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Chiropractic Benefits:
From I Ching To Ka-Ching
By Anthony L. Rosner, Ph.D.
Director of Research, FCER
Reprint from Spring/Summer 2004 FCER Advance
Back in college
and especially graduate school at Harvard, I remember countless and
endless bull sessions (some influenced by wine, some egged on a bit
further by pitchers of beer in which I was, like, totally transported into
the subjunctive) which were shaped by our ethical and spiritual values as
to how we might actually change the world. One of our hallowed symbols of
this period coming out of the late 1960s was the I Ching, [1]
an ancient Chinese divination manual full of symbolism and poetic text.
This was to be our vision of the world order, motivated by a strong moral
commitment.
Now, of course, so
many of these lofty goals are driven by money — seen in globalization, publishing conglomerates, the Disney entertainment empire, or the postings
each week in USA Today of the top-grossing movies from Hollywood (this used to be just a specialty item published in Variety rather than an issue of national consciousness). And so it is with healthcare and
chiropractic in particular. This occurs against the background of the
beleaguered U.S. healthcare system—spending upwards of twice as much per
capita yet ranking lower than France or Japan and holding 37th place in an
overall list of 191 [2] — as it struggles to keep pace with major
inflationary pressures within the healthcare industry.
On one hand, the
efforts of the chiropractic research community to document the theory and
practice of chiropractic—in no small part due to the efforts of FCER—have
been amply recognized in the indexed literature as having enabled the
profession to approach mainstream status. [3, 4] However, the
economics of chiropractic care seem to be far less established to date.
This is not at all helped by the fact that out of a total of 50,000
randomized clinical trials in healthcare, only 121 (0.2%) were reported just
a little over a decade ago to have included economic analyses. [5]
In terms of what appears to have captured public attention, a stream of
reports from the Workers Compensation Research Institute (WCRI) in recent
years [6, 7] as well as from the California Workers' Compensation
Institute [8] have all suggested that chiropractors are a major cost
driver in at least two states (CA and TX) and consequently require strict
controls.
Here is the problem,
taken in broad strokes. What are the leading alternatives to chiropractic
services for back care? We know that the total expenditure for back pain in
the U.S. is over $90B in recent years. We also know that the costs of
prescription drugs runs about $14B annually, more than 15% of the
total, the drug expenditures increasing more rapidly than such health
services as inpatient or outpatient care, office-based visits, emergency
room, or home health. [9] On top of this we can graft the rate of
all surgeries (17.6%) found to be unnecessary by the Congressional
Committee on Interstate and Foreign Commerce. [10] Plugging in the
number of lower back surgeries in the U.S. found to exceed $250,000 per year
at a hospital cost of $11,000 per patient, [11] this would mean that
the total number of unnecessary back surgeries in the U.S. could approach
44,000 with a total cost of $484 million. As far as prescription drug
expenditures are concerned, with the total spending on them having doubled
from 1995–2000 and tripled from 1990–2000 and having been identified as a
key factor spiking U.S. healthcare costs in recent years, [12] costs
associated with chiropractic services would seem to be small potatoes
indeed.
If we are going to
argue dollars and cents, then, the chiropractic community has a significant
issue to deal with—to which FCER has risen to the challenge. Beginning with
an appearance in Harrisburg in November 2001 at the Pennsylvania state
legislature, I have been rebutting the arguments put forth by the WCRI [6, 7]
and have just returned from Austin where I put in a similar appearance
before the Select Interim Workers' Compensation Senate Committee of Texas
(see “FCER’s Research Director Testifies to Texas Senate Public Hearing” in
this issue) for the same purpose. In both California and Texas, chiropractic
workers' compensation benefits have been getting hammered based on evidence
that is far from convincing. To quote Tom and Ray Magliozzi on National
Public Radio ("In my humble opinion..."), these are the major flaws in the
WCRI arguments erroneously used to downgrade chiropractic services in
workers' compensation systems:
Sampling frames
have to be clearly identified: In the state of California, in which
similar trends have been presented by the California Workers' Compensation
Research Institute, [8] it has been suggested that the large
number of visits observed can be attributed to just 3–5% of chiropractors
who are responsible for 80% of the costs. [13] Until we see a
complete set of data allowing us to verify that the sampling frame of
chiropractors chosen is truly representative of all practitioners within
the state of Texas AND what the distribution of the costs, number of
visits, and numbers of procedures is within this sampling frame, we cannot
draw any meaningful conclusions.
