Advance Care Planning in Older Adults with CKD: Patient, Care Partner, and Clinician Perspectives.

BACKGROUND: Older patients with advanced CKD are at high risk for serious complications and death, yet few discuss advance care planning (ACP) with their kidney clinicians. Examining barriers and facilitators to ACP among such patients might help identify patient-centered opportunities for improvement. METHODS: In semistructured interviews in March through August 2019 with purposively sampled patients (aged ≥70 years, CKD stages 4-5, nondialysis), care partners, and clinicians at clinics in across the United States, participants described discussions, factors contributing to ACP completion or avoidance, and perceived value of ACP. We used thematic analysis to analyze data. RESULTS: We conducted 68 semistructured interviews with 23 patients, 19 care partners, and 26 clinicians. Only seven of 26 (27%) clinicians routinely discussed ACP. About half of the patients had documented ACP, mostly outside the health care system. We found divergent ACP definitions and perspectives; kidney clinicians largely defined ACP as completion of formal documentation, whereas patients viewed it more holistically, wanting discussions about goals, prognosis, and disease trajectory. Clinicians avoided ACP with patients from minority groups, perceiving cultural or religious barriers. Four themes and subthemes informing variation in decisions to discuss ACP and approaches emerged: (1) role ambiguity and responsibility for ACP, (2) questioning the value of ACP, (3) confronting institutional barriers (time, training, reimbursement, and the electronic medical record, EMR), and (4) consequences of avoiding ACP (disparities in ACP access and overconfidence that patients' wishes are known). CONCLUSIONS: Patients, care partners, and clinicians hold discordant views about the responsibility for discussing ACP and the scope for it. This presents critical barriers to the process, leaving ACP insufficiently discussed with older adults with advanced CKD.

Synergy between the pay-for-performance scheme and better physician-patient relationship might reduce the risk of retinopathy in patients with type 2 diabetes.

AIMS/INTRODUCTION: This study investigated whether participation by patients with type 2 diabetes in Taiwan's pay-for-performance (P4P) program and maintaining good continuity of care (COC) with their healthcare provider reduced the likelihood of future complications, such as retinopathy. MATERIALS AND METHODS: The analysis used longitudinal panel data for newly diagnosed type 2 diabetes from the National Health Insurance claims database in Taiwan. COC was measured annually from 2003 to 2013, and was used to allocate the patients to low, medium and high groups. Cox regression analysis was used with time-dependent (time-varying) covariates in a reduced model (with only P4P or COC), and the full model was adjusted with other covariates. RESULTS: Despite the same significant effects of treatment at primary care, the Diabetes Complications Severity Index scores were significantly associated with the development of retinopathy. After adjusting for these, the hazard ratios for developing retinopathy among P4P participants in the low, medium and high COC groups were 0.594 (95% confidence interval [CI] 0.398-0.898, P = 0.012), 0.676 (95% CI 0.520-0.867, P = 0.0026) and 0.802 (95% CI 0.603-1.030, P = 0.1062), respectively. Thus, patients with low or median COC who participated in the P4P program had a significantly lower risk of retinopathy than those who did not. CONCLUSIONS: Diabetes care requires a long-term relationship between patients and their care providers. Besides encouraging patients to participate in P4P programs, health authorities should provide more incentives for providers or patients to regularly survey patients' lipid profiles and glucose levels, and reward the better interpersonal relationship to prevent retinopathy.

Factors influencing Australian chiropractors who choose not to join national professional associations: a qualitative study.

