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
This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
FROM: Mercer Health and Benefits LLC ~ October 12, 2009 ~ FULL TEXT
OPEN ACCESS Arnold Milstein, MD, MPH, and Niteesh Choudhry, MD, PhD
New Report Finds Chiropractic Is More Effective for Neck and Low Back Complaints
April 15th, 2010
A report, prepared for the Foundation for Chiropractic Progress by the esteemed medical authors Niteesh Choudhry, MD, PHD (Harvard Medical School) and Arnold Milstein, MD, MPH (Mercer health and Benefits), produced these conclusions from the Executive Summary:
Chiropractic care is more effective than other modalities for treating low back and neck pain
Total cost of care per year:
For low back pain, chiropractic physician care increases total annual per patient spending by $75 compared to medical physician care
For neck pain, chiropractic physician care reduces total annual per patient spending by $302 compared to medical physician care.
Cost-effectiveness:
When considering effectiveness and cost together, chiropractic physician care for low back and neck pain is highly cost-effective, represents a good value in comparison to medical physician care and to widely accepted cost-effectiveness thresholds. Because we were unable to incorporate savings in drug spending commonly associated with US chiropractic care, our estimate of its comparative cost-effectiveness is likely to be understated.
They go on to state: Our findings in combination with existing US studies published in peer-reviewed scientific journals suggest that chiropractic care for the treatment of low back and neck pain is likely to achieve equal or better health outcomes at a cost that compares very favorably to most therapies that are routinely covered in US health benefit plans. As a result, the addition of chiropractic coverage for the treatment of low back and neck pain at prices typically payable in US employer-sponsored health benefit plans will likely increase value-for-dollar by improving clinical outcomes and either reducing total spending (neck pain) or increasing total spending (low back pain) by a smaller percentage than clinical outcomes improve.
Choudhry N, Milstein A (2009)
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.
Harvard Medical School, Boston, Mercer Health and Benefits, San Francisco.
Arnold Milstein, MD, MPH, who holds degrees in economics, medicine and health services planning from Harvard, Tufts and the University of California, Berkeley is Chief Physician in Mercer at San Francisco and described by Mercer as its “national thought leader”.
He is also Medical Director of the Pacific Business Group on Health (PBGH), the largest employer healthcare purchasing coalition in North America. He is as influential as anyone in managed care program innovation and design, a field in which he has extensive publications and a number of national awards, and he serves on the Permanent Advisory Commission for the US federal Medicare program.
Niteesh Choudhry, MD, PhD is an Assistant Professor at Harvard Medical School where a focus of his research is pharmaco-economics – the clinical and economic effects of different patterns of drug use. His medical degree is from the University of Toronto, his PhD in health policy at Harvard was in statistics and evaluative sciences.
Chiropractic Research & Practice: State of the Art
By Daniel Redwood, D.C.
Niteesh Choudhry, MD, PhD, of Harvard Medical School, and Arnold Milstein, MD, Chief Physician at Mercer Health and Benefits and Medical Director of the Pacific Business Group on Health, co-authored the 2009 report, 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 Healthcare Spending. [61] This report combined a rigorous analysis of direct and indirect costs with equally relevant (though often missing from such analyses) evidence concerning clinical effectiveness. In other words, Choudhry and Milstein started with the assumption that low cost is only a virtue if a product or service effectively delivers what it promises. Including both clinical effectiveness and cost in their analysis, they concluded that chiropractic care was far more valuable than medical treatment for neck and low back pain.
These analysts found that for neck pain, chiropractic physician care decreases annual spending by $302 compared to medical physician care, and that for low back pain, chiropractic increases total annual per patient spending by $75 compared to medical physician care. Their analysis also noted that chiropractic care, particularly when combined with exercise, is significantly more effective than medical care for patients for low back and neck pain. This combination of factors led them to conclude that, “when considering effectiveness and cost together, chiropractic physician care for low back and neck pain is highly cost effective, represents a good value in comparison to medical physician care and to widely accepted cost-effectiveness thresholds. Because we were unable to incorporate savings in drug spending commonly associated with US chiropractic care, our estimate of its comparative cost-effectiveness is likely to be understated.”
