The title of this article may seem a bit strange; after all, Congress recently passed the Patient Protection and Affordable Care Act of 2010, which will dramatically reform the face of American health care system. So, how can I say that chiropractic is the original version of health care reform? Because the basic foundation of chiropractic practice addresses many of the fundamental problems within our present-day health care delivery system. Let me explain.
Dealing With the Two-Headed Monster: Cost and Efficiency
First, it is important to recognize that true health care reform will not be achieved merely by extending health insurance coverage to all Americans. It is certainly reasonable to expect that the richest nation in the world should be able to provide a safety net of health care coverage for all of its citizens, but this issue is somewhat tangential to the two key problems with our health care delivery system: 1) It is extremely expensive; and 2) It is extremely inefficient.
Giving more Americans access to an expensive and inefficient health care system does not provide a solution to the runaway costs and widespread variations in our present health care system. The solution requires both reducing the costs of health services and improving the efficiency of the delivery of those services.
Second, most people do not realize that the Affordable Care Act contains within it nine separate sections or "titles," each of which addresses a different aspect of health care reform. Most of the attention has been focused on Titles 1 and 2; Title 1 addresses the issues of providing universal health care coverage and insurance reform, while Title 2 expands the role of public programs (Medicare and Medicaid) to provide this coverage to underserved segments of our population.
However, Titles 3 and 4 address issues that have direct relevance to chiropractic care. Title 3 addresses the need to improve the quality and efficiency of health care delivery; Title 4 addresses the need for prevention of chronic disease and improving public health. These titles contain provisions for substantial investment to improve the quality and delivery of care, and to support research to inform consumers about patient outcomes resulting from different approaches to treatment and care delivery. Additional funding has been provided for the Agency for Healthcare Research and Quality (AHRQ), which has the mission of improving the quality, safety, efficiency and effectiveness of health care for all Americans.
Prevention and Wellness Services
The titles also address the importance of providing wellness and preventive services to lower the burden of chronic diseases. A Prevention and Public Health Investment Fund has been established to provide an expanded and sustained national investment in prevention and public health. Barriers to accessing clinical preventive services will be removed and developing healthy communities will become a priority.
Comparative Effectiveness Research: An Opportunity for Chiropractic
More than $1 billion has been specifically earmarked for comparative effectiveness research to be managed through the AHRQ. Comparative effectiveness research (CER) is designed to inform health-care decisions by providing evidence on the effectiveness, benefits, and harms of different treatment options. On the AHRQ Web site, CER is explained in this way: "When you shop for a new car, phone or camera, you have lots of information about your choices. But when it comes to choosing the best health-care treatment, clear and dependable information can be very hard to find." It should be obvious that the chiropractic profession is well-positioned to potentially benefit from comparative effectiveness research and a new emphasis on wellness/prevention.
One condition that clearly stands out as a public health priority crying out for this type of comparative effectiveness research is the current management of low back pain in our country. Studies of Medicare claims data have shown outrageous increases over the past 10 years in the utilization and payment for epidural injections, lumbar MRIs, opiate prescriptions, and spinal fusion surgeries. Over $50 billion was spent last year on direct costs for the management of low back pain. Yet despite this expanding utilization of tests and invasive treatments, there has been no documented reduction in the prevalence of low back pain. Disability rates from chronic low back pain continue to rise, making it the most common reason for work loss in the American work force. The number of failed back surgery patients also continues to rise, becoming an epidemic of iatrogenic disability. Addiction to opiate medication is rapidly becoming another iatrogenic epidemic that threatens the health of our nation.
Can the chiropractic profession help to provide a solution to this public health crisis of low back pain? Absolutely! This brings us back to my original premise: The foundation of chiropractic practice addresses many of the fundamental problems with our present-day health care delivery system. We were taking alternative approaches to the management of back pain that were far ahead of their time, yet have now become recognized as "evidence-based," such as avoidance of bed rest and advice to stay active. We found a successful way to manage a common health care condition at low cost, without expensive drugs, diagnostic tests or invasive procedures, while getting good clinical outcomes with high patient satisfaction. Essentially, we were the original version of health care reform with respect to the management of back pain.
Fundamental Principles, Profound Public Health Implications
Chiropractic practice was founded upon some very fundamental principles that have profound public health implications. First, chiropractic has always emphasized the inherent recuperative powers of the body and that non-drug, non-surgical treatment methods should be the first strategy. How many low back pain patients would be spared from opiate addiction and unnecessary surgery if chiropractors were truly recognized and utilized as the non-surgical spine experts by public health agencies?
Second, chiropractic has been focused on finding the cause of the problem, fixing it and leaving it alone. The almost-immediate reduction in pain and restoration of function following a successfully applied spinal adjustment is what captured the attention of our patients and third-party payers, and led to the collective success of our profession in gaining licensure and recognition within the health care system.
Third, chiropractors have traditionally told their patients to stay active and to get back to their normal activities as quickly as possible. We have provided patients with the reassurance that most cases of back pain don't require advanced testing such as EMG or MRI, and can be corrected with simple, non-invasive methods such as spinal manipulation and exercise. This reassurance that back pain is a simple condition with a simple solution can go a long way in reducing fear and anxiety in the general public; fear and anxiety that leads to unnecessary medical procedures.
Of course, chiropractors are well-trained to recognize red flags of serious pathology and make appropriate referrals for medications, advance imaging and invasive spinal procedures. In this sense, we have been historically acting as primary care physicians for the spine.
Finally, chiropractic has always emphasized a holistic approach to the management of patients. We see the patient with low back pain as a whole person - not just a low back case. We have traditionally understood the importance of counseling about diet, exercise, emotional stress, and other factors when treating our patients. It is interesting to note that many of the chronic conditions seen as public health threats can also be comorbidities associated with back pain. These include smoking, obesity, diabetes / metabolic syndrome, anxiety / depression, opiate / pharmaceutical addictions, vitamin D deficiency, and lack of physical exercise. Chiropractors have been taking a comprehensive and holistic approach to the management of back pain that encompasses these factors for more than 100 years.
From a public health perspective, low back pain is a national epidemic that has not been managed well by the medical profession. Low back pain continues to be one of the most common conditions for which the average American seeks medical attention and is the leading cause of disability in the American work force. There is no doubt that the AHRQ and other federal agencies such as the National Institutes of Health will be funding comparative and cost-effectiveness research in an effort to find novel and innovative solutions to this epidemic of low back pain. Certainly the chiropractic profession should be playing a key role in assisting with the efforts to reduce costs and improve the quality of care for back pain patients in our country.
The Chiropractic Health Care (CHC) section of the American Public Health Association is actively engaged in the process of advancing the cultural authority of the chiropractic profession within this newly emerging model of national health care reform. We believe there are some very significant opportunities for the chiropractic profession to thrive under the Affordable Care Act of 2010 due to our ability to provide high-quality health care at a low cost while maintaining high patient satisfaction. There is certainly strength in numbers, and we encourage all chiropractors to join the CHC section of the APHA. You can get more information and find a link to join the CHC section at www.apha.org/membergroups/sections/aphasections/chc.
Click here for previous articles by Rand Baird, DC, MPH, FICA, FICC.
Dr. Michael Schneider is a 1982 graduate of Palmer College of Chiropractic and has been in private practice for 30 years. He obtained a PhD in rehabilitation science from the University of Pittsburgh in 2008, where he now works full-time as an assistant professor in the School of Health and Rehabilitation Sciences. Dr. Schneider is a founding member of the West Hartford Group, a chiropractic think-tank devoted to advancing the identity of chiropractors as primary spine care physicians.