BACKGROUND: Professional associations (PAs) are perceived to promote their professions and support their members. Despite these advantages, about 1 in 3 Australian chiropractors choose not to belong to either of the two PAs. Our study had two objectives: 1) to explore the views of non-member chiropractors about PAs in general; 2) seek to understand the motivations of non-member Australian chiropractors about not joining a PA. METHODS: This qualitative descriptive study utilised in-depth semi-structured interviews with open-ended questions for thematic analysis and was conducted from January to April 2020. Nine participants were interviewed before no new themes were articulated. Participants had to be registered chiropractors who had not been members of a PA for at least three years. Recruitment was through a Facebook advertisement and snowball sampling. Interviews were transcribed and imported into NVivo qualitative analysis software, allowing identification of key concepts surrounding non-membership of chiropractic PAs. RESULTS: Five themes were identified. 1) A tarnished image, suggested the profession has a poor standing in the eyes of the public and other health professionals. 2) Not worth the money, expressed the annual membership dues were not viewed as good value for money. 3) Going it alone / what's in it for me? indicated there was no direct benefit or anything deemed essential for practice. 4) Two warring factions, reflected not wanting to be seen to be part of the internal conflict between conservative and evidence-based practitioners. 5) Lack of visibility, described no visible presence or strong communication that clearly displayed the advantages of membership. CONCLUSIONS: Non-members are looking for PAs to enhance the respectability of the profession in a manner that ultimately results in increased patient volume and the provision of readily accessible day-to-day resources and information. These results can inform the construction of a survey for the broader chiropractic non-membership community to confirm and expand upon these findings and potentially improve PAs.

Dilemmas Within the Korean Health Insurance System.

The health insurance system in Korea is well-established and provides benefits for the entire national population. In Korea, when patients are treated at a hospital, the hospital receives a partial payment for the treatment from the patient, and the remaining amount is provided by the health insurance service. The Health Insurance Review and Assessment Service (HIRA) assesses whether the treatment was appropriate. If HIRA deems the treatment appropriate, the doctor can receive payment from the health insurance service. However, this system has several drawbacks. In this study, we aimed to provide examples of the problems that can occur in relation to HIRA assessments in Korea through actual clinical cases.

Effect of Financial Bonus Size, Loss Aversion, and Increased Social Pressure on Physician Pay-for-Performance: A Randomized Clinical Trial and Cohort Study.

Importance: Despite limited effectiveness of pay-for-performance (P4P), payers continue to expand P4P nationally. Objective: To test whether increasing bonus size or adding the behavioral economic principles of increased social pressure (ISP) or loss aversion (LA) improves the effectiveness of P4P. Design, Setting, and Participants: Parallel studies conducted from January 1 to December 31, 2016, consisted of a randomized clinical trial with patients cluster-randomized by practice site to an active control group (larger bonus size [LBS] only) or to groups with 1 of 2 behavioral economic interventions added and a cohort study comparing changes in outcomes among patients of physicians receiving an LBS with outcomes in propensity-matched physicians not receiving an LBS. A total of 8118 patients attributed to 66 physicians with 1 of 5 chronic conditions were treated at Advocate HealthCare, an integrated health system in Illinois. Data were analyzed using intention to treat and multiple imputation from February 1, 2017, through May 31, 2018. Interventions: Physician participants received an LBS increased by a mean of $3355 per physician (LBS-only group); prefunded incentives to elicit LA and an LBS; or increasing proportion of a P4P bonus determined by group performance from 30% to 50% (ISP) and an LBS. Main Outcomes and Measures: The proportion of 20 evidence-based quality measures achieved at the patient level. Results: A total of 86 physicians were eligible for the randomized trial. Of these, 32 were excluded because they did not have unique attributed patients. Fifty-four physicians were randomly assigned to 1 of 3 groups, and 33 physicians (54.5% male; mean [SD] age, 57 [10] years) and 3747 patients (63.6% female; mean [SD] age, 64 [18] years) were included in the final analysis. Nine physicians and 864 patients were randomized to the LBS-only group, 13 physicians and 1496 patients to the LBS plus ISP group, and 11 physicians and 1387 patients to the LBS plus LA group. Physician characteristics did not differ significantly by arm, such as mean (SD) physician age ranging from 56 (9) to 59 (9) years, and sex (6 [46.2%] to 6 [66.7%] male). No differences were found between the LBS-only and the intervention groups (adjusted odds ratio [aOR] for LBS plus LA vs LBS-only, 0.86 [95% CI, 0.65-1.15; P = .31]; aOR for LBS plus ISP vs LBS-only, 0.95 [95% CI, 0.64-1.42; P = .81]; and aOR for LBS plus ISP vs LBS plus LA, 1.10 [95% CI, 0.75-1.61; P = .62]). Increased bonus size was associated with a greater increase in evidence-based care relative to the comparison group (risk-standardized absolute difference-in-differences, 3.2 percentage points; 95% CI, 1.9-4.5 percentage points; P < .001). Conclusions and Relevance: Increased bonus size was associated with significantly improved quality of care relative to a comparison group. Adding ISP and opportunities for LA did not improve quality. Trial Registration: ClinicalTrials.gov Identifier: NCT02634879.

