1. “Chiropractic” Can chiropractic physicians be better utilized as viable solutions to help contain and lower workers’ compensation costs?

2. the problems. First, let’s explore the problems. What is the financial impact of drugs, surgery, medical errors and pain management/PT, and hospital-based care?

3. Overview: Four main challenges and failures. 1. Drugs: Between 1998 and 2003 drug usage skyrocketed from $47 million to over $139 million, with LESS claims in the system. 2. Surgery: is largely out of control and ineffective. 3. Administrative costs: skyrocketed due to denial-minded consultants who are often actually violating state law (fraud). Chiropractic patients particularly hit hard. 4. Case Management: Too much time spent on reviewing all cases instead of the 10% that drive the greatest costs.

4. Cost Drivers: Drugs, surgery, hospital-based care/PT Statistics: Drugs use skyrocketed from 1998 thru 2003. $59 million to $139 million, with LESS claims in the system, at the same time Chiropractic care was basically under assault regarding chronic pain management. Result: drug addiction, no improvement in RTW.

5. http://journals.lww.com/spinejournal/pages/articleviewer.aspx?year=2009&issue=04010&article=00018&type=abstract

6. Surgery: Ohio BWC Data Long-term Outcomes of Lumbar Fusion Among Workers’ Compensation Subjects. An Historical Cohort Study. Nguyen, Randolph et al. SPINE ©2010

7. Surgery: Ohio BWC Data Results. Two years after fusion surgery:  26% had RTW,  67% of nonsurgical controls had RTW within 2 years from the date of injury.  Reoperation rate was 27% for surgical patients.  Of the lumbar fusion subjects, 36% had complications.  Permanent disability rates were 11% for surgical cases and  2% for nonoperative controls  Seventeen surgical patients and 11 controls died by the end of the study  For lumbar fusion subjects, daily opioid use increased 41% after surgery.  With 76% of cases continuing opioid use after surgery.

8. Surgery: Ohio BWC Data Results. Two years after fusion surgery:  Total number of days off work was more prolonged for cases compared to controls, 1140 and 316 days, respectively Conclusion. This Lumbar fusion for the diagnoses of disc degeneration, disc herniation, and/or radiculopathy in a WC setting is associated with significant increase in disability, opiate use, prolonged work loss, and poor RTW status.

9. Brand Names VioxxAdvil CelebrexMotrin Voltaren

10. http://journals.lww.com/spinejournal/pages/articleviewer.aspx?year=2009&issue=04010&article=00017&type=abstract

11. Executive Order 2010 – 4S Establishing the Ohio Prescription Drug Abuse Task Force

12. Prescription drug abuse is a national public health problem. Prescription drug abuse is a national public health problem. admissions “The Substance Abuse and Mental Health Services Administration reported that the number of admissions for substance abuse treatment for prescription drugs increased by 141% from 1998 to 2006.”

13. Executive Order 2010 – 4S Establishing the Ohio Prescription Drug Abuse Task Force Ohio’s prescription drug abuse problem is an epidemic. Ohio’s prescription drug abuse problem is an epidemic. Ohio’s death rate due to unintentional drug poisonings increased more than 300 percent Prescription opioids are associated with more overdoses than any other prescription or illegal drug, including cocaine and heroin.” “In 2007, unintentional drug poisoning became the leading cause of injury death in Ohio, surpassing motor vehicle crashes and suicide for the first time on record. From 1999 to 2007, Ohio’s death rate due to unintentional drug poisonings increased more than 300 percent. The increase in deaths has been driven largely by prescription drug overdoses caused by opioids (pain medications). Prescription opioids are associated with more overdoses than any other prescription or illegal drug, including cocaine and heroin.”

