Health and medical economics applied to integrative medicine.

Cost-benefit analyses (CBA) of every aspect of health and medical care are a necessity to address both the clinical effectiveness and cost effectiveness of health and medical care for the purpose of allocating limited practitioner, organizational, governmental, and monetary resources while maintaining the highest quality outcomes. In response, there are an array of approaches that emphasize the full continuum of prevention, restructuring primary care, involvement of the workplace and communities, and adoption of innovative strategies and interventions ranging from genomic assessments to complementary and alternative medicine (CAM). Among these approaches is an integrative medicine (IM) model that is consistent with these national objectives and that uniquely and explicitly includes "evidence-based global medical strategies" in its definition. All of these strategies require rigorous, appropriate, state-of-the art medical economic analyses. Since few if any IM models have been rigorously evaluated in terms of CBA, it is possible to draw upon the cost-effectiveness research focused on a limited number of CAM modalities as well as from the work-site/corporate clinical and cost outcomes research to suggest the evidence-based foundation from which a true healthcare system will evolve.

Effects of a managed chiropractic benefit on the use of specific diagnostic and therapeutic procedures in the treatment of low back and neck pain.

OBJECTIVE: The aim of this study was to measure the effects of a managed chiropractic benefit on the rates of specific diagnostic and therapeutic procedures for the treatment of back pain and neck pain. DESIGN: This study is a retrospective analysis of claims data from a managed-care health plan over a 4-year period. The use rates of advanced imaging, surgery, inpatient care, and plain-film radiographs were compared between employer groups with and without a chiropractic benefit. RESULTS: For patients with low back pain, the use rates of all 4 studied procedures were lower in the group with chiropractic coverage. On a per-episode basis, the rates in the group with coverage were reduced by the following: surgery (-32.1%); computed tomography (CT)/magnetic resonance imaging (MRI) (-37.2%); plain-film radiography (-23.1%); and inpatient care (-40.1%). On a per-patient basis, the rates were reduced by the following: surgery (-13.7%); CT/MRI (-20.3%); plain-film radiography (-2.2%); and inpatient care (-24.8%). For patients with neck pain, the use rates were reduced per episode in the group with chiropractic coverage as follows: surgery (-49.4%); CT/MRI (-45.6%); plain-film radiography (-36.0%); and inpatient care (-49.5%). Per patient, the rates were surgery (-31.1%); CT/MRI (-25.7%); plain-film radiography (-12.5%); and inpatient care (31.1%). All group differences were statistically significant. CONCLUSION: For the treatment of low back and neck pain, the inclusion of a chiropractic benefit resulted in a reduction in the rates of surgery, advanced imaging, inpatient care, and plain-film radiographs. This effect was greater on a per-episode basis than on a per-patient basis.

Chiropractic as spine care: a model for the profession.

BACKGROUND: More than 100 years after its inception the chiropractic profession has failed to define itself in a way that is understandable, credible and scientifically coherent. This failure has prevented the profession from establishing its cultural authority over any specific domain of health care. OBJECTIVE: To present a model for the chiropractic profession to establish cultural authority and increase market share of the public seeking chiropractic care. DISCUSSION: The continued failure by the chiropractic profession to remedy this state of affairs will pose a distinct threat to the future viability of the profession. Three specific characteristics of the profession are identified as impediments to the creation of a credible definition of chiropractic: Departures from accepted standards of professional ethics; reliance upon obsolete principles of chiropractic philosophy; and the promotion of chiropractors as primary care providers. A chiropractic professional identity should be based on spinal care as the defining clinical purpose of chiropractic, chiropractic as an integrated part of the healthcare mainstream, the rigorous implementation of accepted standards of professional ethics, chiropractors as portal-of-entry providers, the acceptance and promotion of evidence-based health care, and a conservative clinical approach. CONCLUSION: This paper presents the spine care model as a means of developing chiropractic cultural authority and relevancy. The model is based on principles that would help integrate chiropractic care into the mainstream delivery system while still retaining self-identity for the profession.