Revenue of consultant physicians for private out-patient consultations.

Objective The aim of this study was to determine the revenue to consultant physicians for private out-patient consultations. Specifically, the study determined changing patterns in revenue from 2011 to 2015 after accounting for bulk-billing rates, changes in gap fees and inflation. Methods An analysis was performed of consultant physician Medicare claims data from 2011 to 2015 for initial (Item 110) and subsequent (Item 116) consultations and, for patients with multiple morbidities, initial management planning (Item 132) and review consultations (Item 133). The analysis included 12 medical specialties representative of common adult non-surgical medical care. Revenue to consultant physicians was calculated for initial consultations (Item 110: standard; Item 132: complex) and subsequent consultations (Item 116: standard; Item 133: complex) accounting for bulk-billing rates, changes in gap fees and inflation. Results From 2011 to 2015, there was a decrease in inflation-adjusted revenue from standard initial and subsequent consultations (mean -$2.69 and -$1.03 respectively). Accounting for an increase in the use of item codes for complex consultations over the same time period, overall revenue from initial consultations increased (mean +$2.30) and overall revenue from subsequent consultations decreased slightly (mean -$0.28). All values reported are in Australian dollars. Conclusions The effect of the multiyear Medicare freeze on consultant physician revenue has been partially offset by changes in billing practices. What is known about the topic? There was a 'freeze' on Medicare schedule fees for consultations from November 2012 to July 2018. Concerns were expressed that the schedule has not kept pace with inflation and does not represent appropriate payments to physicians. What does this paper add? Accounting for bulk-billing, changes in gap fees and inflation, revenue from standard initial and subsequent consultations decreased from 2011 to 2015. Use of item codes for complex consultations (which have associated higher schedule fees) increased from 2011 to 2015. When standard and complex consultation codes are analysed together (and accounting for bulk-billing, changes in gap fees and inflation), revenue from initial consultations increased and revenue from subsequent consultations decreased slightly. What are the implications for practitioners? Efforts to control government expenditure through Medicare rebate payment freezes may result in unintended consequences. Although there were no overall decreases in bulk-billing rates, the shift to higher-rebate consultations was noticeable.

Doctors and Canadian Medicare: Improving Accountability and Performance.

Physician compensation has been a rapidly growing segment of healthcare costs in Canada since the late 1990s. In comparative terms, Canadian physicians are now well compensated compared to physicians in other high-income countries. This has caused provincial governments to begin constraining physician remuneration. However, physician payment should be examined in a larger governance context, including the potentially changing role of physicians, as provincial governments try to improve quality, increase coordination and improve overall health system performance. Although limited progress has been made through primary care reforms in a few jurisdictions, substantive improvement has been hampered by a misalignment between the policy goals and intentions of provincial governments and existing governance and accountability structures. This creates an environment in which both administrators and physicians feel they have limited input or control, seeding an adversarial rather than a collaborative relationship. Effective reform will require addressing governance and accountability at the same time as physician payment.

Profit efficiency of physician practices: a stochastic frontier approach using panel data.

