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State of Chiropractic 2021: Part 3 – Cost Effectiveness

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Cost-Effectiveness

Welcome back to part three of our four part series on the overall state of chiropractic as we enter the calendar year of 2022.  Parts one and two covered patient satisfaction and clinical outcomes in chiropractic as well as direct comparisons to the healthcare industry as a whole.

Today I will continue that trend by discussing chiropractic through the lens of cost effectiveness or value.

In the US alone, the estimated cost of musculoskeletal pain on the healthcare system (led by the spine) has topped 1 trillion dollars.  Complicating things further, musculoskeletal pain is listed as the most common cause of long term pain and disability in the US as well. (162)

With costs comparable to the GDP of Mexico, it becomes important to find solutions with the highest level of cost-effectiveness.  So how do we measure cost-effectiveness or value?

Value, as it relates to medical care, is calculated by dividing the clinical outcome by the cost of delivering care represented by the equation below:

The Healthcare Value Formula

Considering that evidence-based chiropractors deliver above-average clinical outcomes at low expense, consumers could expect their value to the healthcare system to be high and this expectation is supported by the research.  Multiple studies assessing the healthcare value formula have all come to similar conclusions: chiropractic care is highly cost-effective. (157, 158, 163, 164, 185-189)

Cost Comparison by Provider Type

Extensive systematic review in 2004 compared chiropractic care to standard medical care and physical therapy for treatment of musculoskeletal pain and highlighted a growing trend in the research:

Manual therapy techniques [including chiropractic manipulation] were more cost-effective than usual general practitioner care…for improving low back and shoulder pain/disability. (157)

Multiple other studies have come to similar conclusions:

A claims analysis of Blue Cross Blue Shield showed that when care for low back pain was initiated with a doctor of chiropractic (DC), overall healthcare costs for management of that case were reduced by nearly 40 percent when compared to care initiated with a medical doctor (MD). (163)

Average Insurances Costs for Low Back Pain Claims by Healthcare Provider Type

A similar cost analysis examining treatment of various spine, hip, and shoulder problems found costs to be significantly lower when management was initiated by a DC vs. MD. (164)

Overall Cost of Musculoskeletal Treatment by Healthcare Provider Type

The British Medical Journal found an even more significant disparity:

The total costs of manual therapy were around one-third of the costs of physiotherapy and general practitioner care. (158) see below

Overall Cost of Neck Pain Treatment by Healthcare Provider Type

Ancillary Costs – Healthcare Referrals

Generally speaking, health care costs rise as additional providers enter the clinical picture through referral.  One of the biggest determinations in cost expectation and multiplication is the choice of provider at the start of the process.  It also has a significant effect on likelihood of future referrals, tests, and procedures performed.

Several studies have shown that patients who initiate care with chiropractors end up seeing fewer total providers throughout the course of case management without an overall effect on clinical outcomes. (165-167) Data from Optum health showed that on average, patients who initiate care with a chiropractor see an average of 1.7 different providers by comparison to 3.2 different providers when initiating care from other specialties. (167)

Average Number of Providers Visited Relative to Choice of Initial Provider

Ancillary Costs – Surgery

By and large, most musculoskeletal problems achieve resolution without the need for surgical intervention.  In addition, many issues once thought to be exclusively surgical are now being effectively managed conservatively.  A study out of the Global Spine Journal in 2020 found that 97% of lumbar disc herniations are successfully managed without the need for surgical intervention. (168)

Another study out of Spine found that approximately 42.7% of injured workers who first saw a surgeon had surgery, in contrast to only 1.5% of those who sought care with a chiropractor. (166)

Likeliohood of Having Surgery Relative to Choice of Initial Provider

Ancillary Costs – Opioids & Other Drugs

While Covid has largely taken center stage the last 2 years as the pandemic, it should be noted that this country is still very much in the grips of an opioid pandemic.  A cursory search of the CDC website shows that in last year alone deaths related to opioid use topped 75,000.  This is further compounded by that fact that time and time again, research shows that these drugs, and others like them, are largely ineffective for managing mechanical musculoskeletal problems like back pain. (169-173)

Lack of Evidence for Managing Low Back Pain with Medication

Between 2000-2010, overdose death rates and substance use rates saw an increase of 3-4 fold – mirroring the overall increase in sales of these particular prescription pain relievers –  with expectations that 2010-2020 will see show similar increases. (175)

Thankfully alternative treatments like chiropractic care may be able to play a larger role in mitigation of this unfortunate situation:

A 2019 Pain Medicine systematic review found that patients participating in chiropractic care were 64% less likely to receive an opioid prescription than nonusers. (176)

Opioid RX Rate for Chiropractic vs. Non-Chiropractic Patients

Another review from the same journal in the same year found that patients with back pain who engaged with chiropractic care exhibited “half the risk of filling an opioid prescription” over the following six years by comparison to those who did not. (177)

6- Year Opioid Use Rate for Chiropractic VS. Non-Chiropractic Patients

Ancillary Costs – Hospitalizations, Surgery & Medication

It is easy to assume that the addition of specialty to any care plan would automatically increase overall cost of care and reduce the Value equation discussed earlier in this blog.  Fortunately, this is not always the case.

One 4-year study out of JMPT demonstrated that integration of chiropractic into the standard medical model of care can substantially decrease healthcare expenditures. (157)

Complementary & Alternative Medicine (CAM) Use Decreases Healthcare Costs

Value to Healthcare Plans

An Optum Healthcare review concluded that healthcare plans which formally incorporate chiropractic care typically realize a 2:1 return for every dollar spent. (178)

Health Plan Cost Savings Via Chiropractic Inclusion

Because of our ability to deliver high-value care with lower secondary costs, its easy to see how chiropractors become more appealing to patients seeking care for musculoskeletal pain and to the companies who insure them.

Conclusion

From the advantages in cost-effectiveness, value improvements when integrated in the medical model, lack of adverse reactions by comparison to drugs and savings for health insurance companies, its easy to see the value of seeking care with a doctor of chiropractic for musculoskeletal pain.

If you or anyone you know is in pain but is hesitant to seek care due to the perceived cost, I hope you would give this post your consideration.  Thanks again for reading and look for the fourth and final part of this series Safety in the weeks to come.

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