Chiropractors are involved in only a small fraction or workers’ compensation claims for low back pain in states where insurers or employers control the choice of medical provider, but a report released Tuesday suggests that skepticism about runaway costs may be unfounded.
A study by the Workers’ Compensation Research Institute found that medical care costs less and claimants return to work more quickly when low back pain treatment is provided solely by chiropractors. Costs were also lower when chiropractors provided physical medicine services but other types of clinicians were in charge of evaluation and management, but the difference was not as dramatic.
“This study will be helpful for policymakers and stakeholders who are interested in re-evaluating the role of chiropractors, especially those who have been adopting evidence-based practices and contributing to cost-effective care,” stated WCRI President and Chief Executive Officer John Ruser in a press release.
WCRI researchers examined more than 2 million claims from 28 states with injuries dating from Oct. 1, 2015 through Sept. 30, 2017 to compare costs and claim duration for workers who were treated exclusively by chiropractors to workers who received no chiropractic care and workers who received services from both chiropractors and other types of providers. Claims that involved serious conditions needing immediate care, such as tumors and fractures, were excluded.
The average medical cost per claim for low back pain patients who were treated exclusively by a chiropractor for both physical medicine and evaluation and management was $1,366, 61 percent less than the $3,522 treatment cost for low back pain cases that received no chiropractic treatment.
Indemnity costs were also lower for workers whose low back pain was treated exclusively by a chiropractor: $492 compared to $3,604 for workers who received no chiropractic treatment.
For workers who received physical medicine services by a chiropractor and evaluation and management services by other types of clinicians, medical costs averaged $3001, 15% less than workers who did not receive chiropractic care. Indemnity costs averaged $2,502, 31% less.
Injured workers treated exclusively by chiropractors also refused fewer drugs and diagnostic imaging scans, the report says. Comparing a subset of claims with similar characteristics, the researchers found only 1% of claimants treated by chiropractors were prescribed opioids, compared to 10.3% of claimants who were not treated by chiropractors. In the chiropractic group, 4.3% of claimants received a magnetic-resonance imaging scan, compared to 18.9% for the non-chiropractic claimants.
The report cautions readers that the data provides evidence of an association between chiropractic care and the outcomes that were noted, but not a causal relationship. Researchers cannot fully account for unobserved individual and system characteristics that likely influence the choice of chiropractic care and outcomes, the report says.
The use of chiropractic care varied widely among the states. In Minnesota, 34% of low back pain cases had chiropractic care, 285 in Wisconsin, 25% in California and 20% in New York. On the other end of the spectrum, only 1% of low back claims in South Carolina, Georgia, Arkansas, New Jersey and North Carolina had chiropractic care.
WCRI said those states were among 16 in the study group that allow employers or insurers to control the selection of the treating clinician. None of those employer-choice states saw more than an average of 11% of low back cases with chiropractic care. By contrast, Wisconsin allows employees to choose their medical provider while California, New York and Minnesota allow limited employee control.
The report says that fast-rising medical costs in the early 1990s caused employers to become concerned about the cost-effectiveness of chiropractic care. As a result, states began imposing new rules to control costs. Colorado, for example, adopted low back guidelines that required demonstrable functional progress after five visits and capped total visits at 36. California allows no more than 24 chiropractic visits. In Oregon the cap is 12.
Patients outside of workers’ compensation are much more likely to seek chiropractic care for low back pain. WCRI said a 2017 study found that in non-occupational settings, 31% of patients with back pain sought care by a chiropractor within 12 months of injury. Only a few of the 28 state workers’ compensation systems studied had a similar prevalence of chiropractic care for low-back pain cases.
“Without updated information on chiropractic care and the associated costs and outcomes, it is conceivable that some employers and insurers were still concerned about the cost-effectiveness of chiropractic care,” the report says. “The negative perception of chiropractic care on the part of employers and insurers may also be in part because some chiropractors may still provide prolonged maintenance care without measurable benefits regarding function and disability.”
The study is available for download by WCRI members or for purchase by non-members here.
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