While determinants of efficiency have been the subject of a large number of studies in the inpatient sector, relatively little is known about factors influencing efficiency of physician practices in the outpatient sector. With our study, we provide the first paper to estimate physician practice profit efficiency and its' determinants. We base our analysis on a unique panel data set of 4964 physician practices for the years 2008 to 2010. The data contains information on practice costs and revenues, services provided, as well as physician and practice characteristics. We specify the profit function of the physician practice as a translog functional form. We estimated the stochastic frontier using the comprehensive one-step approach for panel data of Battese and Coelli (1995). For estimation of the profit function, we regressed yearly profit on several inputs, outputs and input/output price relationships, while we controlled for a range of control variables such as patients' case-mix or share of patients covered by statutory health insurance. We find that participation in disease management programs and the degree of physician practice specialization are associated with significantly higher profit efficiency. In addition, our analyses show that group practices perform significantly better than single practices.

Vertical Integration of Hospitals and Physicians: Economic Theory and Empirical Evidence on Spending and Quality.

Hospital-physician vertical integration is on the rise. While increased efficiencies may be possible, emerging research raises concerns about anticompetitive behavior, spending increases, and uncertain effects on quality. In this review, we bring together several of the key theories of vertical integration that exist in the neoclassical and institutional economics literatures and apply these theories to the hospital-physician relationship. We also conduct a literature review of the effects of vertical integration on prices, spending, and quality in the growing body of evidence ( n = 15) to evaluate which of these frameworks have the strongest empirical support. We find some support for vertical foreclosure as a framework for explaining the observed results. We suggest a conceptual model and identify directions for future research. Based on our analysis, we conclude that vertical integration poses a threat to the affordability of health services and merits special attention from policymakers and antitrust authorities.

Management of Cancer Cachexia and Guidelines Implementation in a Comprehensive Cancer Center: A Physician-Led Cancer Nutrition Program Adapted to the Practices of a Country.

CONTEXT: Cancer-associated cachexia is correlated with survival, side-effects, and alteration of the patients' well-being. OBJECTIVES: We implemented an institution-wide multidisciplinary supportive care team, a Cancer Nutrition Program (CNP), to screen and manage cachexia in accordance with the guidelines and evaluated the impact of this new organization on nutritional care and funding. METHODS: We estimated the workload associated with nutrition assessment and cachexia-related interventions and audited our clinical practice. We then planned, implemented, and evaluated the CNP, focusing on cachexia. RESULTS: The audit showed a 70% prevalence of unscreened cachexia. Parenteral nutrition was prescribed to patients who did not meet the guideline criteria in 65% cases. From January 2009 to December 2011, the CNP team screened 3078 inpatients. The screened/total inpatient visits ratio was 87%, 80%, and 77% in 2009, 2010, and 2011, respectively. Cachexia was reported in 74.5% (n = 2253) patients, of which 94.4% (n = 1891) required dietary counseling. Over three years, the number of patients with artificial nutrition significantly decreased by 57.3% (P < 0.001), and the qualitative inpatients enteral/parenteral ratio significantly increased: 0.41 in 2009, 0.74 in 2010, and 1.52 in 2011. Between 2009 and 2011, the CNP costs decreased significantly for inpatients nutritional care from 528,895€ to 242,272€, thus financing the nutritional team (182,520€ per year). CONCLUSION: Our results highlight the great benefits of implementing nutritional guidelines through a physician-led multidisciplinary team in charge of nutritional care in a comprehensive cancer center.

Difference in R01 Grant Funding Among Osteopathic and Allopathic Emergency Physicians over the Last Decade.

