Monday, 25 January 2016 15:48

Workers Compensation and Chiropractic: A Solution for Lowering Healthcare Costs for the Acute and Chronic Care Patient

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Workers Compensation and Chiropractic:

A Solution for Lowering Healthcare Costs for the Acute and Chronic Care Patient

 

by Mark Studin DC, FASBE(c), DAAPM, DAAMLP

William J. Owens DC, DAAMLP

 

Legislators and Regulators Must Stay Current on Healthcare Outcome Research in Order to Continue to Effectively Support the Needs of the People 

 

Interventions for the diagnosis, treatment and management of spinal complaints are at the forefront of the health care debate.  There are a multitude of health professionals that are involved with the care of these patients.  Let’s take a look at the current healthcare system relating to spinal injuries and subsequent costs for intervention and management.  It was reported by Zigler in 2011 that 200,000 spinal fusion surgeries are performed each year, just in the United States alone. An equal number of microdiscectomies are performed as reported by Mayer (2006), which is considered by many to be a conservative number. Let's consider the chiropractic impact of exposing the public to treatment that could avoid needless surgeries, using the 400,000 disc surgeries [spinal fusions + microdiscectomy] as a conservative number, while reducing the revenue lost to both governmental agencies and workers from absenteeism [due to recovery from surgery]. Allen and Garfin (2010) reported that spine-related health care expenditures totalled over $97.5 billion (2011 inflation adjusted), a 65% increase from 1997. With an aging population, this trend, based on the biomechanics of the aged, will continue.

It was reported by McMorland, Suter, Casha, du Plessis, and Hurlbert in 2010 that over 250,000 patients a year undergo elective lumbar discectomy (spinal surgery) for the treatment of low back disc issues in the United States. The researchers did a comparative randomized clinical study comparing spinal microdiscectomy (surgery) performed by neurosurgeons to non-operative manipulative treatments (chiropractic adjustments) performed by chiropractors. They compared quality of life and disabilities of the patients in the study.

The study was limited to patients with distinct one-sided lumbar disc herniations as diagnosed via MRI and had associated radicular (nerve root) symptoms. Based upon the authors’ review of available MRI studies, the patients participating in the study were all initially considered surgical candidates. Both the surgical and chiropractic groups reported no new neurological problems and had only minor post-treatment soreness. 60% of the patients who underwent chiropractic care reported a successful outcome while 40% required surgery and of those 40%, all reported successful outcomes. This study concluded that 60% of the potential surgical candidates had positive outcomes utilizing chiropractic as the alternative to surgery.

Let's do the math. If we take the 400,000 disc surgeries (adding cervical surgeries to the equation) done each year as discussed in the opening paragraph and apply McMorland et al.'s (2010) findings that 60% of surgical candidates had successful outcomes with chiropractic as an alternative to surgery, 240,000 patients yearly could avoid needless surgery if they sought chiropractic care.

According to Sherman, Cauthen, Schoenberg, Burns, Reaven and Griffith in 2010, the 2010 inflation adjusted amount per case in Medicare dollars is $13,243.82 per patient once you take into consideration the complications, but exclude many other variables such as repeated MRI's, myelograms, and many hospital charges. Allen and Garfin (2010), taking into account total charges, including mean hospital charges for a single level, uncomplicated, minimally invasive surgery, reported the cost to be $70,159 for all payors. They also went on to report that for 2-level disc surgeries the complication rate increased by 25% with significantly more costs.

If you consider 240,000 preventable surgeries at $70,159 per patient, that equates to $16,838,160,000 healthcare dollars that did not have to be spent. MEDSTAT, as reported by Chiropractic Lifecare of America (2009), estimated that the average cost of chiropractic care per patient per case is $3,918 (2011 inflation adjusted dollars.) If you take this amount and apply it to the 240,000 unnecessary surgeries, you have a net savings of $66,241 per patient. The net savings to the Medicare system and private insurers is $15,897,840,000!

