Tuesday, July 10, 2018

What Does Research Reveal About Chiropractic Costs?

By Christine Goertz, DC, PhD

Those who have listened to me speak about the evolution of chiropractic research over the past 30 years may have already heard me talk about the questions that I am asked most frequently by policy makers regarding what we do and why. Without a doubt, the most common issues raised by those outside the profession relate to the quality and consistency of chiropractic care delivery. The second most commonly asked question invariably pertains to the costs associated with chiropractic care.

While there is still no definitive answer to this question (yes, more research is needed!), to date approximately 30 studies have looked at the cost of including chiropractic care and/or spinal manipulative therapy (SMT) within workers’ compensation, other healthcare delivery systems or multi-disciplinary clinics. The available evidence varies in quality; however, it consistently shows that patients with low back and neck pain who are treated by chiropractors have either similar or lower costs than those seeking care from other providers. In particular, it appears that patients who visit a chiropractor are less likely to undergo hospitalization, resulting in lower global healthcare costs than those who receive medical care only.

The literature relevant to the costs associated with chiropractic care include three systematic reviews, two focused on chiropractic’s signature treatment (SMT) and one specifically targeting chiropractic. Lin et al (2011)1 reviewed the cost-effectiveness of low back pain treatments, including SMT, that had been included in existing clinical practice guideline recommendations. They concluded that SMT was cost-effective for chronic and subacute low back pain. However, there was insufficient data to draw conclusions regarding acute low back pain. 

A year later, Michaleff et al (2012)2 examined the cost-effectiveness of SMT when compared to other treatments, including physiotherapy, general medical practice, and exercise. These authors found that spinal manipulation was cost-effective when compared to these other treatments, regardless of whether it was delivered alone or in combination with the other treatment approaches evaluated.

Later, Dagenais et al (2015)3 conducted a systematic review designed to evaluate the cost of chiropractic care. The study team reviewed 25 studies and concluded that “chiropractic care may be associated with lower health care costs when compared to care from other health care providers.”

In 2016, Hurwitz et al4, 5, 6 added to the state of knowledge regarding costs of chiropractic care by conducting three studies designed to explore healthcare costs and utilization in patients seeking care from chiropractors, physical therapists or medical doctors in the state of North Carolina. They found that healthcare expenditures for patients with low back pain, neck pain and headaches were all lower in those who received chiropractic care alone when compared to any other combination of healthcare providers.   

A common weakness shared by many of the studies described above has to do with how comparisons are made between those receiving and not receiving chiropractic care. We know that patients who visit a DC tend to be different in some ways from those who do not. Thus, it can be tricky to figure out if any lower costs found in this population are a result of chiropractic care or other factors that influence healthcare expenditures, such as age, education, socioeconomic status and/or existing co-morbidities.

Taking all of this into consideration, the best estimate to-date regarding patient care costs for those seeking chiropractic care when compared to alternatives was published by Martin et al in 20127, a study that is not included in the previous systematic reviews described, likely because neither spinal manipulation or chiropractic were listed as MeSH (key search) terms in the article when it was published. I encourage you to read this important paper, which can be downloaded for free.

Martin and his team identified more than 12,000 patients with low back and neck pain from the Medical Expenditure Panel Survey (MEPS) and estimated whether those seeking complementary and integrative health care (CIH) such as chiropractic, acupuncture, massage, and herbalism had higher or lower healthcare costs when compared to non-users. They found that propensity-score matched costs for spine care were $526 lower and total health care costs were $298 lower for CIH users versus non-users. Propensity score matching is a statistical tool used to account for covariates such as age and sex that predict whether or not a patient receives a specific treatment.8 Although a number of CIH practices were included in this study, chiropractic care comprised approximately three quarters of the CIH services identified. As a result, investigators conducted a chiropractic-specific analysis of expenditures and found that the results were the same. Of note is the fact that patients who used CIH providers, including doctors of chiropractic, had lower in-patient hospitalization costs.

Dr. Goertz is senior scientific advisor for the American Chiropractic Association. She is also CEO of the Spine Institute for Quality (Spine IQ).

References

  1. Lin, C. W., Haas, M., Maher, C. G., Machado, L. A., & van Tulder, M. W. (2011). Cost effectiveness of guideline-endorsed treatments for low back pain: A systematic review. European Spine Journal, 20(7), 1024-38.
  2. Michaleff , Z. A., Lin, C. W., Maher, C. G., & van Tulder, M. W. (2012). Spinal manipulation epidemiology: Systematic review of cost effectiveness studies. Journal of Electromyography and Kinesiology, 22(5), 655-62.
  3. Dagenais S, et al. A systematic review comparing the costs of chiropractic care to other interventions for spine pain in the United States. BMC Health Serv Res. 2015 Oct 19;15:474. http://www.ncbi.nlm.nih.gov/pubmed/26482271
  4. EL, et al. Variations in patterns of utilization and charges for the care of low back pain in North Carolina, 2000 to 2009: A Statewide Claims' Data Analysis. J Manipulative Physiol Ther. 2016 May;39(4):252-62. http://www.ncbi.nlm.nih.gov/pubmed/27166406.
  5. EL, et al. Variations in patterns of utilization and charges for the care of neck pain in North Carolina, 2000 to 2009: A Statewide Claims' Data Analysis. J Manipulative Physiol Ther. 2016 May;39(4):240-51. doi: 10.1016/j.jmpt.2016.02.007.
  6. EL, et al. Variations in patterns of utilization and charges for the care of headache in North Carolina, 2000-2009: A Statewide Claims' Data Analysis. J Manipulative Physiol Ther. 2016 May;39(4):229-39. http://www.ncbi.nlm.nih.gov/pubmed/27166405
  7. Martin BI, Gerkovich MM, Deyo RA, Sherman KJ, Cherkin DC, Lind BK, Goertz CM, Lafferty WE.The Association of Complementary and Alternative Medicine Use and Health Care Expenditures for Back and Neck Problems. Med Care 2012;50(12):1029-1036.
  8. https://en.wikipedia.org/wiki/Propensity_score_matching (accessed June 21, 2018)

 

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1 comments on article "What Does Research Reveal About Chiropractic Costs?"

Steven Santolin

7/12/2018 9:12 AM

Christine, Every cost comparison study I have seen has not included all the indirect costs and most of them have omitted most of the indirect costs. I have always heard

that diagnostic costs averaged about 20% for chiropractic and about 80% for medical.

How much do you think this has affected the results of these comparison studies and do you see any studies being done in the future that includes all of the indirect costs?

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