J Manipulative Physiol Ther 2010 (Nov); 33 (9): 640–643 ~ FULL TEXT
Richard L. Liliedahl, MD, Michael D. Finch, PhD,
David V. Axene, FSA, FCA, MAAA, Christine M. Goertz, DC, PhD
President & Consulting Actuary,
Axene Health Partners,
Christine M. Goertz, DC, PhD,
300 Brady Street,
Davenport, IA 52803
Commentary From: Chiropractic Cost-Effectiveness
By Daniel Redwood, DC
Blue Cross Blue Shield of Tennessee (2010) 
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) 
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.”
This new study finds that low back pain care, initiated with a doctor of chiropractic (DC), saves 40% on health care costs, when compared with care initiated through a medical doctor (MD), the American Chiropractic Association(ACA) announced today. The study, featuring data from 85,000 Blue Cross Blue Shield beneficiaries, concludes that insurance companies that restrict access to chiropractors for low back pain treatment may inadvertently pay more for care than they would if they removed such restrictions.
Low back pain is a significant public health problem. Up to 85 percent of Americans have back pain at some point in their lives. In addition to its negative effects on employee productivity, back pain treatment accounts for about $50 billion annually in health care costs—making it one of the top 10 most costly conditions treated in the United States.
The study, “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,” which is available online and will also be published in the December 2010 issue of the Journal of Manipulative and Physiological Therapeutics, looked at Blue Cross Blue Shield of Tennessee’s intermediate and large group fully insured population over a two-year span. 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.
Results show that paid costs for episodes of care initiated by a DC were almost 40 percent less than care initiated through an MD. After risk-adjusting each patient’s costs, researchers still found significant savings in the chiropractic group. They estimated that allowing DC-initiated episodes of care would have led to an annual cost savings of $2.3 million for Blue Cross Blue Shield of Tennessee.
6. Liliedahl 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. November - December 2010;33(9):640-643.
7. Nayer 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; 2010.
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.
Key Indexing Terms: Chiropractic, Medicine, Costs and Cost Analysis
From the FULL TEXT Article
Low back pain (LBP) is well recognized as a significant public health problem. It has been estimated that 70% to 85% of Americans have back pain at some point in their lives.  Indeed, back pain is well established as one of the most common reasons for going to see a physician. [2, 3] On the basis of the 2002 National Health Interview Survey, Deyo et a  report that about a quarter of the adult population reports LBP in any 3-month period and that LBP accounts for 2.3% of all physician visits. Druss and his colleagues  noted that back problems are one of the top 10 most costly conditions treated in the United States. According to the National Institute of Neurological Disorders and Stroke at National Institutes of Health, LBP treatment costs more than $50 billion per year. In addition, indirect costs for LBP have been estimated at between $7.4 billion and $19.8 billion per year, and the incremental medical care cost for LBP are estimated to be an additional $26 billion per year. [6, 7]
Carey et a [l8] recently conducted a survey to determine health care use patterns in patients with chronic LBP. They found high health care use in this group, with an average of 21 visits annually to an average of 2.7 provider types per year. Many of the tests and treatments used were not in line with evidence-based practice. The authors conclude that (1) care use for chronic LBP is very high, including high, advanced imaging use rates, narcotics, and physical treatments; (2) use of evidence-based treatments are low when compared with current best evidence; and (3) multiple treatments appear to be overused.
Approximately 7% of the US population seeks care from doctors of chiropractic (DCs) annually, representing nearly 200 million patient visits.  A national survey of patterns and perceptions of care found that 20% of those reporting back or neck pain sought chiropractic care.  Surveys suggest that patients are highly satisfied with chiropractic care. [11, 12] Of chiropractic patients, 61% report their care as being “very helpful,” whereas 27% report the same for conventional medical care. 
Currently, we know much more about the use of chiropractic care than we do about the costs associated with that care. A study performed by Carey and his colleagues  found that chiropractic care for an episode of LBP was less expensive than an orthopedic specialist but more than a primary care provider. Cherkin et al  found similar costs per episode between physical therapists and chiropractors, whereas Lind et al  found that patients seeing only conventional providers had fewer visits and greater costs than patients seeing nonconventional providers or a mix of traditional and nontraditional providers.
We know relatively little regarding the effect of differences in medical management on the cost of an episode of care by different types of providers. In this study, we examine the effect of initiating care for LBP with a medical doctor (MD) or with a DC in a system that has removed the traditional constraints imposed by insurance companies on a patient's use of and access to chiropractic care. We chose LBP as the focus of study because it is a condition that is prevalent, costly, and is treated by both MDs and DCs. This study evaluated if there were differences in the cost for LBP care when a patient chooses a course of treatment with an MD vs a DC, given their insurance provides them with equal access to both provider types.
Selection of Subjects
On the basis of the previous literature16 and recommendations made by the American Chiropractic association, we identified members with a claim for LBP based on the presence of one of the following International Classification of Diseases, Ninth Edition, codes anywhere on a paid claim:
722.** : Intervertebral disk disorders
724.** : Other and unspecified disorders of back
729.** : Other disorders of soft tissues
739.** : Nonallopathic lesions not elsewhere classified
846.** : Sprains and strains of sacroiliac region
847.** : Sprains and strains of other and unspecified parts of back
Of the 669,320 members during this period, 85,402 members meet these criteria.
With both paid claims and allowed amount, we found statistically significant lower costs in episodes of care initiated with a DC as compared to an MD.
In addition, we found that the risk-adjusted paid claims were also significantly lower for care initiated with a DC. In fact, about half the difference between the costs of care initiated with a DC vs an MD is due to risk selection.