INTRODUCTION: Receiving an R01 grant from the National Institutes of Health (NIH) is regarded as a major accomplishment for the physician researcher and can be used as a means of scholarly activity for core faculty in emergency medicine (EM). However, the Accreditation Council for Graduate Medical Education requires that a grant must be obtained for it to count towards a core faculty member's scholarly activity, while the American Osteopathic Association states that an application for a grant would qualify for scholarly activity whether it is received or not. The aim of the study was to determine if a medical degree disparity exists between those who successfully receive an EM R01 grant and those who do not, and to determine the publication characteristics of those recipients. METHODS: We queried the NIH RePORTER search engine for those physicians who received an R01 grant in EM. Degree designation was then determined for each grant recipient based on a web-based search involving the recipient's name and the location where the grant was awarded. The grant recipient was then queried through PubMed central for the total number of publications published in the decade prior to receiving the grant. RESULTS: We noted a total of 264 R01 grant recipients during the study period; of those who received the award, 78.03% were allopathic physicians. No osteopathic physician had received an R01 grant in EM over the past 10 years. Of those allopathic physicians who received the grant, 44.17% held a dual degree. Allopathic physicians had an average of 48.05 publications over the 10 years prior to grant receipt and those with a dual degree had 51.62 publications. CONCLUSION: Allopathic physicians comprise the majority of those who have received an R01 grant in EM over the last decade. These physicians typically have numerous prior publications and an advanced degree.

The impact of provider consolidation on physician prices.

When a clinic system is acquired by an integrated delivery system (IDS), the ownership change includes both vertical integration with the hospital(s), and horizontal integration with the IDS's previously owned or "legacy" clinics, causing increased market concentration in physician services. Although there is a robust literature on the impact of hospital market concentration, the literature on physician market concentration is sparse. The objective of this study is to determine the impact on physician prices when two IDSs acquired three multispecialty clinic systems in Minneapolis-St Paul, Minnesota at the end of 2007, using commercial claims data from a large health plan (2006-2011). Using a difference-in-differences model and nonacquired clinics as controls, we found that four years after the acquisitions (2011), average physician price indices in the acquired clinic systems were 32-47% higher than expected in absence of the acquisitions. Average physician prices in the IDS legacy clinics were 14-20% higher in 2011 than expected. Procedure-specific prices for common office visit and inpatient procedures also increased following the acquisitions.

Types and Distribution of Payments From Industry to Physicians in 2015.

IMPORTANCE: Given scrutiny over financial conflicts of interest in health care, it is important to understand the types and distribution of industry-related payments to physicians. OBJECTIVE: To determine the types and distribution of industry-related payments to physicians in 2015 and the association of physician specialty and sex with receipt of payments from industry. DESIGN, SETTING, AND PARTICIPANTS: Observational, retrospective, population-based study of licensed US physicians (per National Plan & Provider Enumeration System) linked to 2015 Open Payments reports of industry payments. A total of 933 295 allopathic and osteopathic physicians. Outcomes were compared across specialties (surgery, primary care, specialists, interventionalists) and between 620 166 male (66.4%) and 313 129 female (33.6%) physicians using regression models adjusting for geographic Medicare-spending region and sole proprietorship. EXPOSURES: Physician specialty and sex. MAIN OUTCOMES AND MEASURES: Reported physician payment from industry (including nature, number, and value), categorized as general payments (including consulting fees and food and beverage), ownership interests (including stock options, partnership shares), royalty or license payments, and research payments. Associations between physician characteristics and reported receipt of payment. RESULTS: In 2015, 449 864 of 933 295 physicians (133 842 [29.8%] women), representing approximately 48% of all US physicians were reported to have received $2.4 billion in industry payments, including approximately $1.8 billion for general payments, $544 million for ownership interests, and $75 million for research payments. Compared with 47.7% of primary care physicians (205 830 of 431 819), 61.0% of surgeons (110 604 of 181 372) were reported as receiving general payments (absolute difference, 13.3%; 95% CI, 13.1-13.6; odds ratio [OR], 1.72; P < .001). Surgeons had a mean per-physician reported payment value of $6879 (95% CI, $5895-$7862) vs $2227 (95% CI, $2141-$2314) among primary care physicians (absolute difference, $4651; 95% CI, $4014-$5288). After adjusting for geographic spending region and sole proprietorship, men within each specialty had a higher odds of receiving general payments than did women: surgery, 62.5% vs 56.5% (OR, 1.28; 95% CI, 1.26-1.31); primary care, 50.9% vs 43.0% (OR, 1.38; 95% CI, 1.36-1.39); specialists, 36.3% vs 33.4% (OR, 1.15; 95% CI, 1.13-1.17); and interventionalists, 58.1% vs 40.7% (OR, 2.03; 95% CI, 1.97-2.10; P < .001 for all tests). Similarly, men reportedly received more royalty or license payments than did women: surgery, 1.2% vs 0.03% (OR, 43.20; 95% CI, 25.02-74.57); primary care, 0.02% vs 0.002% (OR, 9.34; 95% CI, 4.11-21.23); specialists, 0.08% vs 0.01% (OR, 3.67; 95% CI, 1.71-7.89); and for interventionalists, 0.13% vs 0.04% (OR, 7.98; 95% CI, 2.87-22.19; P < .001 for all tests). CONCLUSIONS AND RELEVANCE: According to data from 2015 Open Payments reports, 48% of physicians were reported to have received a total of $2.4 billion in industry-related payments, primarily general payments, with a higher likelihood and higher value of payments to physicians in surgical vs primary care specialties and to male vs female physicians.