Fayssoux, Goldfarb, Vaccaro, James (2010) studied the indirect costs associated with surgery for low back pain reporting the average lost productivity related to absenteeism resulted in lost wages of $2,884 per patient for the first postoperative year. "The findings demonstrate the significant, though not surprising, impact of spinal disability on productivity, and the importance of including measurement of lost productivity and return to work..." (Fayssoux et al., 2010, p. 9). This equals an additional $692,160,000 in wages to Americans per year by taking the necessity of absenteeism out of the equation with no surgeries from which to recover.  Remember, according to McMorland et al 60% of surgical candidates recovered with chiropractic care.  When surgical intervention is no longer necessary, there is no absenteeism from the procedure. 

 

When we actually look at the ‘big picture” facing spine care in the Unites States, we see that it is not only the actual occurrence of the conditions, but what to do about their recurrence over time. There are numerous recent studies that have established chiropractic as cost effective care that is clinically efficient.2,3,4,5,6,7,8,9,10,11,12,13,14  The conclusions of these recent studies are consistent; chiropractic is less expensive and returns people to work faster and with less disability, thereby alleviating the burden on the workers’ compensation system and overall economy. It begs the question, "If chiropractic care and philosophy were utilized more frequently, how many billions of dollars spent on healthcare in the United States could truly be saved?”

The current trend in healthcare implementation and policy has been labeled as “Evidence Based Care” and the goal is to align the healthcare system to interventions shown to be effective in the research.  On the surface this process seems straight forward, after all how hard could it be to review research papers and then make recommendations on care based on the results of those studies?  Utilizing research in the creation of medical care guidelines is an important step, however it requires a system that encourages updates based on the speed of research outcomes.  There is often a stark difference between the speed of research publication and legislative debates and implementation.  A prime example of this imbalance is the ruling by the New York State Workers’ Compensation Board which, on December 1, 2010, enacted new medical treatment guidelines for the neck, middle/lower back, shoulder and knee.  These guidelines were developed by the American Academy of Occupational and Environmental Health after what was, at the time, a comprehensive review of the peer reviewed research literature.  These guidelines were established for acute care intervention only. 

This ruling by the New York State Workers’ Compensation System effectively ceased coverage of chiropractic intervention for injured workers for the treatment of any chronic conditions.  This included injured workers that had been awarded lifetime chronic care, many at a frequency of 2 visits per month.  These injured workers had demonstrated in a court of law that they were not only injured while working, but their conditions were permanent and required intervention in order for them to continue working.  Ultimately these patients are able to fulfill their roles as productive members of society versus due to absenteeism, becoming financial burdens to the State of New York.  The new law has become so restrictive (and perhaps a constitutional issue) that the injured workers are also denied the ability to use other health insurance or pay out of pocket for continued care.  These guidelines failed to take into consideration that many traumatic musculoskeletal injuries have permanent qualities, not unlike systemic disorders such as diabetes and congestive heart failure.  These legislative changes were enacted in December, 2010, new relevant research that could steer the guidelines to be more effective was published 3 ½ months later. Currently there is no system in place to incorporate updated research.  Evidence Based Care is only effective when the most current resources are used.  There is an apparent inequality in a system that addresses the “acute” portion of spine care and not the management of chronic recurrent spinal conditions, even though the research clearly shows effectiveness for both aspects of spine care.  How long will it take for the New York State Workers’ Compensation Board to respond to this new research?

A more effective way to address this inequality is to consider the definition of "health maintenance" as was done in a recent study released by the American Academy of Occupational and Environmental Health in April, 2011, the very organization that denied the implementation of chronic care guidelines reporting the lack of evidence for the chronic management of spine conditions. In their article, Cifuentes, Willetts and Wasiak define health maintenance care as “…a clinical intervention approach thought to prevent recurrent episodes of LBP [lower back pain]. It conceptually refers to the utilization of health care services with the aim of improving health status and preventing recurrences of a previous health condition” (p. 396).  This paper is specific to health maintenance care and working-related lower back pain and was able to effectively single out chiropractic care for definitive study.

The nuance of the paper was specific because the authors stated, “Given that chiropractors are proponents of health maintenance care, we hypothesize that patients with work-related LBP who are treated by chiropractors would have a lower risk of recurrent disability because this specific approach would be used.  Conversely, similar patients treated by other providers would have higher recurrence rates because the general approach did not include maintaining health, which is a key component to prevent recurrence” (Cifuentes et al., 2011,  p. 396). This research is unique and comprehensive in that it tracked injured workers compensation patients in multiple states (the states were chosen because the patients had the ability to select their doctors on their own and were not mandated providers) and it reviewed claims dated between January and December, 2006, including 894 cases out of a pool of 11,420 claims of non-specific low back pain cases.  