However, even with this self-selection effect based on risk, care initiated with a DC is still significantly, and sizeably, less for patients seeking care for the 6 International Classification of Diseases, Ninth Edition, low back-related disorders investigated in this study.
Although we treated these data as sample from a potential population of LBP patients, one can argue from the payer's view that this is indeed the population of LBP over the 2-year study period. This interpretation would lead us to consider not the statistical properties of the sample but the savings to the payer for allowing DC-initiated episodes of care. In this instance, those savings would be more than $2.3 million per year (the difference in the actual cost for MD-initiated episodes and DC-initiated episodes).
Several limitations are worth noting. First, these results are based on the experience of a single health insurer. The distribution of the type and number of providers in a geographic area is also known to affect the use of services. Also, treatment patterns for specific conditions differ by geography. Finally, this study does not address the mix of services provided, the cost of the individual services, or if chiropractic care is a substitute for conventional care. Further study looking at different aspects of cost across a variety of insurers and geographies are suggested.
This study provides a unique opportunity to evaluate an insured population with open access (including identical co-pays and deductibles) and an unlimited number of visits to providers via self-referral. Our results support a growing body of evidence that chiropractic treatment of low back pain is less expensive than traditional medical care. We found that episode cost of care for LBP initiated with a DC is less expensive than care initiated through an MD. 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 are 20% less expensive than episodes initiated with an MD. Our results suggest that insurance companies that restrict access to chiropractic care for LBP may, inadvertently, be paying more for care than they would if they removed these restrictions.
For low back pain, care initiated with a chiropractor (DC) is less costly
than care initiated through a Medical Doctor (MD). Paid costs for
episodes of care initiated with a DC are almost 40% less then
episodes initiated with an MD.
Even after risk adjusting each patient's costs we found that episodes
of care initiated with a DC are 20% less expensive
than episodes initiated with an MD.
Furlan, AD, Brosseau, L, Imamura, M et al.
Massage for low-back pain: a systematic review within the framework of the Cochrane Collaboration Back Review Group.
Spine. 2002; 27: 1896–1910
Deyo, RA and Weinstein, JN.
Low back pain.
N Engl J Med. 2001; 344: 363–370
Luo X, Pietrobon R, Sun SX, Liu GG, Hey L.
Estimates and Patterns of Direct Health Care Expenditures Among Individuals
With Back Pain in the United States
Spine (Phila Pa 1976) 2004 (Jan 1); 29 (1): 79–86
Deyo, RA, Mirza, SK, and Martin, BI.
Back pain prevalence and visit rates: estimates from U.S. national surveys, 2002.
Spine. 2006; 31: 2724–2727
Druss, BG, Marcus, SC, Olfson, M, and Pincus, HA.
The most expensive medical conditions in america.
Health Aff. 2002; 21: 105–111
Stewart, WF, Ricci, JA, Chee, E, Morganstein, D, and Lipton, R.
Lost productive time and cost due to common pain conditions in the US workforce.
JAMA. 2003; 290: 2443–2454
Ricci, JA, Stewart, WF, Chee, E, Leotta, C, Foley, K, and Hochberg, MC.
Back pain exacerbations and lost productive time costs in United States workers.
Spine. 2006; 31: 3052–3060
Carey, TS, Freburger, JK, Holmes, GM et al.
A long way to go: practice patterns and evidence in chronic low back pain care.
Spine. 2009; 34: 718–724
Barnes, PM and Bloom, BS.
Complementary and Alternative Medicine Use Among Adults and Children: United States, 2007
US Department of Health and Human Services,
Centers for Disease Control and Prevention,
National Center for Health Statistics, Hyattsville, MD, 2008.
Pengel, HM, Maher, CG, and Refshauge, KM.
Systematic review of conservative interventions for subacute low back pain.
Clin Rehabil. 2002; 16: 811–820
Ferreira, ML, Ferreira, PH, Latimer, J, Herbert, R, and Maher, CG.
Does spinal manipulative therapy help people with chronic low back pain?.
Aust J Physiother. 2002; 48: 277–284
Furlan, AD, Clarke, J, Esmail, R, Sinclair, S, Irvin, E, and Bombardier, C.
A critical review of reviews on the treatment of chronic low back pain.
Spine. 2001; 26: E155–E162
Carey, TS, Garrett, J, Jackman, A et al.
Low back pain among patients seen by primary care practitioners, chiropractors,
and orthopedic surgeons. The North Carolina Back Pain Project.
N Engl J Med. 1995; 333: 913–917
Cherkin, DC, Deyo, RA, Battie, M et al.
Comparison of physical therapy, chiropractic manipulation, and provision
of an educational booklet for the treatment of patients with low back pain.
N Engl J Med. 1998; 339: 1021–1029
Lind, BK, Lafferty, WE, Tyree, PT, Sherman, KJ, Deyo, RA, and Cherkin, DC.
The role of alternative medical providers for the outpatient treatment of
insured patients with back pain.
Spine. 2005; 30: 1454–1459
Grieves, B, Menke, JM, and Pursel, KJ.
Cost minimization analysis of low back pain claims data for chiropractic vs
medicine in a managed care organization.
J Manipulative Physiol Ther. 2009; 32: 734–739
Winkleman, R and Mehmud, S.
A comparative analysis of claims-based tools for health risk assessment.
Society of Actuaries. 2007; : 1–70
An approximate distribution of estimates of variance components.
Biom Bull. 1946; 2: 110–114
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