How vertical integration affects the quantity and cost of care for Medicare beneficiaries.

Health systems are employing physicians in growing numbers. The implications of this trend are poorly understood and controversial. We use rich data from the Centers for Medicare and Medicaid Services to examine the effects of a set of physician acquisitions by hospital systems on outpatient utilization and spending. We find that financial integration systematically produces economically large changes in the acquired physicians' behavior, but has less consistent effects at the acquiring system level.

Understanding Health Workers' Job Preferences to Improve Rural Retention in Timor-Leste: Findings from a Discrete Choice Experiment.

BACKGROUND: Timor-Leste built its health workforce up from extremely low levels after its war of independence, with the assistance of Cuban training, but faces challenges as the first cohorts of doctors will shortly be freed from their contracts with government. Retaining doctors, nurses and midwives in remote areas requires a good understanding of health worker preferences. METHODS: The article reports on a discrete choice experiment (DCE) carried out amongst 441 health workers, including 173 doctors, 150 nurses and 118 midwives. Qualitative methods were conducted during the design phase. The attributes which emerged were wages, skills upgrading/specialisation, location, working conditions, transportation and housing. FINDINGS: One of the main findings of the study is the relative lack of importance of wages for doctors, which could be linked to high intrinsic motivation, perceptions of having an already highly paid job (relative to local conditions), and/or being in a relatively early stage of their career for most respondents. Professional development provides the highest satisfaction with jobs, followed by the working conditions. Doctors with less experience, males and the unmarried are more flexible about location. For nurses and midwives, skill upgrading emerged as the most cost effective method. CONCLUSIONS: The study is the first of its kind conducted in Timor-Leste. It provides policy-relevant information to balance financial and non-financial incentives for different cadres and profiles of staff. It also augments a thin literature on the preferences of working doctors (as opposed to medical students) in low and middle income countries and provides insights into the ability to instil motivation to work in rural areas, which may be influenced by rural recruitment and Cuban-style training, with its emphasis on community service.

Keeping the doctor in the loop: Ayurvedic pharmaceuticals in Kerala.