Relating to the results, the authors report, “In our study, after controlling for demographics and severity indicators, the likelihood of recurrent disability due to LBP for recipients of services during the health maintenance care period by all other provider groups was consistently worse when compared with recipients of health maintenance care by chiropractors. Care from chiropractors during the disability episode (“curative”), during the health maintenance period (main exposure variable, “preventative”), and the combination of both (curative and preventive) was associated with lower disability recurrence HRs” (Cifuentes et al., 2011,  p. 403). An interesting note is that although this research study is new, the data that it collected and the philosophy that it outlined are nothing new because the chiropractic profession has been the primary provider of these types of services for over 115 years.  When it comes to comparing the “Return on Investment” [ROI] of chiropractic care there is no other profession that has the ability to save billions in health care costs while at the same time actually delivering healthcare to the population.  Research has VALIDATED chiropractic in both the acute and the chronic phases of spine care. 

Chiropractic offers solutions to the federal government, local government, and public and private insurance companies by avoiding unnecessary surgeries. Chiropractic offers solutions to the economy of local, state and federal governments by increasing the tax base and productivity in the marketplace as a result of keeping workers at work and circulating money into local economies with increased paychecks at the end of the year. The research is conclusive and chiropractic has solutions to many of the economic and societal problems in the United States and worldwide.  It is critical that this type of philosophy of care is allowed to thrive resulting in increased production from injured workers and decreased health care expenditures related to recurring spinal conditions. Oversight and recommendations must be compatible with sustainability.  Although all disciplines are qualified to intervene in the “curative’ phase, chiropractors are unique;/  and most qualified to review, comment and drive chronic care and afford the greatest potential for cost containment.    The research demonstrates two very important facts, the first being the approach of chiropractic care to patients with acute, chronic and permanent injuries and the second, how important it is to provide a bridge between clinical published research and legislative decision making.

 

 

Appendix A –

TABLE 1

Samples of research showing the effectiveness and reduced costs of chiropractic care for spinal-related injuries and conditions.

REFERENCE

FINDINGS

Florida Workers Compensation Board2

Study examined 10,652 workers who sustained back-related injuries. Individuals who received chiropractic care as compared with standard medical care had a 51.3% shorter temporary total disability duration 58.8% lower treatment costs and a 20.3% hospitalization rate versus 52.2 in the medical care group.

Utah Workers  Compensation Board Study3

Back-related injuries treated by chiropractors produced a tenfold savings as compared with medical doctors ($68.38 vs. $668.39)

Australian Workers Compensation Study4

Individuals who had work-related mechanical low back pain who received chiropractic care for their back pain returned to work 4 times faster (6.26 days vs. 25.56 days) and their treatment was 4 times less costly ($392 vs. $1,569) than those who received treatments from medical doctors.

North Carolina Workers Compensation Patients5

A retrospective review of 43,650 claims from 1975 to 1994 showed that the average cost of treatment, hospitalization, and compensation payments (for treatment of strain injuries, specific body parts and low back injuries) were much less for patients treated by DCs than they were for patients treated by MDs.

Average treatment cost for a patient seeing a DC = $663

Average treatment cost for a patient seeing an MD = $3,519.

Chiropractic Treatment for Low Back and Neck6

For the treatment of low back and neck pain, receiving chiropractic treatment showed a reduction in the rates of surgery, advanced imaging, inpatient care, and plain-film radiographs.

Costs of Low Back Care7

6,183 patients were studied who first had contact with either a medical or chiropractic provider. Total insurance payments were much less when initial treatment was provided by a chiropractor.

           

Many recent, independent studies confirm that chiropractic can be an extremely effective modality in the treatment of low back pain and by extension, the onset of osteoarthritis, which should be of particular interest to the Workers’ Compensation Board at this time.

