FROM:
Arch Intern Med 2004 (Oct 11); 164 (18): 1985–1892 ~ FULL TEXT
Antonio P. Legorreta; R. Douglas Metz; Craig F. Nelson; Saurabh Ray; Helen Oster Chernicoff; Nicholas A. DiNubile
Department of Health Services, UCLA School of Public Health, Los Angeles, Calif
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.
From the FULL TEXT Article:
COMMENT
The high prevalence and recurrent incidence of back pain, as well as the heavy economic and disability burden that it imposes on society as documented in the literature, point to a major area of public health concern. Simultaneously, there is growing evidence for the low risks associated with chiropractic spinal manipulation in most cases and favorable evidence for its effectiveness in treating low back pain. In addition, patients treated for back pain by DCs tend to be more satisfied than patients treated by MDs. However, despite this evidence for safety, effectiveness, and growing public demand, health insurance coverage for chiropractic care continues to remain restricted, relative to other health services, particularly in the managed care sector.
This restriction of access to health insurance for chiropractic care is not due to a lack of DCs, however. Rather, chiropractic care is becoming increasingly prevalent in the American health care system. The increasing acceptance of chiropractic care as a source of comprehensive complementary care for NMS problems is reflected in that the chiropractic field is the fastest growing among all doctoral-level health professions. [17]
To date, there has been little research linking chiropractic and medical utilization data at a patient level. Thus, a powerful opportunity to compare the effects of chiropractic and medical management of costly NMS conditions, such as back pain, in a real-world managed care setting has been underused. This study integrated and analyzed comprehensive administrative data from a large managed medical care organization and the chiropractic care plan that provided an additional chiropractic benefit to more than 40% of its members. By comparing members within the same medical managed care plan both with and without direct access to chiropractic care, this study provides additional information on the effect of chiropractic insurance benefits on the resource utilization within a managed care network.
For the managed care plan studied, the presence of a supplementary chiropractic insurance option was associated with favorable member selection by the plan. This is evident in that members with covered chiropractic benefits were significantly younger and had less comorbidity burden. This favorable selection could have been an artifact of 2 factors that reflect employer and employee preferences. The larger companies in particular, in the interest of maintaining a large productive workforce, may have been likely to offer additional benefits, such as supplementary insurance, to attract younger and healthier individuals. At the same time, potential employees, particularly those who maintain a healthier lifestyle may have been more likely to seek employment in companies that offer benefits covering complementary care (eg, chiropractic or acupuncture) that can be perceived as less aggressive treatment modalities.
This study found that members with chiropractic coverage had a 12% lower annual medical care cost, not adjusting for member risk characteristics. After controlling for the cost-saving effects associated with favorable demographic and medical risk factors, the regression analysis found a statistically significant 1.6% reduction in total medical care costs that can be isolated to the presence of chiropractic coverage. Most of this 1.6% reduction in the plan's total medical costs is likely derived from the 13% reduction in the total medical costs observed for the subset of members with NMS conditions who also had chiropractic coverage. In our study population of 0.7 million members who had chiropractic coverage in the medical plan, we estimated an annual reduction of approximately $16 million as a result of lower utilization of high-cost items. This is a conservative estimate of the cost savings for the plan that can be associated with members in the medical plan using their supplementary benefits to seek chiropractic treatment of their NMS problems. The estimated cost saving appears to more than offset the amount spent to cover the associated costs of the chiropractic benefit.
The analyses related to NMS episodes elucidate sources of these cost savings relating to chiropractic treatment of common NMS complaints, such as neck and back pain. Focusing on low back pain diagnoses that were selected specifically for comparability between medical and chiropractic practice, our analysis found that patients with chiropractic coverage had significantly lower rates of use of resource-intensive technologies, such as x-ray examinations, MR image, and surgery, and lower use of more expensive patient care settings, such as inpatient care. This is reflected in the significantly lower cost, at both the episode level and the patient level, of providing care for back pain. The difference in episode-specific and patient-level resource utilization did not seem to be due solely to a difference in severity of cases seen by DCs and physicians, since the estimated 2% difference in severity between chiropractic and medical patients of back pain did not constitute a clinically meaningful difference. In addition, the substitution of chiropractic for physician care evident from the shift in the case distribution between physicians and DCs when chiropractic coverage was present also contributed to the conservation of health care resources.
Although the results from the study may carry policy implications in the managed care industry, the limitations of this study are worth noting, especially since they also open up avenues for future research. This study only analyzes effects of chiropractic coverage in a large but specific managed care population. Future research covering geographically diverse populations across several plans is needed to ascertain and validate the effect of a chiropractic benefit on utilization patterns and cost effects, after controlling for differences arising from factors, including location, plan-specific benefit design, industry type, and other undetected biases, such as patient burden of disease. Comorbidity score and demographic characteristics such as age were controlled for in the regression model. However, the significantly more favorable profile of the plan members who selected chiropractic coverage poses some concern regarding the generalizability of the results to a sicker, older population. Especially as the average age of the American population continues to increase in the next decade, the safety and appropriateness of chiropractic care for elderly patients will need to be more thoroughly evaluated. Further research is also necessary to quantify utilization and costs associated with DC vs MD care for other NMS conditions, and to ascertain clinical outcomes for specific NMS conditions.
The substitution of chiropractic utilization for medical care is central to the issue of providing cost-effective care for NMS conditions in a managed care environment, since the provision of chiropractic benefits as supplementary insurance raises the possibility of induced demand for medically unnecessary care. This study found evidence that a substantial portion of the chiropractic care sought by the members with insurance coverage was more often substituted for medical care rather than add-on care. Further research is needed to quantify this substitution effect. The effects of substitution of chiropractic care utilization for medical care could be further pursued by analyzing data on patients with episodes of NMS care comanaged by DCs and MDs, which was beyond the scope of this study. Although most back pain patients have nonspecific syndromes, a few back pain cases are caused by severe underlying conditions. Accurate diagnosis and appropriate referral are essential for this subset of low back pain cases and demand an integrative approach. This point is especially important in light of the substitution between DCs and internists found by this study. Finally, questions continue to remain regarding the effectiveness of chiropractic care relative to the cost of care and quality of the health care received. Future research using patient surveys (quality-of-life and patient satisfaction measures) in conjunction with medical record review are warranted to further evaluate the cost-effectiveness of chiropractic care in managed care settings.
This study provides additional information regarding the economic benefits and utilization patterns associated with systematic access to chiropractic care. Furthermore, it offers an integrated baseline (combining chiropractic and medical utilization claims data for a common cohort of members) for future research evaluating the effect of alternative clinical management approaches to medical conditions (ie, back pain specifically) with high direct and indirect consumption of medical resources and a high derivative societal cost given the absenteeism and burden of disease associated with them.
