In 1985, the Department of Defense was directed by Congress to undertake a demonstration project to determine the cost effectiveness of adding chiropractic as a benefit for military families. The study was conducted by the Office of the Civilian Health and Medical Program of the Uniformed Services (OCHAMPUS).
OCHAMPUS awarded a contract to the Midwest Research Institute (MRI) to provide background particulars about the chiropractic profession: development, modalities, utilization, literature review, and the efficacy and cost of its care.
MRI concluded that chiropractic studies had not produced "sufficient evidence for definitive statements about the cost effectiveness or efficacy of this type of treatment." Further, that while cost per visit tends to be higher for medical treatment than under chiropractic, that the number of visits of care tends to be higher with chiropractic patients than medical patients.
With this guidance, CHAMPUS began their formal two-year demonstration project April 1, 1990 in Colorado and Washington state.
In August of this year, a report to the Committees on Armed Services and Appropriations, prepared by the Office of the Assistant Secretary of Defense for Health Affairs, was prepared. The "Executive Summary" (italics added) stated:
Although demonstration survey results indicated a high level of satisfaction for both conventional medical and chiropractic patients, chiropractic patients rated their health care experience higher than did beneficiaries using medical model forms of treatment. One objective of this study was to make some determination as to the cost effectiveness of chiropractic care. Data collected as a result of this demonstration provide only a limited basis upon which to make such a determination. In other studies, such as that conducted by the RAND Corporation in 1991, chiropractic has been identified as an appropriate form of treatment in limited circumstances. However, current research -- including this demonstration -- has not demonstrated the extent to which chiropractic serves as a substitute for other forms of treatment.
Although it seems reasonable to conclude that a new benefit would increase demand -- and probably overall program costs -- the long-term impact is difficult to predict. Because the chiropractic demonstration in Washington and Colorado did not occur in a managed care setting, the level of control over cost was less than that which current Defense Department initiatives are attempting to achieve.
Editor's question: If the DOD is geared to achieving cost controls via managed care, then why didn't they conduct the demonstration project of chiropractic within a managed care setting?
Given current crises in health care costs, and fiscal constraints within the military health care system, DOD does not favor inclusion of a benefit which cannot be justified with compelling evidence. To date, chiropractic studies have not produced such evidence.
Editor's note: As the demonstration project ended in 1992, the DOD needs to update its reading with the Manga Report (see front page story in this issue). The Manga findings are diametrically at odds with the DOD's conclusions. The Manga Report, among other findings, states:
- "There is an overwhelming body of evidence indicating that chiropractic management of low-back pain is more cost-effective than medical management."
- " On evidence, particularly the most scientifically valid clinical studies, spinal manipulation applied by chiropractors is shown to be more effective than alternative treatments for LBP."
The DODs "Executive Summary" concluded:
Should Congress nevertheless choose to establish a chiropractic budget, its provisions should remain consistent with cost containment initiatives now evolving. Any requirement to establish these services under CHAMPUS should occur in the context of a managed care environment, should impose associated quality and utilization controls, and should be limited to the services payable under Medicare. Only with strict controls over quality and utilization can the Department ensure delivery of care which is cost effective, appropriate and medically necessary.
The DOD is at the bottom of the usual "learning curve" that so many individuals and organizations experience when studying the benefits of chiropractic care. It seems that either lack of interest or outright prejudice cause many to reject the cost effectiveness of chiropractic care until they are confronted with the information available. Inclusion in CHAMPUS is an issue the chiropractic profession needs to pursue.