14. Executive Order 2010 – 4S Establishing the Ohio Prescription Drug Abuse Task Force Ohio needs a more coordinated, multi- disciplinary, multi-jurisdictional approach to the problem of prescription drug abuse. Ohio needs a more coordinated, multi- disciplinary, multi-jurisdictional approach to the problem of prescription drug abuse. ” “Too many Ohioans have lost their lives or have been impacted by the devastating effects of addiction because of abuse and diversion of prescription drugs. ”

15. The Solution… Given the following cost-effectiveness studies, it is clear that Chiropractic physicians should be utilized much earlier and in greater frequency in an effort to lower cost, improve RTW and prevent disability. Why?

17. Chiropractic: A solution for chronic pain sufferers. Consider the alternatives: Chiropractic is the “obvious choice”.Options: 1. MD/Drugs…ineffective, and costly. 2. Orthopedic surgeon: $350 to walk thru the door. 3. Pain Management: Same as surgeon, plus high cost injections and invasive procedures. 4. Physical therapy…excessive treatment and costs.

18. Chiropractic: A solution for chronic pain sufferers. OR, one can visit a DC: Spinal manipulation and one therapy: $65 Spinal manipulation and one therapy: $65 Instead of allowing this low cost treatment, the system often spends thousands of dollars in denial/appeals, hearing, IMEs, etc. Result: Result: Forces patients into medical directed care: higher costs, invasive and dangerous, less effective.

19. Guidelines: All recommend DC care for both acute and chronic pain. Council on Chiropractic Guidelines and Practice Parameters (CCGPP): Acute and chronic spine pain Official Disability Guidelines (ODG) American College of Physicians and American Pain Society

20. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society 2 October 2007 | Volume 147 Issue 7 | Pages 478-491 acute spinal manipulationchronic or subacute interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation Recommendation 7: For patients who do not improve with self-care options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits—for acute low back pain, spinal manipulation; for chronic or subacute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation, moderate- quality)

21. Official Disability Guidelines Recommended for chronic pain if caused by musculoskeletal conditions, and manipulation is specifically recommended as an option in the Low Back Chapter and the Neck Chapter.Low Back ChapterNeck Chapter

22. Official Disability Guidelines “The latest project completed by the Council on Chiropractic Guidelines and Practice Parameters (CCGPP) addresses chiropractic management of the chronic pain patient. The CCGPP guideline provides clear case management suggestions and dosing recommendations when confronted with the patient suffering ongoing chronic pain after treatments that exceed ODG recommendations. Chiropractic management may be more beneficial, safer, and rendered at much lower costs, compared to narcotics or invasive medical procedures to control chronic pain. (Farabaugh, 2010)”Farabaugh, 2010

23. The elephant in the room… What are the goals of care provided by DCs once a patient has reached a plateau in care (MTB)? Minimize lost time on the job Support patient's current level of function/ADL Pain control/relief to tolerance Minimize further disability Minimize exacerbation frequency and severity Maximize patient satisfaction Reduce and/or minimize reliance on medication

24. Cost Effectiveness Studies A quick view of several of the most recent studies.

25. Health maintenance care in work-related low back pain and its association with disability recurrence. Cifuentes M, Willetts J, Wasiak R. J Occup Environ Med. 2011 Apr;53(4):396-404. OBJECTIVES: To compare occurrence of repeated disability episodes across types of health care providers who treat claimants with new episodes of work- related low back pain (LBP). CONCLUSIONS: the use of health maintenance care provided by physical therapist or physician services was associated with a higher disability recurrence than in chiropractic services In work-related nonspecific LBP, the use of health maintenance care provided by physical therapist or physician services was associated with a higher disability recurrence than in chiropractic services or no treatment.

26. The Chiropractic Hospital-based Interventions Research Outcomes (CHIRO) study: a randomized controlled trial on the effectiveness of clinical practice guidelines in the medical and chiropractic management of patients with acute mechanical low back pain. Bishop et al. Spine J. 2010 Dec;10(12):1055-64. CONCLUSIONS: This is the first reported randomized controlled trial comparing full CPG-based treatment, including spinal manipulative therapy administered by chiropractors, to family physician-directed UC in the treatment of patients with AM-LBP. Compared to family physician-directed UC, full CPG-based treatment including CSMT is associated with significantly greater improvement in condition-specific functioning.

