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Dynamic Chiropractic
April 20, 1998, Volume 16, Issue 09

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Manga Report II

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A second report from well-known Canadian health economist Pran Manga, PhD, is now available on the Internet. The paper, "Enhanced Chiropractic Coverage Under OHIP as a Means of Reducing Health Care Costs, Attaining Better Health Outcomes and Achieving Equitable Access to Health Services" (which we'll refer to as Manga II), can be downloaded free from the Ontario Chiropractic Association's website (

It is co-authored by University of Ottawa Professor Doug Angus, director of the masters program in health administration.

This paper reviews the cost effectiveness of chiropractic care and estimates the amount of money that the Ontario province would save if chiropractic services were covered as part of OHIP (Ontario Health Insurance Plan), the province's health plan that covers all residents.

The executive summary makes these primary points:

  1. The deterrent effect of existing copayments or user fees for chiropractic care is now very high, and represents a major barrier to access for most Ontarians. Patients are steered away from chiropractic care to medical management which is free under OHIP.

  2. The OCA proposes improved access to chiropractic services through enhanced coverage under OHIP, specifically that OHIP would cover 75% of the fee per visit, 100% for the elderly and the poor. The additional sum required for this policy is $200 million by the third year, i.e., 2000.

  3. This reform will result in the doubling of the proportion of the public that visits chiropractors in Ontario from 10% to 20%. It will also mean that these patients will visit chiropractors sooner for their problems. Currently 4 out of 5 chiropractic patients have had their disorders for over 6 months and many have already had extensive medical diagnosis and treatment.

  4. Expenditure to improve access to chiropractic services, and the changed utilization patterns it produces, will lead to very substantial net savings in direct and indirect costs. Direct savings to Ontario's health care system may be as much as $770 million, will very likely be $548 million, and will be at least $380 million. The corresponding savings in indirect costs, made up of the short and long term costs of disability, are $3.775 billion, $1.849 billion and $1.255 billion.

  5. The reasons why such substantial savings will accrue include:
  6. a. The poor and lower-middle income groups and the elderly are low users of chiropractic mainly due to the deterrent effect of the high copayments or user fees. Yet the prevalence of neuromusculoskeletal conditions is highest among these socioeconomic groups.

    b. There is considerable empirical support for the cost-effectiveness and the safety of chiropractic management of musculoskeletal disorders. This means that chiropractic care can bring about improved health outcomes at a lower cost.

  7. The Ministry of Health of Ontario should employ chiropractors on a salaried basis in hospitals, community health centres, and long-term institutions.

  8. More workers with neuromusculoskeletal disorders covered by the Workers' Safety and Insurance Board should be channelled to chiropractic care.

The authors makes these additional important points:

"It so happens that DC management of many conditions is highly 'own-labour' intensive (i.e., doctors of chiropractic provide mostly hands-on therapy and very little else), whereas medical management is a lot more complex and costly involving one or more prescription drugs; referrals to other caregivers including specialists and physiotherapists; laboratory tests and diagnostic imaging, and sometimes hospitalization as well. The literature on costing medical and chiropractic management of low-back pain shows that payments to chiropractors for their own services constitute more than 80% of the costs per episode. In the case of medical management the payments to medical doctors is only about 23% of the costs per episode (Mange et al., 1993)."




NMS Disorders and Injuries

Patient episode begins (T0)


costs of all costs of all
visits to DC visits to MD

cost of x-ray prescription

drug costs
other cost lab & other
+ +

diagnostic costs
referrals diagnostic

imaging Tx = Ty + referrals to specialists & other health caregivers + hospital

Tx Ty

Patient episode ends

"Currently, an overwhelming majority of patients with NMS conditions and injuries visits medical doctors first. A staggering 81% of patients of chiropractors have had their back pain or other NMS disorders for more than 6 months (Aker et al., 1993) and typically would have had extensive medical and/or physiotherapy care up to the time they decide to see a chiropractor. This suggests both an enormous amount of unnecessary direct and indirect cost and worsening health of the patients.

