FROM: Health Insights Today
By Daniel Redwood, DC
“Doctors of chiropractic are a vital part of our nation’s health care system. Your services have been proven both effective and cost-effective and every day you help countless Americans with a variety of health conditions.”
~ Kathleen Sebelius,
Secretary of Health and Human Services
2011 National Chiropractic Legislative Conference
Health care costs in the United States continue to rise and now account
for 17.6% of the economy. In the public sector, Medicare and Medicaid
budgets are under continual strain, while accelerating private sector
insurance premium increases are pricing millions of American families
out of the market each year.
Aside from outlawing pre-existing condition exclusions and providing
premium subsidies for those who need them most, the Patient Protection
and Affordable Care Act of 2010 (PPACA) empowers the Department of
Health and Human Services to take a variety of steps toward controlling
costs. But attempts to utilize these powers will trigger strong
opposition from groups facing adverse impact to their bottom lines.
Further complicating matters, the future of PPACA remains uncertain as
opponents seek to vilify, defund and repeal it.
In the current economic and political climate, one of the most important
arguments to be made for any health care method is that it is
cost-effective. As a result, researchers are redoubling their efforts to
identify cost-effective approaches. This includes a growing number of
studies addressing the cost-effectiveness of chiropractic services.
Chiropractors and chiropractic students need to understand this
information and to share it with others.
Low Cost Plus High Effectiveness Is the Goal
The most critical point when seeking cost savings is to distinguish
between high-value and low-value services. On the scale of relative
value per dollar spent, health economists identify the highest value
services as those that effectively prevent or treat disease and cost
less than competing approaches; services of the lowest value are those
that have less satisfactory outcomes and cost more than the
alternatives. The goal is to incentivize the use of high-value services
and discourage the use of low-value services. Across-the-board budget
cuts that fail to make such qualitative distinctions are the equivalent
of substituting a meat cleaver for a surgeon’s scalpel, or a
sledgehammer for a chiropractic adjustment.
We need both solid data and insightful analysis of that data. If we
accept that high-value services should be incentivized, then we must
engage in a rigorous, ongoing search for health care services that
effectively prevent and treat illnesses and do so at a reasonable cost.
Within the past few years, there have been several key developments in
the evaluation of the effectiveness and cost-effectiveness of various
approaches for back pain and neck pain. These conditions comprise a
significant majority of cases seen by chiropractors.
National Guidelines: American Pain Society and the
American College of Physicians (2007) [1]
As has been true of low back pain guidelines worldwide, the 2007
guidelines prepared by a panel of the American Pain Society and American
College of Physicians recognized spinal manipulation (over 90 percent
of which is delivered by chiropractors) [2]
as an effective procedure for both acute and chronic low back pain.
This is consistent with the 1994 Guidelines on Acute Lower Back Pain in
Adults [3] from the U.S. Agency for
Healthcare Policy and Research (AHCPR). Both the APS-ACP guidelines and
the earlier AHCPR guidelines were prepared by expert panels based on a
full review of all existing research.
A 2011 systematic review [4] of the
cost-effectiveness of treatments endorsed in the APS-ACP guidelines
found that spinal manipulation was cost-effective for subacute and
chronic low back pain, as were other methods usually within the
chiropractor’s scope of practice (interdisciplinary rehabilitation,
exercise, and acupuncture). For acute low back pain, this review found
insufficient evidence for reaching a conclusion about the
cost-effectiveness of spinal manipulation. It also found no evidence at
all on the cost-effectiveness of medication for low back pain.
Mercer Health and Benefits (2009) [5]
In 2009, Arnold Milstein, MD, MPH, of Mercer Health and Benefits, and
Niteesh Choudhry, MD, PhD, of Harvard Medical School, compared
chiropractic care to that provided by medical physicians, and concluded
that, “When considering effectiveness and cost together, chiropractic
physician care for low back pain and neck pain is highly cost effective
[emphasis in original], represents a good value in comparison to medical
physician care and to widely accepted cost-effectiveness thresholds.”
Blue Cross Blue Shield of Tennessee (2010) [6]
An important 2010 study evaluated low back pain care for Blue Cross Blue
Shield of Tennessee’s intermediate and large group fully insured
population over a two-year period. The 85,000 BCBS subscribers in the
insured study population had open access to MDs and DCs through
self-referral, and there were no limits applied to the number of MD/DC
visits allowed and no differences in co-pays. Thus, the data from this
study reflect what happens when chiropractic and medical services
compete on a level playing field.