27. Does maintained Spinal manipulation therapy for chronic non-specific low back pain result in better long term outcome? Senna et al. Rheumatology and Rehabilitation Department, Mansoura Faculty of Medicine, Mansoura University. Spine (Phila Pa 1976). 2011 Jan 17. Subjects and Methods. 60 patients with chronic, nonspecific LBP lasting at least 6 months were randomized to receive either (1) 12 treatments of sham SMT over a one-month period, (2) 12 treatments, consisting of SMT over a one-month period, but no treatments for the subsequent nine months, or (3) 12 treatments over a one-month period, along with "maintenance spinal manipulation" every two weeks for the following nine months.

28. Does maintained Spinal manipulation therapy for chronic non-specific low back pain result in better long term outcome? (Cont’d) this study suggests maintenance spinal manipulations after the initial intensive manipulative therapy. Conclusion. SMT is effective for the treatment of chronic non specific LBP. To obtain long-term benefit, this study suggests maintenance spinal manipulations after the initial intensive manipulative therapy.

30. Blue Cross/Blue Shield: Wellmark Announces Results of Physical Medicine Pilot on Quality. 2009 The Wellmark Blue Cross and Blue Shield 2008 pilot was a quality improvement program for Iowa and South Dakota physical medicine providers. A total of 238 chiropractors, physical therapists, and occupational therapists participated in the pilot, submitting information on the care provided to 5500 Wellmark members with musculoskeletal disorders.

31. Blue Cross/Blue Shield: Wellmark Announces Results of Physical Medicine Pilot on Quality. 2009 The comparison showed that those who received chiropractic or physical therapy care were less likely to have surgery and experienced lower total health care costs.

32. Mercer/Harvard Study 2009 by Choudhray and Milstein Do Chiropractic Physician Services for Treatment of Low Back and Neck Pain Improve the Value of Health Benefits Plans. An Evidence-based Assessment of Incremental Impact of Population and Total Health Care Spending

33. Mercer/Harvard Study (cont’d) Effectiveness: Chiropractic care is more effective than other modalities for treating low back and neck pain. is highly cost effective Cost Effectiveness: When considering the effectiveness and cost together DC care for low back and neck pain is highly cost effective, and represents a good value in comparison to medical physician care and to widely accepted cost- effectiveness thresholds.

34. Mercer/Harvard Study (cont’d) by improving clinical outcomes and either reducing total spending The addition of DC coverage for the treatment of LB and neck pain at prices typically payable in the US employer-sponsored health benefits plans will likely increase value-for-dollar by improving clinical outcomes and either reducing total spending (neck pain) or increase total spending (LB) by a smaller percentage than clinical outcomes improve.

35. Mercer/Harvard Study (cont’d) Interventions with cost-effectiveness ratios between $50,000 and $100,000 per QALY (quality adjusted life years) are generally considered to be cost effective. DC care….$1837!! When combined with exercise chiropractic physician care is also very cost effective compared to exercise alone.

36. CLINICAL AND COST OUTCOMES OF AN INTEGRATIVE MEDICINE IPA Sarnat, Winterstein JMPT June 2004 Results: Analysis of clinical and cost outcomes on 21,743 member months over a 4-year period demonstrated decreases of 43.0% in hospital admissions 58.4% hospital days 43.2% outpatient surgeries and procedures 51.8% pharmaceutical cost reductions when compared with normative conventional medicine IPA

37. CLINICAL UTILIZATION AND COST OUTCOMES FROM AN INTEGRATIVE MEDICINE INDEPENDENT PHYSICIAN ASSOCIATION: AN ADDITIONAL 3-YEAR UPDATE Sarnat, Winterstein, Cambron JMPT May 2007 Results: Clinical and cost utilization based on 70274 member- months over a 7-year period demonstrated decreases of 60.2% in-hospital admissions 59.0% hospital days 62.0% outpatient surgeries and procedures, and 85% pharmaceutical costs when compared with conventional medicine IPA performance for the same health maintenance organization product in the same geography and time frame.

