Study Design: Data were reviewed from the Ohio Bureau of Workman's Compensation (BWC) files.Statistics from 1998 through 2002 were reviewed to determine trends in health care case reviewing and the effect on overall costs.
Objectives: To determine the reason for a rise in the cost of care in the aforementioned system, and its relationship to decreased use of chiropractic providers.
Summary of Background Data: In 1998, the Ohio BWC began using a health care review system, which statistically has been shown to gear "back pain patients," specifically chronic pain patients, away from chiropractic providers. Data reviewed showed a significant increase in prescription drug costs, vocational rehabilitation costs and hospital costs, with a minor increase in medical provider costs.
Methods: Data were collected from Ohio BWC statistics and presented at the "Symposium on Rising Health-Care Cost" in January 2003.
Results: Over a four-year period (1998-2002), the general cost of health care rose 44%, from $554 million to $800 million. General medical costs increased 55% for hospitalization, 9% for physicians, 104% for prescription drugs and 309% for vocational rehabilitation. During this period of increase, the cost of chiropractic care decreased by 67%.
Discussion: The Ohio Workman's Compensation/Industrial Commission has provided data on their claims from 1998 through 2002. The BWC system uses a case-review and preapproval format. It is statistically demonstrated that restriction of chiropractic care has been initiated since the beginning of the BWC's Health Partnership Program (HPP). This restriction is likely due to some of the literature indicating that physical therapy and chiropractic are equally helpful.8 Studies like that of Skargren8 have led to aggressive chiropractic control formats and the managed care organization's (MCO's) practice of limiting chronic care/supportive care by the chiropractic physician for injured workers, resulting in a shift of these same injured workers to the medical provider for management.
Thinking physical therapy is just as cost-effective and outcome-effective as chiropractic management is based upon limited studies, in spite of certain research using small populations and short-range outcome figures.8 Many studies, both past and present, show how the same parts in the management model still hold promise in reducing costs.26,27,28 Some focus on controlling excessive hospitalization costs,29 yet several tangents became apparent and were tested. For example, patient education documents geared toward home self-care were felt to be an acceptable standard of care for acute and chronic back pain. This has since been proven to be an ineffective way to care for patients.9 Several other protocols and studies have since been shown to have been incorrect in their conclusions.22 Musculoskeletal injuries make up the majority of claims, specifically lower back pain.30
Chiropractic care has been one of the focuses for control of costs. More recently, chiropractic has been found to be cheaper and more effective in outcome studies.13 Some of the difficulty with the earlier research is that chiropractic is rarely compared to high-cost chronic medical treatments. Most chronic medical treatments are compared to other medical treatments.2 Other studies take into account cost, but fail to relate to the outcome of the success of individual treatments.1 The majority of medical doctors feel that physical therapy is 80% effective in their treatments of lower back pain, while less than 50% felt chiropractic treatment to be ineffective.39 Given the MCO nurse-driven and medically educated position on lower back pain, the inevitable has occurred. The reason is interpreted in the previous study by several factors; one is that the medical community has ignorance or rejection of existing scientific evidence.
According to the data available in the current study, the chiropractic physician has been limited for reimbursement from the Ohio BWC when compared to the medical or osteopathic physician. Studies have shown that the chiropractic physician performs the same, if not more, work for the same E & M codes.6 Data from the Ohio BWC's 1998-2002 report show chiropractic being limited for reimbursement as compared to rising drug, hospitalization and vocational rehabilitation costs. Controlling hospitalization costs is a very successful way of maintaining lower total costs.28
Several insurance companies include chiropractic services as part of their health coverage.4,12 Chiropractic care has been shown to be useful in the treatment of several conditions other than simple back pain, including complicated chronic pain syndromes.14,31,32,33,34,35,36,37,38,40,41,42 Case review has misinterpreted the Mercy Guidelines' restrictions on supportive care. Clearly, page 118, chapter 8, shows that therapeutic necessity exists for supportive care. The literature clearly shows why the inclusion of chiropractic care in a reimbursement system is necessary.3,4,7,10 The inclusion of chiropractic has been proven to lower health care costs.10,13,16,17 The restriction of chiropractic care has been proven to raise the cost of care.19,21 The need for additional clarification on this issue has been pointed out.5,15
The primary cost of some workers' compensation systems is related to lost time claims.7 This same study shows that chiropractic is one of the least used providers in workers' compensation. Chiropractic patients return to work quicker.20,24 In fact, injured workers return to work faster even if they had seen a chiropractor at one time.25 Further study is necessary to reduce our total costs.28 Specifically, we need more research to determine if chiropractic plays a greater role in quicker return-to-work statistics and reduced costs in both acute and chronic pain management than what was previously published.