The selection effects of the inclusion of a chiropractic benefit on the patient population of a managed health care organization.

OBJECTIVE: The aim of this study is to measure the selection effects of the inclusion of a chiropractic benefit on a managed care health plan. DESIGN: An analysis of enrollment data from a managed care health plan over a 4-year period was conducted. Employers could select the managed care plan with or without a chiropractic care benefit. Comparisons of demographic and comorbid characteristics were made between employees who had the chiropractic benefit and those who did not, and between individuals who self-selected chiropractic care and those who self-selected medical care. RESULTS: The cohort with chiropractic coverage was younger with fewer subjects in the older age group (>65 years; 6.5% vs 9.6%) and more subjects in the younger age group (0-17 years; 31.9% vs 26.2%). The mean age of the group with coverage was 32.9 compared with 35.5 in the group without coverage. Comparing self-selected chiropractic patients to self-selected medical patients, there were fewer subjects older than 65 years in the chiropractic group (4.9% vs 9.2%) and fewer subjects aged 0 to 17 years (9.4% vs 19.4%). In 6 of the 8 comorbid conditions studied, the rates were lower in the cohort with chiropractic coverage compared with the group without coverage. The rates of comorbid conditions in self-selected chiropractic patients were lower in all 8 categories compared with self-selected medical patients. CONCLUSION: The inclusion of a chiropractic benefit in a health plan produces a modest favorable selection processes resulting in a slightly younger patient population with fewer comorbidities. At the level of patient self-selection, chiropractic patients are considerably younger and healthier than comparable medical patients.

Comparative analysis of individuals with and without chiropractic coverage: patient characteristics, utilization, and costs.

BACKGROUND: Back pain accounts for more than $100 billion in annual US health care costs and is the second leading cause of physician visits and hospitalizations. This study ascertains the effect of systematic access to chiropractic care on the overall and neuromusculoskeletal-specific consumption of health care resources within a large managed-care system. METHODS: A 4-year retrospective claims data analysis comparing more than 700 000 health plan members with an additional chiropractic coverage benefit and 1 million members of the same health plan without the chiropractic benefit. RESULTS: Members with chiropractic insurance coverage, compared with those without coverage, had lower annual total health care expenditures ($1463 vs $1671 per member per year, P<.001). Having chiropractic coverage was associated with a 1.6% decrease (P = .001) in total annual health care costs at the health plan level. Back pain patients with chiropractic coverage, compared with those without coverage, had lower utilization (per 1000 episodes) of plain radiographs (17.5 vs 22.7, P<.001), low back surgery (3.3 vs 4.8, P<.001), hospitalizations (9.3 vs 15.6, P<.001), and magnetic resonance imaging (43.2 vs 68.9, P<.001). Patients with chiropractic coverage, compared with those without coverage, also had lower average back pain episode-related costs ($289 vs $399, P<.001). CONCLUSIONS: Access to managed chiropractic care may reduce overall health care expenditures through several effects, including (1) positive risk selection; (2) substitution of chiropractic for traditional medical care, particularly for spine conditions; (3) more conservative, less invasive treatment profiles; and (4) lower health service costs associated with managed chiropractic care. Systematic access to managed chiropractic care not only may prove to be clinically beneficial but also may reduce overall health care costs.

Chiropractic care: is it substitution care or add-on care in corporate medical plans?

An analysis of claims data from a managed care health plan was performed to evaluate whether patients use chiropractic care as a substitution for medical care or in addition to medical care. Rates of neuromusculoskeletal complaints in 9e diagnostic categories were compared between groups with and without chiropractic coverage. For the 4-year study period, there were 3,129,752 insured member years in the groups with chiropractic coverage and 5,197,686 insured member years in the groups without chiropractic coverage. Expressed in terms of unique patients with neuromusculoskeletal complaints, the cohort with chiropractic coverage experienced a rate of 162.0 complaints per 1000 member years compared with 171.3 complaints in the cohort without chiropractic coverage. These results indicate that patients use chiropractic care as a direct substitution for medical care.