Data on actual
comparative outcomes in comparison years is lacking:
There is no indication in the WCRI data of what the comparative levels of
disability were at the workplace when the worker returned to his or her
place of employment. Should the worker have returned in a shorter period
of time and/or performed at a higher efficiency in the more recent years,
the increase in workers’ compensation (WC) payments would have been offset
by higher worker productivity with lower costs for replacement training
and long-term rehabilitation. This simply has to do with good medicine
rather than simply closing the books on a claim at an arbitrary time point
without validation.
Bundling and
billing of services is problematical:
Bundling of all germane costs for an episode of care remains
elusive—whether for ancillary issues such as the actual costs of all
medications, laboratory or hospital services or for indirect costs such as
(i) workdays lost by patient, (ii) retraining for replacement labor, (iii)
caregiver to assist in domestic duties, (iv) iatrogenic events associated
with treatment, and (v) legal (malpractice) settlements and premiums.
Previous studies have never fulfilled all these criteria, [14]
although a recent report from CIGNA comes closer than most. [15] A
report from a leading healthcare economist commissioned by the Ontario
Provincial Government concluded that, in a typical patient's visit to the
office of an M.D., 20% of medical services lie within the office visit
itself while 80% of the charges are billed to ancillary services. For
visits to the chiropractor's office, these two percentages are almost
diametrically opposed—as most costs are contained within the
chiropractor's office. [16, 17] The data from the WCRI studies [6, 7]
bears no resemblance to these proposed ratios and raises further questions
as to precisely how they were calculated. The caveat is to avoid splitting
up the actual treatments for non-D.C. patients into separate categories
when in fact they are linked to the same episode and must consequently be
bundled. Finally, surgical costs were omitted in one report [7]
while drug costs, a notorious driver of the high costs of healthcare, [12, 18–20]
seem vastly underestimated as suggested by postings of $7 or
"insignificant" amounts per episode in the state of Connecticut. [7]
Data on case
severity and case mix are conspicuously lacking:
Other than a general weighting of different states, there is no primary
data evident which adequately defines the allocation of case mix and
severity between provider groups or years being compared. Regarding back
pain alone, for instance, one must ask whether the incidence of
specific conditions or injuries (such as herniated disc) changed from
earlier to later periods. Should the more difficult cases such as
herniated disc have appeared more frequently in later years, they would be
expected to require the more exhaustive treatment periods and assortments
of procedures reported.
Data on
permissible scopes of practice in the comparison years are lacking:
The increase in the number of procedures reported may have to do with
changes in the permissible scope of practice during that period. Also, the
number of procedures/case for other healthcare professions should
be reported for comparison.
WC benefits
paid to chiropractors represents a minuscule proportion of the total:
From the WCRI's own sampling frame of 12 representative states, the actual
distribution of medical payments per claim to chiropractors is a paltry 4%
of the total, substantially less than the 31% given to physicians, the 10%
allocated to PT/OTs, or the 36% earmarked for hospitals. [6] In
Georgia, chiropractors workers' compensation cost recoveries were just
0.8% of the benefits disbursed to physicians in 1997 and 1998, [21, 22]
while low back pain costs have been estimated to consume between
16–33% of workers' compensation distributions. [23]
These are but a few
of the problems with the recent reports from the WCRI [6, 7] which I
have deconstructed elsewhere, addressing the WCRI in particular [24]
and workers' compensation issues in general. [25]
So where should the
limited number of healthcare dollars be spent? We can applaud the advances
of heroic medicine but in these times must maintain our focus upon those
aspects of chiropractic healthcare that are designed to minimize the onset
of more costly and invasive procedures further on. Although a couple of
encouraging studies that could be interpreted as suggestive of the benefits
of maintenance care have appeared in the journals, [26, 27] far more
attention has to be paid to the fact that the lion's share of the current
cost burden upon healthcare systems is not within the chiropractic
realm at all. This problem can only be solved with properly designed
cost-effectiveness studies which to date lack all of the elements needed to
capture the true direct and indirect costs of an episode of illness. [14]
Furthermore, far more research to document the potential benefits of
maintenance care is needed.