Conclusions: The State of Ohio initiated a review system on its medical usage of workers' compensation. With lower back pain representing the highest number of claims from the BWC, the proven trend to use less chiropractic care in chronic back pain has resulted in significant increases in the cost of health for this system of reimbursement. Chiropractic care results in effective treatment and cost-containment for lower back pain, as indicated in the literature. Restriction of chiropractic care by the current Ohio BWC health review system has resulted in a transposition (paradigm shift) of patients to standard medical providers, and has resulted in a significant increase in medical costs. A few studies support the hypothesis that limiting chiropractic care forces a majority of the injured workers to withdraw from the health care system, resulting in abandonment crisis medical coverage. Additional studies are necessary to provide insight on how chiropractic may reduce health care costs in a BWC payment system.
It would seem that the inclusion of chiropractic care helps reduce the general costs of health care, and that restricting patients from this form of case management results in a shift of patients to a significantly more expensive form of provider groups.
- Stano M, Haas M, Goldberg B, Traub PM, Nyiendo J. Chiropractic and medical care costs of low back care: results from a practice-based observational study. Am J Manag Care Sept. 2002;8(9):802-9.
- Kumar K, Malik S, Demeria D. Treatment of chronic pain with spinal cord stimulation versus alternative therapies: cost-effectiveness analysis. Neurosurgery July 2002;51(1):106-15; discussion 115-6.
- Manga P. Economic case for the integration of chiropractic services into the health care system. J Manipulative Physiol Ther Feb. 2000;23(2):118-22
- Pelletier KR, Astin JA. Integration and reimbursement of complementary and alternative medicine by managed care and insurance providers: 2000 update and cohort analysis. Altern Ther Health Med Jan-Feb 2002;8(1):38-9, 42, 44.
- Maniadakis N, Gray A. The economic burden of back pain in the UK. Pain Jan. 2000;84(1):95-103.
- Hess JA, Mootz RD. Comparison of work and time estimates by chiropractic physicians with those of medical and osteopathic providers. J Manipulative Physiol Ther June 1999;22(5):280-91.
- Williams DA, Feuerstein M, Durbin D, Pezzullo J. Health care and indemnity costs across the natural history of disability in occupational low back pain. Spine, Nov. 1, 1998;23(21):2329-36.
- Skargren EI, Carlsson PG, Oberg BE. One-year follow-up comparison of the cost and effectiveness of chiropractic and physiotherapy as primary management for back pain. Subgroup analysis, recurrence, and additional health care utilization. Spine Sept. 1, 1998;23(17):1875-83; discussion 1884.
- Cherkin DC, Deyo RA, Battie M, Street J, Barlow W. A 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 Oct. 8, 1998;339(15):1021-9.
- Horwitz AD, Hosek R, Boyle J, Cianciulli A, Glass J, Codario R. A new gatekeeper for back pain. Am J Manag Care April 1998;4(4):576-9.
- Smith M, Stano M. Costs and recurrences of chiropractic and medical episodes of low-back care. J Manipulative Physiol Ther Jan. 1997;20(1):5-12.
- Simpson CA. Integrating chiropractic in managed care. Manag Care Q Winter 1996;4(1):50-8.
- Tuchin PJ, Bonello R. Preliminary findings of analysis of chiropractic utilization and cost in the workers' compensation system of New South Wales, Australia. J Manipulative Physiol Ther Oct. 1995;18(8):503-11.
- Brouillette DL, Gurske DT. Chiropractic treatment of cervical radiculopathy caused by a herniated cervical disc. J Manipulative Physiol Ther Feb. 1994;17(2):119-23.
- Assendelft WJ, Bouter LM. Does the goose really lay golden eggs? A methodological review of Workmen's Compensation studies. J Manipulative Physiol Ther Mar-Apr 1993;16(3):161-8.
- Jarvis KB, Phillips RB, Morris EK. Cost per case comparison of back injury claims of chiropractic versus medical management for conditions with identical diagnostic codes. J Occup Med Aug. 1991;33(8):847-52.
- Dagenais S, Haldeman S. Chiropractic. Prim Care June 2002;29(2):419-37.
- Muir JM, Vernon H. Complex regional pain syndrome and chiropractic. J Manipulative Physiol Ther Sept. 2000;23(7):490-7.
- Stano M. Further analysis of health care costs for chiropractic and medical patients. J Manipulative Physiol Ther Sept. 1994;17(7):442-6.
- Cote P, Clarke J, Deguire S, Frank JW, Yassi A. Chiropractors and return-to-work: the experiences of three Canadian focus groups. J Manipulative Physiol Ther June 2001;24(5):309-16.
- Jarvis KB, Phillips RB, Danielson C. Managed care preapproval and its effect on the cost of Utah worker compensation claims. J Manipulative Physiol Ther Jul-Aug 1997;20(6):372-6.
