While the cost effectiveness of chiropractic care is well demonstrated and established in the minds of many, what about chiropractic care delivered in a managed care system? This question has undoubtedly been asked in the board rooms of managed care corporations across the United States.
The answer to that question came in the March 1996 issue of the American Journal of Managed Care (AJMC). The AJMC is a new publication that refers to itself as "the forum for peer-reviewed literature on managed healthcare." A paper by Mosley et al. in that issue, "Cost-Effectiveness of Chiropractic Care in a Managed Care Setting,"1 came to some interesting conclusions, several of which were surprising. The study looked at patients of an "independent physician model HMO" operating in Louisiana. The abstract tells the story:
"The authors retrospectively evaluated the cost of health care for back or neck pain (ICD-9 codes 720 through 724) for members of a health maintenance organization who sought chiropractic care (n=121) or other treatment methods (n=1,838). In addition, differences between the groups in surgical rates, the use of diagnostic imaging (computed tomography and magnetic resonance imaging), and patient satisfaction were compared. The analysis was conducted on claims paid between October 1, 1994 and October 1, 1995.
The cost of healthcare for back and neck pain was substantially lower for chiropractic patients than for non-chiropractic patients ($539 vs $774). Utilization of prescription drugs and diagnostic imaging were significantly greater in the nonchiropractic group whereas surgical rates and patient satisfaction were nearly identical. The authors conclude that properly managed chiropractic care can yield outcomes in terms of surgical requirements and patient satisfaction, that are equal to those of non-chiropractic care at a substantially lower cost per patient."
One interesting finding of the study was that chiropractors used diagnostic imaging much less frequently than the non-chiropractic group (4.9% of the time, versus 16.5%). And it came as no surprise that the non-chiropractic patients received twice as many prescriptions.
But the appearance of similar satisfaction scores and surgical rates in the Mosley et al. study are surprising findings and raise a number of questions. For example, there's a study that has demonstrated three times the patient satisfaction with chiropractic care than convention medical care for low back pain.2 It is quite possible that the size of the population in the Mosley et al. study was too small to reveal potential differences.
Co-investigator, Ilana G. Cohen, AIC, DC, was the only chiropractor to work on this study. In an exclusive interview she commented:
"The paper clearly demonstrates that chiropractic services, managed by a chiropractor, was integrated within the mainstream of Community Health Network of Louisiana. It has proven to be satisfactory to patients and providers, as well as cost effective for care of low back and neck problems."
When asked what the most important aspects of the paper was, Dr. Cohen told us that it was the offering of self-referral chiropractic services that were implemented and "strongly recommended as a treatment of choice by Roy M. Arnold, MD, medical director of Community Health Network of Louisiana." Dr. Cohen said that the possibility of the similar surgery and patient satisfaction rates changing when tested against a larger population "remains to be determined."
Dr. Cohen will be continuing her work by comparing the outcomes of this research with the continued increase of the subscriber populations. She also plans to study other "products" (PPO, POS, etc.) in other managed care and non-managed care populations.
This paper ultimately makes two comments that we would like to hear echo down the halls of managed care:
"We are somewhat puzzled by the relatively low proportion of HMO members who chose chiropractic care for back pain when compared with published figures.3 This phenomenon merits additional study in our sample. If even half the study patients treated by traditional therapies could have been cared for in the chiropractic setting, the annual savings would have exceeded $215,000." "Although a larger sample of patients must be studied in order to definitively show broad-based success, we believe that managed chiropractic is an extremely promising method of treating acute back and neck discomfort. We recommend its wider application by the managed care industry and the physician community."
References - Mosley CD, Cohen IG, Arnold AM. Cost-effectiveness of chiropractic care in a managed care setting. Am J Man Care 1996;2:280-282.
- Cherkin DC, MacCornack FA. Patient evaluations of low back pain care from family physicians and chiropractors. West J Med 1989 Mar; 150:351-355.
- Shekelle PC; Markevich H. Louie R. Factors associated with choosing a chiropractor for episodes of back pain care. Med Care 1995:33; 843-850.
