Restricting Chiropractic Care Results in Higher Medical Costs

By David Ryan, BS, DC

Ryan DT, Farabaugh R, et al. Chiropractic care is reduced and health care costs rise in State of Ohio Bureau of Workman's Compensation by 44% over a four-year period. In that same time, chiropractic reimbursement is reduced by 67%.

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.

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Dave Ryan, DC
Columbus, Ohio

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.

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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.