions and methods that were most commonly used by chiropractors when administering MC and to determine whether there were differences between patients who have had long-term exposure to these preventive services versus those who have not.

DESIGN: This descriptive study was accomplished by selecting chiropractic patients (age 65 years and over) who had received health-promotion and prevention services for at least 5 years, with a minimum of 4 visits per year. To enhance the probability of securing a more representative patient sample, selection was made through the participation of chiropractors from 6 diverse geographic locations across the United States. Doctors were asked to enroll the first 10 consenting patients who met the inclusion criteria. A battery of diverse assessment instruments were completed by each patient to provide a patient health profile. Information related to each patient included answers to the SF-36D survey, patient health habits, expenditures of health services, frequency of use of health providers, and perceived value of chiropractic prevention and health promotion services.

RESULTS: A total of 73 chiropractors participated in this investigation from the 6 study sites. In addition to an average 1.9 manual procedures used per patient, it was common to recommend stretching exercises (68.2%), aerobic exercises (55.6%), dietary advice (45.3%), and a host of other prevention strategies, including vitamins and relaxation. The patients investigated in this study reported making only half the annual number of visits to medical providers (4.76 visits per year) compared with the national average (9 visits per year) for individuals age 65 years and over.

CONCLUSIONS: On the basis of the response of participating chiropractors, this study describes the therapeutic components of MC for the elderly patient. For these patients, MC does not simply consist solely of periodic visits for joint manipulation, but it involves an eclectic host of interventions (e.g., exercise, nutrition, relaxation, physical therapy, and manipulation) that are directed at both musculoskeletal and visceral conditions.