A study published in the American Journal of Managed Care underscores why so many chiropractic patients go out of network in order to get the care they need:1 Managed care may be effectively locking them out.The study authors compared chiropractic and acupuncture utilization by adults with chronic musculoskeletal pain (CMP) at Kaiser Permanente Northwest (KPNW), an HMO. When comparing utilization, the authors found a startling percentage of chiropractic users did so entirely or partially out of the HMO plan (43 percent and 54 percent, respectively) – much higher rates of out-of-network utilization than acupuncture users. In addition, while the majority of acupuncture users (55 percent) did so solely on clinician referral, rather than self-referral (only 9 percent), the percentages essentially were reversed for chiropractic users (36 percent utilization solely on self-referral; only 9 percent solely on clinician referral).
Chiropractic "out-of-plan only" users had a tendency "to be older, to use long-term opioids, and to have more pain diagnoses," according to the study authors. Acupuncture clinician referral patients tended "to exhibit these same characteristics." The authors noted that this utilization pattern "is consistent with the acupuncture referral guidelines, which allow for care only in the setting of chronic, as opposed to acute, pain. Chiropractic benefits for self-referral are limited in the dollar amount allowed, and for clinician referral, are constrained by referral guidelines allowing use only for acute pain. Those who desire ongoing maintenance treatments will go out of plan due to necessity."
- "The use of acupuncture and chiropractic care among HMO chronic pain patients responding to our survey was substantial. Those using neither acupuncture nor chiropractic care (42%) were in the minority.
- "Our data suggest that, to a substantial extent, insurance benefits influence who uses acupuncture and chiropractic care, and under what circumstances. For acupuncture, the majority of utilization was based upon clinician referral. In contrast, for chiropractic care, relatively little utilization was based upon clinician referral, with the great majority of patients accessing care out of plan (with no insurance coverage), through self-referral, or both. Chiropractic care may be commonly used for chronic pain by patients, but at KPNW, medical necessity criteria limit clinician referrals for chiropractic care to acute pain.
- "At the same time, patients seeking chiropractic care may be dissuaded from using HMO benefits when the fee per visit for obtaining chiropractic care out of plan is only marginally higher than their HMO co-pay."
This study serves as an additional demonstration of how the policies implemented within managed care programs are preventing patients from receiving the care they want and need. While this may appear to be better for the HMO's bottom-line profitability, it is obviously penny-wise and pound-foolish.
As the authors' conclude, "Better acupuncture and chiropractic integration could offer potential opportunities for improved management algorithms and more efficient utilization of resources. The potential for these 2 types of care to serve as noninvasive alternatives to pharmacologic and procedural interventions, or as tools to facilitate the reduction of chronic pharmacotherapy, would seem to warrant further investigation."
|Total # of patients||887||667|
|Entire out-of-plan utilization||43%||25%|
|Some out-of-plan utilization||54%||34%|
|Utilization solely on clinician referral||9%||55%|
|Utilization solely on self-referral||36%||9%|
Editor's Note: For additional insights on this study, read the publisher's report of findings in this issue.