"Medical payments are 61% and 47% higher than chiropractic payments for total and outpatient care respectively (i.e. 1.61 and 1.47 in Table 3)."


First episode $635 $1,272
Second episode $658 $1,505
No. of patients 311 579

Stano and Smith, 1996, p.201.

"The Ministry of Health may also wish to use a small part of the additional funding to support salaried or sessional positions for chiropractors in hospitals, hospital outpatient departments, long-term care facilities, community health centres, health service organizations or comprehensive health organizations. We made this recommendation five years ago (Manga et al., 1993) and it was supported in the Chiropractic Services Review Committee Report (1994). We also recommended a greater involvement of chiropractors in the Workers' Safety and Insurance Board. This is best done through salaried positions. Al of these recommendations constitute cost-effective deployment of chiropractic but would account for a small fraction of the additional funding requested by the OCA. The bulk of the new funding would of necessity involve the fee-per-visit method of remunerating chiropractors.

"There is no reason to perpetuate the existing perverse situation in which cost-effective and safer services are subject to a copayment which inhibits access to the, whereas care which is less effective and safe and more costly is offered free of any copayments."



Diagnostic Total Direct Costs Total Indirect Costs
Category 1986 1993 %increase 1986 1993 %increase

Skeletal 1473 2444.8 66.0 6426 15328.4 138.5

Nervous Sys &
Sense Org 2031 2189.4 7.8 1476 7321.3 396.0
Injuries 1971 3115.4 58.1 6389 11221.7 75.6
All Diseases 27662 43617.5 57.7 47020 85122.7 81.0

"It is apparent that under any scenario the savings in indirect costs are much higher than the savings in direct costs. The Ministry of Health will no doubt be principally interested in net direct health care costs savings. We conclude that these are significant on the most conservative reasonable estimates. Savings will significantly exceed the costs of the expanded coverage of chiropractic services under OHIP. Needless to say other scenarios can also be worked out by applying different savings-ratios to Table 18.

"All of these observations point to a clear need for greater coverage of chiropractic care under private and public insurance systems. This will assure gains in both efficiency (producing health care services at the lowest costs) and effectiveness (getting the best health outcomes per dollar spent. Furthermore, greater insurance coverage will also mean greater access to chiropractic care, especially for population groups who are presently deterred from visiting chiropractors for financial reasons.

"Increasing the funding for chiropractic care is consistent with the Government of Ontario's Business Plan of 1997 which called for reallocating resources for evidence-based frontline services in a community setting. This initiative substitutes community-based services for institutional and hospital care, and emphasizes getting "the right care from the right provider at the right time."

"There is a final principle that is important in making decisions about manpower substitution in the health care system, one that is repeatedly overlooked or discounted by health care bureaucracies and decision makers. We are referring to the principle of distributive justice which is hardly ever mentioned, let alone seriously considered, in studies of manpower substitution. We would argue that the principle of distributive justice requires that the government implement all cost-effective substitutions because failure to do so results in unfairness to the taxpayers and the health care professionals concerned. It is clear that some professions enjoy economic rent at the expense of the taxpayers, and thus the distribution of the burden and benefits of publicly supported health insurance is inequitable from the standpoint of the taxpayers. OHIP is more costly than it needs to be, hence taxes in Ontario are correspondingly higher than they should be. The imposition of the high copayment for chiropractic care, when publicly financed medical services are free, results in a higher tax burden on the public to cover the less cost-effective medical management of prevalent conditions such as common back pain -- a major cause of disability in the community. The resu lt should be of concern to a government that emphasizes the need to reduce taxes in Ontario. The monopolization of health care services turf is also inequitable from a related perspective. It denies some professions equal opportunity to earn income commensurate with their ability, effectiveness and effort."

While much of the information cited in Manga II is known by the chiropractic profession, this kind of study should be reported every few years. Government agencies and legislators need to be reminded of the cost-saving advantages of chiropractic and the benefit to society in saving billions of dollars.

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Dynamic Chiropractic
April 20, 1998, Volume 16, Issue 09

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