More Pieces of the Health Reform Puzzle (Part 2)

Editor's note: Part 1 of this article appeared in the Nov. 1 issue of DC. Both parts appeared originally as a single interview / article in Health Insights Today, a web publication produced by Cleveland Chiropractic College - Kansas City, which granted us permission to reprint.

Cost-Effectiveness: Bringing Chiropractic's Message to Employers and Insurers

You've given a number of presentations over the past few years to employer, insurance and health industry groups on behalf of the Foundation for Chiropractic Progress. One of these was at the Accountable Care Organizations (ACO) Summit in Texas early in 2013. What are you telling these groups and how have people at these conferences responded? The first thing we're telling them is that everyone in healthcare is paying all sorts of attention to heart disease, obesity and diabetes. But the number-one cause of disability worldwide in 2012 was low back pain. The number-two reason that a person visits a healthcare provider in the United States is a musculoskeletal complaint.

This observation is what I call low-hanging fruit. I explain that while they're off dealing with the activity and situations that TV shows are about, the real basics of human endeavor are going unattended or poorly attended. Then I give them key research articles.

Last year there was a study¹ from the Washington State Department of Labor and Industry [which] found that on a risk-adjusted basis, if a person sees a surgeon first, they are 28.5 times more likely to have surgery than if they see a chiropractor first. If you're running a hospital that's trying to contain costs, and you know what those numbers are, your ears perk up big-time at these findings.

When somebody explains the magnitude of this problem, and gives low-cost, low-tech, high-touch interventions to replace what is currently being done, showing evidence of money being saved individually and globally, from radiography to MRI to surgery to hospitalization, then as the hospital administrator you want to make changes!

I would underscore that the 28.5 to 1 ratio you cited, regarding the greater likelihood of having surgery if you go first to a surgeon rather than a chiropractor, was the difference after the severity of the condition had been accounted for. Yes, this was apples to apples, oranges to oranges.

It's a remarkably powerful point for chiropractors to make. There was also a 2010 study out of Tennessee² that looked at low back pain patients. They provided data on a non-risk-adjusted basis, as well as on a risk-adjusted basis. In that study, the chiropractic care produced a 40% savings if risk was not accounted for. But it also produced a 20% savings on a risk-adjusted basis.

How to Present the Best Case for Inclusion in a PCMH or ACO

So, for an individual chiropractor, who is in private practice on their own or with a chiropractic group, or for a student who is about to graduate, am I hearing you correctly that you're saying these DCs need to know these facts well, if they're trying to make the case that they should be considered for inclusion in a Patient-Centered Medical Home or Accountable Care Organization that's forming in their area? That having this information is critical?

Are there any other comparable studies or talking points you would recommend our doctors of chiropractic have at their fingertips? Yes. In the insurance world, chiropractic is seen as a cost center. But it's not actually a cost center, it's a savings center. All of these data show this to be true. We need to begin discussing the cost-replacement value. We don't add cost to the system; we take expense out of it.

And this is because if people don't go to a chiropractor, they'll go to a more costly, less cost-effective practitioner for the same condition? Yes, exactly. This fact involves a huge shift in thinking for folks in the insurance world because they don't see chiropractors in that light. It's very important that we keep bringing this concept of expense reduction to the attention of people in the insurance and policy worlds. That's number one.

Number two, there's probably no hotter issue today in all healthcare than prescription drug abuse. It must be understood by all that the chiropractor not only gets the patient back to an improved, more functional state sooner and at less cost, but without the drugs and the secondary issues of abuse, dependency and addiction.

Think of it from the ACO's perspective: A patient with a hot low back starts down Oxycontin Road and he's a liability to the ACO over time. We know the chiropractor can help that patient reduce his drug use profile, a significant contribution that the chiropractor can offer through his or her participation in the ACO or PCMH. Thus, including chiropractors in ACOs or PCMHs will save them money; it will help their bottom line.

So, my advice to chiropractors approaching an ACO or PCMH about participation is to commit to memory the data on prescription drug abuse – Vicodin and Oxycontin – [and] rattle that off, along with the average costs of surgery and the studies showing that chiropractic care makes many surgeries unnecessary.

You've got to know all of those things, because this is "follow the money." You need to demonstrate where they're spending money and how we can give them a safer, more cost-effective, minimally iatrogenic intervention in place of it down the road. That's the issue; that's the picture we've got to paint. Now, they're not going to believe us just because we say it. But they'll start thinking about it. We have to make the "What if?" strong enough.

I don't know if you happened to catch the testimony before Senator Sanders' recent hearing on some veterans bills that he's put forward, including an expansion of chiropractic services.

I'm aware of the bills. What can you tell us about the testimony at the hearing? If you go to that hearing, at the one-hour-and-nine-minute mark, you can pick up the discussion about chiropractic services. There's a fellow [who] represents the Vietnam Veterans of America. He's saying that Congress set this in place 10 years ago, yet the military are still screwing around with it when veterans need and want chiropractic coverage. Then Wayne Jonas, the president of the Samueli Institute and former director of the National Center for Complementary and Alternative Medicine at NIH, gets up and talks about how the veteran of today, the injured warrior of today, needs chiropractic care. He made very strong statements about it, not equivocal at all.

Dr. Jonas was also a military medical doctor for over 20 years. He knows what he speaks of. Yes. Those kinds of discussions are available online for free. I'd encourage folks to send this type of info as an email attachment as these conversations begin. We've got to make our case, pure and simple.

References

1. Keeney BJ, Fulton-Kehoe D, Turner JA, Wickizer TM, Chan KC, Franklin GM. Early predictors of lumbar spine surgery after occupational back injury: results from a prospective study of workers in Washington state. Spine, May 15, 2013;38(11):953-964.
2. Liliedahl RL, Finch MD, Axene DV, Goertz CM. Cost of care for common back pain conditions initiated with chiropractic doctor vs medical doctor / doctor of osteopathy as first physician: experience of one Tennessee-based general health insurer. J Manipulative Physiol Ther, November – December 2010;33(9):640-643.