The Trials of Evidence: Interpreting Research and the Case for Chiropractic
The Chiropractic Report ~ July 2011
In the Mercer Report leading US health economists at Mercer Health and Benefits and Harvard University assessed the cost-effectiveness of chiropractic management of patients with neck and back pain. They noted that “low-back and neck pain are extremely common conditions that consume large amounts of healthcare resources” and conclude that “when considering effectiveness and cost together, chiropractic physician care for low-back and neck pain is highly cost-effective, and represents a good value in comparison to medical physician care and to widely accepted cost-effectiveness thresholds”. [22]
The question of cost-effectiveness, both from the points of view of the individual patient and third party payors, is complex and no field for amateurs. Many studies by health sciences researchers without expertise in economics are inconsistent because of problems such as poor matching of patients, failure to include all costs, invalid attribution of costs and inadequate sample size. Relevant costs that must be incorporated are direct costs of care, costs arising from harm from treatments, compensation costs for disability and time of work, and other indirect costs incurred by patients, families and employers.
For a full discussion of cost-effectiveness, and the research evidence including the Mercer Report, see the November 2009 issue of The Chiropractic Report available at www.chiropracticreport.com under Past Issues. Some key points include:a) With chiropractic care the chiropractors’ fees represent 80% of total healthcare costs – only 20% is secondary costs from other diagnostic tests and therapy/specialist/in-hospital services. With medical care the situation is reversed. Physicians’ fees represent 23% of total healthcare costs – the other 77% is secondary healthcare cost. These were the findings of Canadian health economists Manga and Angus when they reviewed all the international evidence from workers compensation, employer and other data in 1998 relative to back pain. [23] They conclude that there is 20 to 60% total cost saving when a matched group of patients receive chiropractic care rather than medical care for back pain, depending upon jurisdiction and healthcare system.
b) A major issue for third party payors is substitution. Even if chiropractic care is cost-effective for patients with back and neck pain, headaches and other neuromusculoskeletal disorders, will a chiropractic benefit given to patients be an add-on cost similar for example to a dental benefit and most other benefits, and therefore increasing overall costs even though cost-effective in itself, or will chiropractic services given under the benefit truly “substitute” for more expensive medical care? The first large study, on that issue, based on data from 1.7 million members of a managed-care network in California, confirms that virtually all chiropractic services used by plan members were used in direct substitution for medical services. This was for all conditions seen by chiropractors – a range of 654 ICD-9 Codes covering neuromusculoskeletal disorders such as spinal pain, rib disorders, headache, extremity problems and myalgias or arthralgias. [24]SEE ALSO:
Cost-Effectiveness Revisited
The Chiropractic Report. 2009; 23 (6): 1–8
Study Finds the Availability of Chiropractic Care Improves the Value of Health Benefits Plans
Chiropractic Economics ~ October 20, 2009
Executive Summary:
Low back and neck pain are extremely common conditions that consume large amounts of health care resources. Chiropractic care, including spinal manipulation and mobilization, are used by almost half of US patients with persistent back-pain seeking out this modality of treatment.
The peer-reviewed scientific literature evaluating the effectiveness of US chiropractic treatment for patients with back and neck pain suggests that these treatments are at least as effective as other widely used treatments. However, US cost-effectiveness studies have methodological limitations.
High quality randomized cost-effectiveness studies have to date only been performed in the European Union (EU). To model the EU study findings for US populations, researchers applied US insurer-payable unit price data from a large database of employer-sponsored health plans. The findings rest on the assumption that the relative difference in the cost-effectiveness of low back and neck pain treatment with and without chiropractic services are similar in the US and the EU.
The results of the researchers’ analysis are as follows:
Effectiveness:
Chiropractic care is more effective than other modalities for treating low back and neck pain.
Total cost of care per year:
For low back pain, chiropractic physician care increases total annual per patient spending by $75 compared to medical physician care.
For neck pain, chiropractic physician care reduces total annual per patient spending by $302 compared to medical physician care.
Cost-effectiveness: When considering effectiveness and cost together, chiropractic physician care for low back and neck pain is highly cost-effective, represents a good value in comparison to medical physician care and to widely accepted cost-effectiveness thresholds.
These findings, in combination with existing US studies published in peer-reviewed scientific journals, suggest that chiropractic care for the treatment of low back and neck pain is likely to achieve equal or better health outcomes at a cost that compares very favorable to most therapies that are routinely covered in US health benefits plans. As a result, the addition of chiropractic coverage for the treatment of low back and neck pain at prices typically payable in US employer-sponsored health benefit plans will likely increase value-for-dollar by improving clinical outcomes and either reducing total spending (neck pain) or increasing total spending (low back pain) by a smaller percentage than clinical outcomes improve.
“Colleagues should note that the report did not include analysis of prescription drug costs - - a factor that is likely to have increased overall cost of medical physician services,” concludes Greenawalt.
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