2011 ACS Message to Arizona Legislature:
Chiropractors are part of the solution and here is the evidence
What happens in a typical state BCBS plan when chiropractors are the first contact provider compared to MDs for patients with low back pain? This has been studied with the Tennessee BCBS plan and results published in a peer-reviewed journal. Costs were 40% less when patients started care with a chiropractor compared to an MD. The proof is in: Putting chiropractors in charge of low back pain saves money.
Click here to read the full study published in the Journal of Manipulative and Physiological Therapeutics in 2010. At the time the study was performed, according to a personal communication to Dr. Immerman from one of the study's authors, there were no limits on the number of chiropractic visits. Tennessee BCBS now has a utilization review system for chiropractic care that allows up to about 20 visits for an acute condition, and 30+ visits for a chronic or complicated condition. Click here to read the Tennessee Chiropractic Utilization Review Guidelines which are far more liberal than the Arizona BCBS ASH guidelines.
What happens when you add chiropractic care to a large health plan like AHCCCS? This has been thoroughly researched and here is the answer:
"Comparative Analysis of Individuals With and Without Chiropractic Coverage," Patient Characteristics, Utilization, and Costs. Antonio P. Legorreta, MD, MPH; R. Douglas Metz, DC; Craig F. Nelson, DC, MS; Saurabh Ray, PhD; Helen Oster Chernicoff, MD, MSHS; Nicholas A. DiNubile, MD. Archives Internal Medicine 2004;164:1985-1992.
Methods: A 4-year retrospective claims data analysis comparing more than 700 000 health plan members with an additional chiropractic coverage benefit and 1 million members of the same health plan without the chiropractic benefit.
Results: Members with chiropractic insurance coverage, compared with those without coverage, had lower annual total health care expenditures ($1463 vs $1671 per member per year, P<.001). Having chiropractic coverage was associated with a 1.6% decrease (P = .001) in total annual health care costs at the health plan level. Back pain patients with chiropractic coverage, compared withthose without coverage, had lower utilization (per 1000 episodes) of plain radiographs (17.5 vs 22.7, P<.001), low back surgery (3.3 vs 4.8, P<.001), hospitalizations (9.3 vs 15.6, P<.001), and magnetic resonance imaging (43.2 vs 68.9, P<.001). Patients with chiropractic coverage, compared with those without coverage, also had lower average back pain episode–related costs ($289 vs $399, P<.001).
Conclusions: Access to managed chiropractic care may reduce overall health care expenditures through several effects, including (1) positive risk selection; (2) substitution of chiropractic for traditional medical care, particularly for spine conditions; (3) more conservative, less invasive treatment profiles; and (4) lower health service costs associated with managed chiropractic care. Systematic access to managed chiropractic care not only may prove to be clinically beneficial but also may reduce overall health care costs.
What happens when chiropractors become primary care physician (PCP) gatekeepers? This has been thoroughly researched with results published in peer-reviewed medical literature:
Journal Manipulative Physiological Therapeutics 2004 Jun;27(5):336-47.
Richard L Sarnat, MD and James Winterstein, DC
Objective: We hypothesized that primary care physicians (PCPs) specializing in a nonpharmaceutical/nonsurgical approach as their primary modality and utilizing a variety of complementary/alternative medicine (CAM) techniques integrated with allopathic medicine would have superior clinical and cost outcomes compared with PCPs utilizing conventional medicine alone.
Results: Analysis of clinical and cost outcomes on 21,743 member months over a 4-year period demonstrated decreases of 43.0% in hospital admissions per 1000, 58.4% hospital days per 1000, 43.2% outpatient surgeries and procedures per 1000, and 51.8% pharmaceutical cost reductions when compared with normative conventional medicine IPA performance for the same HMO product in the same geography over the same time frame.
Conclusion: In the limited population studied, PCPs utilizing an integrative medical approach emphasizing a variety of CAM therapies had substantially improved clinical outcomes and cost offsets compared with PCPs utilizing conventional medicine alone. While certainly promising, these initial results may not be consistent on a larger and more diverse population.
This study is the 3-year update to the above research and confirmed the earlier findings:
J Manipulative Physiol Ther. 2007 May;30(4):263-9.
Richard L. Sarnat, MD, James Winterstein, DC, Jerrilyn A. Cambron, DC, PhD
Objective: Our initial report analyzed clinical and cost utilization data from the years 1999 to 2002 for an integrative medicine independent physician association (IPA) whose primary care physicians (PCPs) were exclusively doctors of chiropractic. This report updates the subsequent utilization data from the IPA for the years 2003 to 2005 and includes first-time comparisons in data points among PCPs of different licensures who were oriented toward complementary and alternative medicine (CAM).
Results: Clinical and cost utilization based on 70274 member-months over a 7-year period demonstrated decreases of 60.2% in-hospital admissions, 59.0% hospital days, 62.0% outpatient surgeries and procedures, and 85% pharmaceutical costs when compared with conventional medicine IPA performance for the same health maintenance organization product in the same geography and time frame.
Conclusion: During the past 7 years, and with a larger population than originally reported, the CAM-oriented PCPs using a nonsurgical/nonpharmaceutical approach demonstrated reductions in both clinical and cost utilization when compared with PCPs using conventional medicine alone. Decreased utilization was uniformly achieved by all CAM-oriented PCPs, regardless of their licensure. The validity and generalizability of this observation are guarded given the lack of randomization, lack of statistical analysis possible, and potentially biased data in this population.
Attention policymakers: If you want to save money and improve outcomes, put chiropractors in charge of neck and back pain and consider chiropractors as PCPs.