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 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 Adults3 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 review4 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 Calgary10)
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.
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.
- 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. Oct 2 2007;147(7):492-504.
- Shekelle 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-FCER.
- Bigos 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. 95-0643.
- Lin 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;2009.
- 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.
- 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.
- Elton 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. Oct 2 2010.
- McMorland G, Suter E, Casha S, du Plessis SJ, Hurlbert RJ. Manipulation or microdiskectomy for sciatica? A prospective randomized clinical study. J Manipulative Physiol Ther. Oct 2010;33(8):576-584.