- Nyiendo J. Disabling low back Oregon workers' compensation claims. Part III: Diagnostic and treatment procedures and associated costs. J Manipulative Physiol Ther June 1991;14(5):287-97.
- Nyiendo J, Lamm L. Disabling low back Oregon workers' compensation claims. Part I: Methodology and clinical categorization of chiropractic and medical cases. J Manipulative Physiol Ther Mar-Apr 1991;14(3):177-84.
- Nyiendo J. Disabling low back Oregon Workers' Compensation claims. Part II: Time loss. J Manipulative Physiol Ther May 1991;14(4):231-9.
- Johnson MR, Schultz MK, Ferguson AC. A comparison of chiropractic, medical and osteopathic care for work-related sprains and strains. J Manipulative Physiol Ther Oct. 1989;12(5):335-44.
- Gallagher PA, Milliman & Robertson, Inc., Radnor, PA, USA. HMO strategies for managing workers' compensation claims. Healthc Financ Manage March 1996;50(3):40-4.
- Green-McKenzie J, Rainer S, Behrman A, Emmett E. The effect of a health care management initiative on reducing workers' compensation costs. J Occup Environ Med Dec. 2002;44(12):1100-5.
- Melhorn JM, Wilkinson L, Riggs JD. Management of musculoskeletal pain in the workplace. J Occup Environ Med Feb. 2001;43(2):83-93.
- Wickizer TM, Lessler D, Franklin G. Controlling workers' compensation medical care use and costs through utilization management. J Occup Environ Med Aug. 1999;41(8):625-31.
- Nordberg M. Capping comp costs. Back injuries send 80% of us for medical help. Emerg Med Serv Aug. 1993;22(8):37-9, 67.
- Polkinghorn BS, Colloca CJ. Chiropractic treatment of postsurgical neck syndrome with mechanical force, manually assisted short-lever spinal adjustments. J Manipulative Physiol Ther Nov-Dec 2001;24(9):589-95.
- Nayak S, Matheis RJ, Agostinelli S, Shifleft SC. The use of complementary and alternative therapies for chronic pain following spinal cord injury: a pilot survey. J Spinal Cord Med Spring 2001;24(1):54-62.
- Davis C. Chronic pain/dysfunction in whiplash-associated disorders. J Manipulative Physiol Ther Jan. 2001;24(1):44-51.
- Hains G, Hains F. A combined ischemic compression and spinal manipulation in the treatment of fibromyalgia: a preliminary estimate of dose and efficacy. J Manipulative Physiol Ther May 2000;23(4):225-30.
- Gimblett PA, Saville J, Ebrall P. A conservative management protocol for calcific tendinitis of the shoulder. J Manipulative Physiol Ther Nov-Dec 1999;22(9):622-7.
- Hawk C, Long C, Azad A. Chiropractic care for women with chronic pelvic pain: a prospective single-group intervention study. J Manipulative Physiol Ther Feb. 1997;20(2):73-9.
- Mior S. Manipulation and mobilization in the treatment of chronic pain. Clin J Pain Dec. 2001;17(4 Suppl):S70-6.
- Seaman DR, Cleveland C 3rd. Spinal pain syndromes: nociceptive, neuropathic, and psychologic mechanisms. J Manipulative Physiol Ther Sept. 1999;22(7):458-72.
- Cherkin DC, Deyo RA, Wheeler K, Ciol MA. Physician views about treating low back pain. The results of a national survey. Spine Jan. 1, 1995;20(1):1-9; discussion 9-10.
- Meade TW, Dyer S, Browne W, Townsend J, Frank AO. Low back pain of mechanical origin: randomised comparison of chiropractic and hospital outpatient treatment. BMJ June 2, 1990;300(6737):1431-7.
- Meade TW, Dyer S, Browne W, Townsend J, Frank AO. Randomised comparison of chiropractic and hospital outpatient management for low back pain: results from extended follow up. BMJ Aug. 5, 1995;311(7001):349-51.
- Troyanovich SJ, Harrison DE, Harrison DD. Structural rehabilitation of the spine and posture: rationale for treatment beyond the resolution of symptoms. J Manipulative Physiol Ther Jan 1998; 21(1): 37-50.
Dave Ryan, DC
Editor's note: For more research findings regarding chiropractic's cost-effectiveness in the workers' compensation system, see "Work Comp Study: Chiropractic Less Expensive, More Effective Than Medical Care" in the Nov. 18 issue: www.chiroweb.com/archives/22/24/06.html.
Dr. David Ryan has been the medical director and co-chairman of the Arnold Fitness Weekend (www.arnoldclassic.com) for the past 10 years, and is the lead writer for www.bodybuilding.com. He practices in Columbus, Ohio.