The researchers, led by an actuary, compared the costs of low back pain
care initiated with a doctor of chiropractic with care initiated through
a medical doctor or osteopathic physician. They found that costs for
the chiropractic group were 40 percent lower. Even after factoring in
the severity of the conditions with which patients presented, costs when
initiating care with a DC rather than an MD/DO were 20 percent lower.
The researchers concluded that insurance companies that restrict access
to chiropractic care for low back pain treatment may inadvertently pay
more for care than they would if they removed such restrictions.
According to this analysis, had all of the low back cases initiated care
with a DC, this would have led to an annual cost savings of $2.3
million for BCBS of Tennessee.
Center for Health Value Innovation Report (2010) [7]
The Center for Health Value Innovation (www.vbhealth.org) is a
membership organization of employers and insurance plan sponsors that
“shares actionable health data, strategies and tools for better business
performance.” This organization’s core mission is to align incentives
for individual responsibility and corporate accountability. CHVI’s 2010
report, “Outcomes-Based Contracting™: The Value-Based Approach for
Optimal Health with Chiropractic Services,” addresses the role of
chiropractic services as part of the continuum of care in value-based
benefit design.
After analyzing available data on clinical effectiveness and
cost-effectiveness, CHVI concluded that “the addition of chiropractic
coverage for the treatment of low back and neck pain at prices typically
payable in US employer-sponsored health plans will likely increase
value-for-dollar.”
Three Other Studies Demonstrate That Chiropractors Deliver a High-Value Service
(ACN/UnitedHealth Group, [8], University of British Columbia, [9] and
University of Calgary [10)
Two newly released studies comparing chiropractic and medical care
highlight a central theme in current health care planning – the critical
importance of having health care practitioners follow evidence-based
guidelines. These two studies, one from Minnesota and the other from
British Columbia, Canada, convey the same clear message – that when
chiropractic services for back pain and neck pain are compared to
medical services for these conditions in head-to-head competition on a
level playing field, chiropractic consistently demonstrates superiority
in effectiveness and cost-effectiveness. This was also the case in a
recent Canadian study comparing outcomes for microdiskectomy and spinal
manipulation in patients with low back pain with sciatica.
ACN Group (UnitedHealth Group) Report (2007) [8]
A 2007 report from ACN Group, a subsidiary of UnitedHealth Group (the
nation’s largest health insurer), has recently become publicly
available. After demonstrating that orthopedic conditions account for
more medical expenses than any other condition (surpassing even
cardiology), and that back and neck pain account for a far higher
percentage of orthopedic expenses than any other orthopedic condition,
the report goes on to show that chiropractic services for back and neck
pain are significantly more cost-effective than all competing
approaches. In particular, precisely as was shown in the Blue Cross Blue
Shield of Tennessee study cited earlier, UHC concludes that the single
most important factor in holding down costs is the profession of the
doctor with whom care is initiated.
To briefly sum up these findings – when care is initiated with a
chiropractor, the severity adjusted total episode cost is lower than for
care initiated with a primary care medical physician, and drastically
lower than for care initiated with an orthopedist, physical medicine and
rehabilitation physician, or other practitioner. Among the other
findings in this report are (1) “When first provider seen is a
conservative provider [i.e., a chiropractor], treatment appears to be
characterized by spinal manipulation and active/passive therapies” and;
(2) “When first provider seen is a PCP [primary care physician], spine
care appears to be characterized by radiology, pharmacy, hospitalization
and surgery.” Moreover, the report continues, “… by aligning
decision-making with current clinical evidence Minnesota chiropractors
produce large improvement in disability at a low episode cost.”
Award-Winning Canadian Study Supports Value of
Guidelines and Chiropractic (2010) [9]
A hospital-based study at the University of British Columbia led by Paul
Bishop, DC, MD, PhD, was the winner of the North American Spine
Society’s 2010 Award for Outstanding Paper in Medical and Interventional
Science. Bishop’s team compared guidelines-based care (including
chiropractic spinal manipulation) for low back pain of less than 16
weeks versus usual care administered by primary care medical physicians.
Its key findings were that (1) guidelines-based care including
chiropractic spinal manipulation is significantly more effective than
“usual care” and (2) usual care by primary care MDs is highly
guideline-discordant. Dr. Bishop’s team at the University of British
Columbia and Canada’s National Spine Center is currently engaged in an
ongoing series of studies to further illuminate these issues.