Once this is
achieved, the incessant din of "ka-ching!" in healthcare might be silenced
enough for us to be able to devote more time to the entire well-being of the
patient. Who knows? This might even entail being able to revisit some
forgotten tenets of the I Ching. [1]
REFERENCES:
Ching, or Book of Changes
Wilhelm R, Baynes CF translation, 3rd edition,
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Fezchem RG.
Health systems: More evidence, more debate (editorial).
Bulletin of the World Health Organization 2000; 78(6): 715.
Meeker WC, Mootz RD, Haldeman S.
Back to basics...The state of chiropractic
research.
Topics in Clinical Chiropractic 2002; 9(1): 1-13.
Meeker, W., & Haldeman, S. (2002).
Chiropractic: A Profession at the Crossroads of Mainstream and Alternative Medicine
Annals of Internal Medicine 2002 (Feb 5); 136 (3): 216–227
Adams ME, McCall NT, Gray DT, Orza MJ, Chalmers TC.
Economic analysis in
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Eccleston SM, Zhao X.
The anatomy of workers' compensation medical costs and
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Victor RA, Wang W.
Patterns and cost of physical medicine: Comparison of
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Luo X, Pietrobon R, Sun SX, Liu GG, Hey L.
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Leape LL.
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Herman R.
Back surgery.
Washington Post (Health Section), April 18,
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Walen W.
e-mail sent to Dynamic Chiropractic,
September 19, 2003 and
printed in the same publication, 2003; 21(22): 38.
Branson RA.
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
Schaffer WA, Margoshes B.
The disability and HealthCare connection. How
strong is the link.
Report from CIGNA Corporation, 2004.
Manga, P.
Economic Case for the Integration of Chiropractic Services into the Health Care System
J Manipulative Physiol Ther 2000 (Feb); 23 (2): 118–122
Manga P, Angus DE.
Enhanced Chiropractic Coverage Under OHIP as a Means of Reducing Health Care Costs,
Attaining Better Health Outcomes and Achieving Equitable Access
to Select Health Services
Report to the Ontario Ministry of Health. Ottawa:
Ministry of Health, Government of Ontario; 1998.
Health Care and Financing Administration,
as reported in the New York
Times, October 29, 1999.
National Institute for Health Care Management Research and Education
Program,
prepared by the Barents Group LLC, July 9, 1999.
Findlay S,
National Institute of Health Care Management,
as reported by
Anjetta McQueen, The Boston Globe, May 8, 2001.
www.ganet.org/sbwc/about/
Smith JC. email notice of August 11, 2000.
Hooper P.
Dynamic Chiropractic 1994; 12(25).
Rosner A.
Workmens' compensation issues and chiropractic care: Response to
Workers Compensation Research Institute Data.
Report released to the
Congress of Chiropractic State Associations, October 9, 2003.
Rosner A.
Workers' compensation costs and chiropractic: Taking a position on
center stage.
Journal of the International Association of Industrial
Accidents, Boards and Commissions 2004; 41(1): 22-49.
Coulter ID, Hurwitz EL, Aronow HU, Cassata DM, Beck JC.
Chiropractic
patients in a comprehensive home-based geriatric assessment, follow-up and
health promotion program.
Topics in Clinical Chiropractic 1996; 3(2):
46-55.
Rupert RL, Manello D, Sandefur R.
Maintenance care: Promotion services
administered to US chiropractic patients aged 65 and older, part II.
Journal of Manipulative and Physiological Therapeutics 2000; 23(1):
10-19.
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