38. Sarnat/Winterstein Study… Conclusion AMI ’ s primary care chiropractors are showing the world what the profession has always believed since its inception: Chiropractic has an ability to impact a person ’ s health in a very profound manner.

39. Muse: Utilization, Costs, and Effects of Chiropractic Care on Medicare Program Costs. 2001 The Muse study compared the most recently available CMC Medicare cost and utilization data for those beneficiaries that received chiropractic care versus those beneficiaries that only received traditional medical care. The Muse study found that the global per capita Medicare expenditures for chiropractic patients were significantly lower than the same costs for non-chiropractic patients.

40. Muse Study\Medicare (cont’d) The Muse study concluded, "Chiropractic care significantly reduces per beneficiary costs to the Medicare program. The results of the study suggests that chiropractic services could play a role in reducing costs Medicare reform and/or a new prescription drug benefit."

41. Comparative Analysis of Individuals With and Without Chiropractic Coverage Patient Characteristics, Utilization, and Costs. Legorreta, Metz, Nelson, Ray, Chernicoff, DiNubile, MD Arch Intern Med. 2004;164:1985-1992. 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). * Less total annual health care costs at the health plan level. * Lower utilization (per 1000 episodes) of plain radiographs * Less low back surgery * Less hospitalizations * Less magnetic resonance imaging. * Lower average back pain episode – related costs ($289 vs $399, P<.001).

42. “ Chiropractic Care: is it substitution care or add-on care in corporate medical plans? ” Metz, et al. J. Occupational Environmental Medicine. 2004;46:847-855. The results “ indicate that patients use chiropractic care as a direct substitute for medical care. ” 4 year study: 1997-2001 Not a survey ….used actual claims data. 1,394,070 patients; 174,209 were DC pts; 332,548 were medical pts; 887,313 were medical pts w/o DC coverage. Results: nearly half chose DC care when offered a choice. “ Within a MC setting, the inclusion of a DC benefit does not increase the overall rates of pt. complaints ….pts appear to be directly substituting DC care for medical care ”.

43. “ An Evaluation of Medical and Chiropractic Provider Utilization and Costs: Treating Injured Workers in North Carolina JMPT September 2004 Volume 27 Number 7 Phelan et al. Objective: To examine utilization, treatment costs, lost workdays, and compensation paid workers with musculoskeletal injuries treated by medical doctors (MDs) and doctors of chiropractic (DCs). Design: Retrospective review of 96,627 claims between 1975 and 1994. Results Average cost of treatment, hospitalization, and compensation payments were higher for patients treated by MDs than for patients treated by DCs. Average number of lost workdays for patients treated by MDs was higher than for those treated by DCs. Combined care patients generated higher costs than patients treated by MDs or DCs alone.

44. “ An Evaluation of Medical and Chiropractic Provider Utilization and Costs: Treating Injured Workers in North Carolina (cont’d) Conclusion: These data, with the acknowledged limitations of an insurance database, indicate lower treatment costs, less workdays lost, lower compensation payments, and lower utilization of ancillary medical services for patients treated by DCs. Despite the lower cost of chiropractic management, the use of chiropractic services in North Carolina appears very low.

45. State Specific Workers Compensation Studies NOTE: In the past managed care leaders (usually medical physicians) would flippantly dismiss the studies on DC cost effectiveness, but usually simply due to medical bias. However, given the out-of-control drug and medical costs, the time has come to consider real solutions to these main cost drivers and accept that one cannot discount such a large volume of studies all pointing in the same direction….that being chiropractic IS cost effective, safe, and supported by a large volume of literature.

46. State Specific Workers Compensation Studies There are dozens of studies from all over the US, in fact all over the world which report the same overall theme…. Chiropractic physicians can help lower costs, return patients to work and prevent disability much more efficiently than other forms of treatment. Bottom line: Chiropractic should be encouraged and promoted as an important part of integrated care, especially for complicated and chronic work-related injuries.

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