Canadian Study Compares Chiropractic to Microdiskectomy for
Low Back Pain with Sciatica (2010) [10]
In an excellent example of the kind of comparative effectiveness
research needed to distinguish the relative quality of competing
treatment approaches, researchers in Alberta, Canada studied the
relative costs and benefits of lumbar microdisckectomy and chiropractic
spinal manipulation for patients with low back pain and sciatica
associated with lumbar disk herniation for whom usual medical care had
failed. The results were dramatic: 60 percent of patients with sciatica
who had failed medical management benefited from spinal manipulation to
the same degree as if they had undergone surgical intervention, at a far
lower cost.
The economic implications of these findings are far-reaching. In the
U.S., at least 200,000 microdiskectomies are performed annually at a
direct cost of $5 billion, or $25,000 per procedure. Avoiding 60 percent
of these surgeries would mean a reduction savings of $3 billion
annually. In the Canadian study, patients receiving chiropractic care
averaged 21 visits during their course of care. If a cost of $100 per
patient visit is assumed for the care provided by the chiropractor, then
the total cost per patient would be $2,100, yielding per patient
savings of $22,900, or $2.75 billion dollars annually.
Conclusion:
For the conditions treated most often by chiropractors, chiropractic
services are more cost-effective than competing methods. Health policy
that encourages effective and cost-effective methods leads to superior
outcomes and lower costs.
“In the U.S., at least 200,000 microdiskectomies are performed annually at a direct cost of $5 billion, or $25,000 per procedure. Avoiding 60 percent of these surgeries [by sending the patients to chiropractors] would mean a reduction savings of $3 billion annually. In the Canadian study, patients receiving chiropractic care averaged 21 visits during their course of care. If a cost of $100 per patient visit is assumed for the care provided by the chiropractor, then the total cost per patient would be $2,100, yielding per patient savings of $22,900, or $2.75 billion dollars annually.”
Daniel Redwood, DC, is a Professor at Cleveland Chiropractic College–Kansas City. He is the Editor-in-Chief of Health Insights Today and The Daily HIT, and serves on the editorial boards of the Journal of the American Chiropractic Association, Journal of Alternative and Complementary Medicine, and Topics in Integrative Healthcare.
Dana Lawrence, D.C., the first Editor of the beloved JMPT journal,
draws our attention to this article:
Primer on Cost-Effectiveness Analysis
REFERENCES:
Chou R, Huffman LH.
Nonpharmacologic Therapies for Acute and Chronic Low Back Pain: A Review of
the Evidence for an American Pain Society/American College of Physicians
Clinical Practice Guideline
Ann Intern Med. 2007 (Oct 2); 147 (7): 492-504Shekelle PG, Adams AH.
The Appropriateness of Spinal Manipulation for Low Back Pain: Project Overview and
Literature Review
Santa Monica: RAND; 1991. R-4025/1-CCR-FCERBigos S, Bowyer O, Braen G.
Acute Lower Back Pain in Adults. Clinical Practice Guideline, Quick Reference Guide
Number 14. Rockville: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; 1994. AHCPR Pub. No. 95-0643Lin C-WC, Haas M, Maher CG, Machado LAC, Tulder MW.
Cost-effectiveness of guideline-endorsed treatments for low back pain:
A systematic review
European Spine Journal. 2011 [ePub ahead of print]Choudhry N, Milstein A.
Do Chiropractic Physician Services for Treatment of Low-Back and Neck Pain Improve
the Value of Health Benefit Plans? An Evidence-Based Assessment of Incremental
Impact on Population Health and Total Health Care Spending
San Francisco: Mercer Health and Benefits; 2009Liliedahl RL, Finch MD, Axene DV, Goertz CM.
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
J Manipulative Physiol Ther. 2010 (Nov); 33 (9): 640-643Nayer C, Sherman B, Mahoney J.
Outcomes-Based Contracting: The Value-Based Approach for Optimal Health
with Chiropractic Services.
St. Louis: Center for Health Value Innovation; 2010Elton D.
Conservative Treatment of Spinal Complaints:
ACN Group (UnitedHealth Group);2007.Bishop PB, Quon JA, Fisher CG, Dvorak MF.
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
Spine J. 2010 (Dec); 10 (12): 1055–1064McMorland G, Suter E, Casha S, du Plessis SJ, Hurlbert RJ.
Manipulation or microdiskectomy for sciatica? A prospective randomized clinical study
J Manipulative Physiol Ther. 2010 (Oct); 33 (8): 576-584
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