  • ·Regarding the link between low back pain and the onset of osteoarthritis, Stupar, Pierre, French, &Hawker
  • ·A 2009 study by Aspegren, Enebo, Miller, White, Akuthota, Hyde, & Cox and a 2005 study by DeVocht, Pickar, & Wilder have independently concluded that chiropractic care is a safe, highly effective treatment choice for low back pain patients and perhaps most importantly, that low back pain cannot be ignored, especially in light of the fact that it can be often be treated in a very cost-effective manner. 9,10 Considering that a 2009 study by Russo, Weir and Elixhauser concluded that osteoarthritis is the #2 cause of hospital stays (only behind coronary artery disease), the potential long term health care costs of low back pain as a precursor to osteoarthritis is staggering. 11
  • The study by Aspegren, Enebo, Miller, White, Akuthota, Hyde, & Cox (2009) also concluded that 81.5% of workers with an acute injury causing low back or neck pain reported immediate post-treatment relief with chiropractic treatment, with that percentage increasing over time. 9
  • The 2005 study by DeVocht, Pickar, & Wilder found through objective electrodiagnostic studies that 87% of the chiropractic patients they studied exhibited decreased muscle spasms. 10
  • In 2009, Painter reported that Consumer Reports conducted an independent survey of 14,000 subscribers who rated hands-on therapy as the #1 treatment of choice for low back pain. The report went on to state that 88% of those who tried a chiropractic adjustment reported positive outcomes and 59% were “completely” or “very” satisfied versus 34% who were highly satisfied when treated by a primary-care physician. 12
  • ·A 2010 study by O'Shaughnessy, Drolet, Roy, & Descarreaux estimated that serious side effects from a chiropractic adjustment were less than 1 out of every 3,700,000 to 1 out of every 1,000,000 with low back adjustments (the incident was so low, they had to use a range). In contrast, one of the most common medically-prescribed and over the counter treatments for low back pain is nonsteroidal anti-inflammatory drugs (NSAIDs).  It was reported by the American College of Gastroenterology in 2010 that 14 million Americans with arthritic conditions take NSAIDS regularly and up to 60% will have gastrointestinal side effects as a result.13
  • ·According to a 2010 Virginia Healthcare and Hospital Association study, the average non-surgical hospital stay for back problems in Virginia in 2009 was $15,059 and $77,107 with surgery. 14 A Virginia study by North, Kidd, Shipley and Taylor (2007) revealed that the cost to use spinal cord stimulation to treat failed back surgery syndrome was $117,901 and unsuccessful attempts at reoperation cost an additional $260,584. 15

 

  • A 2004 study by Legorreta compared more than 1.7 million insured patients seeking treatment for back pain. The outcomes showed when chiropractic care was utilized in comparison to the standard medical approach, the cost of treatment was reduced by 28%, hospitalizations were reduced by 41%, back surgery was reduced by 32%, and the cost of medical imaging, including x-rays and MRI’s, was reduced by 37%. Furthermore, 95% of the patients that received chiropractic care reported in the study that they were satisfied with their treatment. Utilizing chiropractic care as the first treatment option for back pain was estimated to have the potential to reduce US healthcare costs by more than $28 billion annually.16
  • ·A 2008 study by Cook, Cook and Worrell reported that manual therapy in a hospital-based setting significantly reduced hospital charges. 17
  • ·A 2007 study by Sarnat, Winterstein and Cambron reported that there was a 60.2% reduction of in-hospital admissions with a 59% decrease in hospital stays and a 62% reduction in outpatient surgeries and procedures when chiropractic was utilized. Furthermore, there was an 85% reduction in pharmaceutical costs. 18

The only responsible solution is for chiropractic to be included not only in the final equation for treating chronic care patients, but in the creation of the guidelines as occupational specialists have no experience in chiropractic and will attempt to "saddle chiropractic" with protocols of other more expensive, less successful disciplines, as outlined by Cifuentes, Willetts and Wasiak.

References

1. Cifuentes, M., Willetts, J., & Wasiak, R. (2011). Health maintenance care in work-related low back pain and its association with disability recurrence. Journal of Occupational and Environmental Medicine, 53(4), 396-404.