Ethnographic inquiry into Ayurvedic commodification in Kerala revealed the prevalence of a distinct regional pharmaceutical market dominated by physician-manufacturers, oriented towards supplying classical medicines to Ayurvedic doctors. This stands in sharp contrast to mainstream Ayurveda that is observed to have undergone biomedicalization and pharmaceuticalization. This paper argues that Kerala's classical-medicine-centric pharmaceutical market constitutes an alternative modernity because it provided Kerala Ayurveda with a different route to modernization impervious to the biomedical regime, as well as endowing it with the institutional power to safeguard its regional identity. Although physician-entrepreneurs are its key architects, it is sustained by value regimes shaped by a unique regional medico-cultural milieu. Even when industrially produced, classical medicines remain embedded within Ayurveda's socio-technical network; unlike proprietary drugs sold as individual product-identities through non-Ayurvedic channels, they travel together as a pharmacopeia, distributed through exclusive doctor-mediated agencies. This clinic-centric distribution format is best conceptualized as an open-source business model as it made low-margin generics viable by packaging them with therapies and services. Besides ensuring better access and affordability, it provided resistance to pharmaceuticalization and intellectual property concentration. By keeping the doctor in the loop, it prevented medicines from degenerating into de-contextualized commodities; the service component of Ayurveda therein preserved went on become the unique selling point in the health-tourism market. The tourism-inspired proliferation of Brand Kerala eventually triggered a paradigm shift in mainstream Ayurveda - shifting focus from 'pharmaceuticals' to 'services' and from 'illness' to 'wellness'. Furthermore, interacting with hybrid Ayurvedas in transnational markets, Kerala Ayurveda co-produces new alterities countervailing the structurally dominant biomedical paradigm.

Variations in Patterns of Utilization and Charges for the Care of Headache in North Carolina, 2000-2009: A Statewide Claims' Data Analysis.

OBJECTIVES: The purpose of the study was to compare patterns of utilization and charges generated by medical doctors (MDs), doctors of chiropractic (DCs), and physical therapists (PTs) for the treatment of headache in North Carolina. METHODS: Retrospective analysis of claims data from the North Carolina State Health Plan for Teachers and State Employees from 2000 to 2009. Data were extracted from Blue Cross Blue Shield of North Carolina for the North Carolina State Health Plan using International Classification of Diseases, Ninth Revision, diagnostic codes for headache. The claims were separated by individual provider type, combination of provider types, and referral patterns. RESULTS: The majority of patients and claims were in the MD-only or MD plus referral patterns. Chiropractic patterns represented less than 10% of patients. Care patterns with single-provider types and no referrals incurred the least charges on average for headache. When care did not include referral providers or services, MD with DC care was generally less expensive than MD care with PT. However, when combined with referral care, MD care with PT was generally less expensive. Compared with MD-only care, risk-adjusted charges (available 2006-2009) for patients in the middle risk quintile were significantly less for DC-only care. CONCLUSIONS: Utilization and expenditures for headache treatment increased from 2000 to 2009 across all provider groups. MD care represented the majority of total allowed charges in this study. MD care and DC care, alone or in combination, were overall the least expensive patterns of headache care. Risk-adjusted charges were significantly less for DC-only care.

Variations in Patterns of Utilization and Charges for the Care of Neck Pain in North Carolina, 2000 to 2009: A Statewide Claims' Data Analysis.

OBJECTIVES: The purpose of the study was to compare utilization and charges generated by medical doctors (MD), doctors of chiropractic (DC) and physical therapists (PT) by provider patterns of care for the treatment of neck pain in North Carolina. METHODS: This was an analysis of neck-pain-related closed claim data from the North Carolina State Health Plan for Teachers and State Employees (NCSHP) from 2000 to 2009. Data were extracted from Blue Cross Blue Shield of North Carolina for the NCSHP using ICD-9 diagnostic codes for uncomplicated neck pain (UNP) and complicated neck pain (CNP). RESULTS: Care patterns with single-provider types and no referrals incurred the least average charges for both UNP and CNP. When care did not include referral providers or services, for either UNP or CNP, MD care with PT was generally less expensive than MD care with DC care. However, when care involved referral providers or services, MD and PT care was on average more expensive than MD and DC care for either UNP or CNP. Risk-adjusted charges for patients in the middle quintile of risk (available 2006-2009) were lower for chiropractic patients with or without medical care or referral care to other providers. CONCLUSIONS: Chiropractic care alone or DC with MD care incurred appreciably fewer charges for UNP or CNP compared to MD care with or without PT care, when care included referral providers or services. This finding was reversed when care did not include referral providers or services. Risk-adjusted charges for UNP and CNP patients were lower for DC care patterns.