Chiropractic in the Eyes of the LBP Patient

In the past quarter-century, dozens of studies have been conducted comparing the typical doctor of chiropractic to the typical medical physician; income, age, education, training, field of specialty, number of years in practice, types of conditions treated and myriad other characteristics have been measured. While these analyses helped draw rather clear pictures of the average DC and the average MD, many failed to take an important factor into consideration: the patient.

What differences, if any, are there between patients who see chiropractors and those who see medical doctors? Do patients choose to see one type of practitioner over the other, and if so, why? How do they pay for treatment? And what does all this say about the public's acceptance of and access to chiropractic in the 21st century?

Researchers in Oregon and Minnesota attempted to answer these questions by conducting an analysis of low back pain (LBP) patients in the U.S. For 18 months, they surveyed more than 1,400 adults with LBP and subjected them to a variety of physical and psychological examinations. The results of their analysis, published in the December 2003 issue of the American Journal of Public Health,¹ show that significant differences exist between patients who see DCs for low back pain versus those who see MDs, especially in the areas of practitioner trust, support for (or opposition to) taking prescription drugs, and payment method.

From December 1994 to June 1996, the study authors collected initial information on 2,872 adults who presented with back pain to a chiropractor or medical doctor. Severity of pain; functional disability; incidence of sciatica; patient stress levels; confidence in the provider's ability to treat LBP; and an assortment of psychosocial tests were administered to each patient upon enrollment in the study. In addition, each patient was asked if he or she:

• trusted medical doctors;
• trusted doctors of chiropractic;
• was against taking prescription drugs; and
• believed in the equality of MD and DC skills in the treatment of LBP.

Of the 2,872 patients enrolled, 1,414 completed all of the requested information and were included in the analysis. Among the survey's more pertinent findings:

• Patients with more severe pain, greater functional disability, and chronic LBP (six weeks or more) were more likely to choose a medical doctor for care. Self-referral to chiropractors was associated with history of LBP and acute LBP.
• Patients who self-referred to a medical doctor for back pain were more likely to smoke and be unemployed, and less likely to have a college education, than patients who self-referred to a chiropractor.
• Only 25.7 percent of patients who opposed taking drugs chose a medical doctor for treatment. This number increased to 43.3 percent for chiropractic patients - an indication that patients who self-refer to a DC are probably more aware of the side-effects of many medications and/or may prefer more natural methods of healing.
• Patients who believed MDs and DCs were equally skilled at treating LBP were slightly more likely to obtain care from an MD. However, patients who expressed confidence in the ability of their chosen provider to treat LBP successfully were more than six times as likely to choose a DC than an MD.
• Of those patients who reported trusting medical doctors, 94.6 percent referred themselves to an MD, but 82.7 percent still chose to see a chiropractor. On the other hand, of the patients who reported trusting chiropractors, 95.3 percent self-referred to a DC, while only 60 percent sought an MD for care.

The most dramatic difference between chiropractic and medical patients was in terms of payment. Only 7.4 percent of medical patients paid for care out-of-pocket, but an overwhelming 43.8 percent of chiropractic patients paid for their own care. Conversely, 75.3 percent of patients who self-referred to an MD had their treatment covered by health insurance or a state health plan, compared to just 39.5 percent for chiropractic patients.

While these figures could be explained to some degree by the fact that more than one-quarter of all self-referred chiropractic patients worked part-time or were self-employed, it also suggests that a barrier still exists that prevents significant amounts of people from gaining access to DCs for treatment of LBP.

In fact, the researchers noted that patient attitudes toward a particular type of provider "may be less important when the choice of provider has a large financial impact." So, why was there such a disparity in the source of payment between chiropractic patients and those who saw a medical doctor? The authors provided a clue in their conclusion:

"Insurance coverage for chiropractic services is often more limited than coverage for medical care. Data from 1993 and 1995 indicated that only 75 percent of those with private coverage had chiropractic benefits (only 44 percent for HMO enrollees), and that most who did not have such benefits faced restrictions such as visit or dollar limits. Thus, even when fees for chiropractic care are less than fees for medical care, so that chiropractic is less costly for uninsured patients, limits on chiropractic benefits may render them more costly for insured patients. Not surprisingly, patients whose treatment is paid for by insurance, private or public, are far more likely to seek medical care; self-pay patients are far more likely to choose a DC."

"... Chiropractic coverage is becoming a nearly universal benefit in private insurance. Nevertheless, restrictions on utilization have tended to be far more severe on chiropractic care than on medical care, and it is unclear whether patients fully understand the nuances of our complicated insurance system, including deductibles and copayments. These questions remain to be addressed in future research."

Chiropractors know that their care is superior to conventional medicine when it comes to the treatment of low back pain. The authors of the study admit as much when they say that "mainstream medicine's record in treating low back pain is poor" and that "evidence has already shown that many surgical and nonsurgical hospital admissions (for low back pain) are unnecessary." With an increasing percentage of the public seeking chiropractic, when will the insurance industry take the necessary steps to ensure patients receive the best type of care from the best provider of care for back pain?

Reference

1. Sharma R, Haas M, Stano M. Patient attitudes, insurance, and other determinants of self-referral to medical and chiropractic physicians. American Journal of Public Health December 2003;93(12): 2111-2117.

Written by Michael Devitt, senior associate editor