2. Legorreta, A. P. (2004). Comparative analysis of individuals with and without chiropractic coverage. Archives of Internal Medicine, 164, 1985-1992.

3. Jarvis, K. B., Phillips, R. B., Morris, E. K. (1991). Cost per case comparison of back injury claims of chiropractic versus medical management for conditions with identical diagnostic codes. Journal of Occupational Medicine, 33(8), 847-852.

4. Ebrall, P.S. (1992). Mechanical low-back pain: A comparison of medical and chiropractic management within the Victorian work care scheme. Chiropractic Journal of Australia 22, 47-53.

5. Phelan, S. P., Armstrong, R. C., Knox, D. G., Hubka, M. J., & Ainbinder, D. A. (2004). An evaluation of medical and chiropractic provider utilization and costs: Treating injured workers in North Carolina. Journal of Manipulative and Physiological Therapeutics, 21(7), 442-448.

6. Nelson, C. F., Metz, R. D. & LaBrot, T. (2005). Effects of a managed chiropractic benefit on the use of specific diagnostic and therapeutic procedures in the treatment of low back and neck pain.Journal of Manipulative Physiological Therapeutics, 28(8), 564-569.

7. Stano, M. & Smith, M. (1996). Chiropractic and medical costs of low back care. Medical Care, 34(3), 191-204. 

8. Stupar, M., Pierre, C., French, M. R., & Hawker, G. A. (2010). The association between low back pain and osteoarthritis of the hip and knee: A population-based cohort study. Journal of Manipulative and Physiological Therapeutics, 33(5), 349-354.

9. Aspegren, D., Enebo, B. A., Miller, M., White, L., Akuthota, V., Hyde, T. E., & Cox, J. M. (2009). Functional Scores and subjective responses of injured worker with back or neck pain treated with chiropractic care in an integrative program: A retrospective analysis of 100 cases. Journal of Manipulative and Physiological Therapeutics, 32(9), 765-771.

10. DeVocht, J. W., Pickar, J. G., & Wilder, D. G. (2005). Spinal manipulation alters electromyographic activity of paraspinal muscles: A descriptive study.  Journal of Manipulative and Physiologic Therapeutics, 28(7), 465-471.

11. Russo, A., Wier, L. M., & Elixhauser, A. (2009, September). Hospital utilization among near-elderly adults, ages 55 to 64 years, 2007. Agency for Healthcare Research and Quality. Retrieved from http://www.hcup-us.ahrq.gov/reports/statbriefs/sb79.jsp

12. Painter, F. M. (2009, April 10). Consumer reports survey shows hands-on therapies were the top-rated treatments. The Chiropractic Rescue Organization. Retrieved from http://www.chiro.org/LINKS/ABSTRACTS/Hands_on_Therapies.shtml

13. O'Shaughnessy, J., Drolet, M., Roy, J-F., & Descarreaux, M. (2010). Chiropractic management of patients’ post-disc arthroplasty: Eight case reports. Chiropractic & Osteopathy, 18(7), Retrieved from http://www.chiroandosteo.com/content/pdf/1746-1340-18-7.pdf

14. Virginia Hospital and Healthcare Association. (2010). MSDRG 552 Medical Back Problems wo MCC. Virginia Hospital and Healthcare Association PricePoint System. Retrieved from http://www.vapricepoint.org/Report_INP.aspx

15. Virginia Hospital and Healthcare Association. (2010). MSDRG 460 Spinal Fusion Exc Cervical w/o MCC. Virginia Hospital and Healthcare Association PricePoint System. Retrieved from http://www.vapricepoint.org/Report_INP.aspx

16. Legorreta, A. P. (2004). Comparative analysis of individuals with and without chiropractic coverage. Archives of Internal Medicine, 164, 1985-1992.

17. Cook, C., Cook, A., & Worrell, T. (2008). Manual therapy provided by physical therapists in a hospital-based setting: A retrospective analysis. Journal of Manipulative and Physiological Therapeutics 31(5), 338-343.

18. Sarnat, R. L., Winterstein, J., Cambron, J. A. (2007). Clinical utilization and cost outcomes from an integrative medicine independent physician association: An additional 3-year update. Journal of Manipulative and Physiological Therapeutics, 30(4), 263-269.

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