A review of more than 43,000 claims of injured workers in North Carolina over a 19-year period has found drastic differences in the average cost of treatment, number of days spent in a hospital for care, and compensation payments among patients treated by doctors of chiropractic, medical doctors, or a combination of providers.Among other things, the analysis revealed that, on average, the cost of treating an injured worker was almost $2,900 less if the worker was cared for by a doctor of chiropractic than if treatment was provided by a medical doctor, and that injured workers treated by chiropractors were able to return to work almost six times as fast as patients who sought an MD for care. According to the authors of the review, which appeared in the September issue of the Journal of Manipulative and Physiological Therapeutics, increasing utilization of chiropractors could result in "substantial savings" in the state's workers' compensation system - a finding that, if implemented nationally, could significantly reduce the costs of treating injured workers in the U.S.
The investigators initially examined more than 96,000 closed injury claims for injured workers in North Carolina that occurred between 1975 and 1994. To be included in the review, each claim had to contain information on the nature of the worker's injury and the part of the body injured, along with several cost variables. After excluding records that didn't meet the selection criteria, the authors were left with 43,650 claims, which were then categorized based upon whether the worker used the services of medical doctors only; used the services of only doctors of chiropractic; used both medical doctors and chiropractors; or used neither MDs nor DCs for care.
Of the remaining claims, an overwhelming 85.4 percent (37,290) were managed by a medical doctor. Only 0.8 percent of the injured workers saw a chiropractor exclusively; the remainder were seen by both MDs and DCs, or were treated in a hospital setting. The total costs of care, including medical costs and compensation paid to patients, totaled approximately $1.1 billion; 7.6 million total cumulative workdays were lost due to injury or disability. The most common type of injury presented to providers involved the lower back, followed by injuries affecting multiple body parts.
The authors found dramatic differences in average treatment costs between chiropractic patients, medical patients, and patients treated by both types of providers. For patients treated by MDs, the average cost of treatment was $3,519 for patient. For patients treated by both MDs and DCs, the average cumulative costs were $5,173. For chiropractic patients, however, average treatment costs were only $663 - roughly 18 percent of the cost of medical care, and 13 percent of the cost of combined care.
Similar differences were seen for the entire spectrum of variables used in the analysis. Injured workers treated by chiropractors, for instance, experienced "temporary total disability" (i.e., lost workdays) for an average of 33 days - 143 days less than workers seeing a medical doctor, and more than 200 days less than workers treated by both medical doctors and chiropractors. Hospital inpatient and outpatient care costs for medical patients were $1,995 and $2,161 more per worker, respectively, than for chiropractic patients. And the average total cost of an injured worker's claim managed by a medical doctor was $25,848 - a whopping $21,774 more than claims managed by a doctor of chiropractic.
|Claims, Lost Workdays, and Average Costs Based on Provider Utilization|
|Variable||MD/DC||MD Only||DC Only|
|Number of claims||2,155||37,290||370|
|Lost workdays per patient (mean)||240||176||33|
|Treatment costs per patient||$5,173||$3,519||$663|
|Hospital inpatient care costs||$2,920||$2,438||$43|
|Hospital outpatient care costs||$2,401||$2,217||$51|
|Total medical costs||$10,494||$8,175||$756|
|Total cost of claims||$33,600||$25,848||$4,074|
|Lumbar/Lumbosacral Sprains: Claims, Lost Workdays, and Average Costs Based on Provider Utilization|
|Variable||MD/DC||MD Only||DC Only|
|Number of claims||958||9,073||181|
|Lost workdays per patient (mean)||223||175||25|
|Treatment costs per patient||$4,864||$3,425||$634|
|Hospital inpatient care costs||$2,845||$2,312||$0|
|Hospital outpatient care costs||$2,141||$2,006||$50|
|Total medical costs||$9,850||$7,743||$685|
|Total cost of claims||$29,446||$23,562||$2,597|
Chiropractic care appeared to be just as - if not more - cost-effective when the analysis was restricted to claims involving injuries of the lower back, such as lumbar or lumbosacral strains. Patients in this category who were treated exclusively by doctors of chiropractic experienced an average of 25 lost workdays (compared to 175 days for medical patients and 223 for combined care patients) and average total medical costs of $685 (versus $7,743 for medical patients and $9,850 for patients treated by MDs and DCs). In addition, the average total cost of a claim for a chiropractic patient with a low back injury was only $2,597. For medical patients, the average was $23,562 (9.07 times more expensive); for patients receiving combined care, the average cost was $29,446 (11.34 times more expensive).
The authors illuminated several potential limitations within the study that could have affected their findings. For instance, in addition to the original set of 96,000 claims, another 52,997 were not included in the analysis because they contained only compensation payments, and the type of provider delivering care had been purged from the records. In addition, the investigators were unable to determine which group of providers treated the more severe or chronic musculoskeletal injuries. "If inpatient and outpatient hospitals costs are an indicator," they surmised, "then the MDs would seem to have treated the more severe and, hence, the more costly injuries." They suggested that a more comprehensive analysis of the claim files be conducted to attain additional information.
The authors also noted that the number of patients utilizing a doctor of chiropractic for care was unusually low, given that there are no legal restrictions to injured workers who wish to see a DC, and that the state's medical fee schedule allows for full scope-of-practice reimbursement for chiropractors. Previous surveys have shown that the percentage of people in North Carolina who see chiropractors for treatment of low back pain may range from 3 percent to 13 percent. "Comparing these rates with the 0.8% utilization rates of chiropractors in our North Carolina data may suggest that barriers to injured worker access to chiropractors exist in North Carolina," they wrote.
These limitations notwithstanding, the results of the analysis suggest that having more injured workers see a doctor of chiropractic for care, rather than a medical doctor, could result in "substantial savings" in workers' compensation costs in North Carolina, with the potential to generate even more savings if utilization of chiropractors increased on a national scale. As noted by the authors in their conclusion:
"The differences in provider management costs, independent of critical issues such as severity and comorbidity suggested by these results indicate lower treatment costs, fewer lost workdays, reduced utilization of ancillary medical services, and reduced compensation payments for patients treated by DCs. Recognizing the study limitations, if indeed the provider subsets are comparable, it seems likely that substantial savings to the workers' compensation would be possible if chiropractic services were increased in North Carolina."
- Phelan SP, Armstrong RC, Knox DG, et al. An evaluation of medical and chiropractic provider utilization and costs: treating injured workers in North Carolina. Journal of Manipulative and Physiological Therapeutics, Sept. 2004;27:442-8.