ChiroACCESS: Where the Money Is: A Case of Tracking Suspects in Reforming Healthcare Delivery

Where the Money Is: A Case of Tracking Suspects in Reforming Healthcare Delivery

This information is provided to you for use in conjunction with your clinical judgment and the specific needs of the patient.

Anthony L. Rosner, Ph.D., LL.D.[Hon.]

Published on July 6, 2009

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As everyone knows, this is a period of a major economic downturn and bailouts to major economic institutions, including our banks. With obsessions as to how safe our funds are, some have even gone so far as to revive interest in such storied bank robbers of the Depression Era, such as John Dillinger or Willie Sutton. So with apologies to Willie Sutton's infamous remark as to why he robbed banks ["Because that's where the money is"], it may be useful to reconsider the cost-effectiveness-in-healthcare delivery issue from another perspective which may tell us exactly what Mr. Sutton was driving at. In other words, where are the real mother lodes when it comes to locating healthcare dollar expenditures? And how would this relate to chiropractic care?

Rather than assume a bottoms-up approach [which has its usefulness, to be certain] in tabulating costs per service in comparing different healthcare providers, why not take a top-down approach instead in tracking those expenditures instead? Consider the following:

1. Relative Economic Burdens of Medical Conditions:

This table speaks volumes:

CONDITION	PERIOD	EXPENDITURE	SOURCE
Spine problems	2005	$85.9B	Medical Expenditure Panel Survey¹
Arthritis	2003	$80.3B	Medical Expenditure Panel Survey²
Cancer	2007	$89.0B	National Heart, Lung, and Blood Institute³
Diabetes	2002	$98.1B	Individual authors⁴
Heart Disease/Stroke	2005	$257.6B	American Heart Association⁵

When you see that spine problems rank amongst the top five conditions in terms of healthcare cost, you can immediately conclude that spine care is an issue that is hardly penny ante. Rather, it is one of the leading determinants of healthcare costs in the United States within the past several years and should immediately bring the relative merits of chiropractic care into our discussions.

2. Increasing Expenditures for Spine Problems in the U.S., 1984-2005:

Once again, a table takes top honors in conveying the most vital information in a minimum of space:

PERIOD	EXPENDITURE	SOURCE
1984	$12.9B	American Academy of Orthopedic Surgeons⁶
1997	$26.3B	Medical Expenditure Panel Survey⁷
2005	$85.9B	Medical Expenditure Panel Survey¹

What is evident is an apparent burst of expenditures for treating spine problems just within the past decade. But where are these funds going?

3. Primary Drivers of Medical Expenditures for Spine Problems:

In continuing with the bank robbery motif, let us consider a lineup of "the usual suspects" as provided by Martin and Deyo's comprehensive and informative article which appeared last year in the Journal of the American Medical Association. Here we are presented with a list of major offenders having the most impact upon medical expenditures:

a. Prescription medications, totalling $7.3B in 1995 (14% of total direct expenditures) and $19.8B in 2007,
representing 23% of total direct expenditures and a whopping 271% increase.¹b. Medical imaging and diagnostic tests.⁸
c. Spinal injections.⁹d. A lower threshold for providing treatment/higher patient expectations.¹e. Increasing use of spinal fusion surgery and instrumentation.¹⁰f. Increasing reports of comorbid conditions.¹

From this list, it is apparent that chiropractors are not anywhere near the major cost drivers which have the greatest impact upon healthcare expenditures in the United States. Rather, the finger turns toward several of the alternatives to chiropractic care.

4. Workers' Compensation Data:

The coup de grace from a macroeconomic point of view might best be offered by just one example of the workers' compensation studies available, in which disbursements have been tracked for years by the State of Georgia to medical and chiropractic physicians from 2001-2004.¹¹

CLAIM GROUP	YEAR
	2001	2002	2003	2004
A. M.D	$115,590,118	$ 98,419,180	$71,025,150	$18,786,118
Pharmacy	22,426,219	16,292,692	13,310,026	2,228,745
B. P.T.	24,696,617	22,731,637	15,669,193	4,087,587
C. D.C.	850,247	641,805	581,687	184,654
C/A (%)	0.7	0.7	0.8	1.0
C/B (%)	3.4	2.8	3.7	4.5

Here it can be seen that chiropractors received 1% or less of the funds paid to medical physicians and just 2.8-4.5% of the disbursements paid to physical therapists. Since low back pain has been proposed to represent 33% of all workers compensation costs and 16% of all workers compensation claims,¹² it is clear that chiropractic care may not represent the significant cost burden as suggested by such entities as the Workers Compensation Research Institute in their overall conclusions.^13,14Indeed, one of the major methodological concerns which compromises the data from the latter study group is that costs of providers other than chiropractors were split into separate categories, whereas all costs relating to chiropractors were bundled into a single entity.^13,14

So, in a few bold strokes, there should be a rising suspicion that chiropractic care does not appear to be among the major cost drivers that requires overhaul or micromanaging such as experienced on the part of several third party payers. To complete our analogy to bank robberies, let us instead cut to the chase and once and for all be courageous enough to capture what truly seem to be the major breaches in cost control of our hemorrhaging healthcare system. Bring them in and book them. At this time in which the Obama administration and Congress have prioritized healthcare reform, these arguments require nothing less than our most serious attention.

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References

1. Martin BI, Deyo RA, Mirza SK, Turner JA, Comstock BA, Hollingsworth W, Sullivan SD. Expenditures and health status among adults with back and neck problems. Journal of the American Medical Association 2008; 299(6): 656-664.

2. Yelin E, Murphy L, Helmick CG. Medical care expenditures and earnings losses of persons with arthritis and other rheumatic conditions in 2003 and comparisons to 1997. Arthritis and Rheumatism 2007; 56(5):1397-1407.

3. NHLBI factbook: Direct and indirect costs of illness by major diagnosis, U.S. 2006. National Heart and Lung Institute Web site. Accessed May 18, 2007. [ Full-Text Link ]

4. Hogan P, Dall T, Nikolov P. American Diabetes Association. Economic costs of diabetes in the US in 2002. Diabetes Care 2003; 26(3): 917-932.

5. American Heart Association. Heart Disease and Stroke Statistics-2005 Update. Dallas, TX: American Heart Association, 2005.

6. Grazier KL, Holbrook TL, Kelsey JL, Stauffer RN. The Frequency of Occurrence, Impact, and Cost of Selected Musculoskeletal Conditions in the United States. Chicago, IL: American Academy of Orthopedic Surgeons, 1984, pp. 72-80.

7. Luo X, Pietrobon R, Hey L. Estimates and patterns of direct health care expenditures among individuals with back pain in the United States. Spine 2004; 29(1): 79-86.

8. Weiner DK, Kim YS, Bonino P, Wang T. Low back pain in older adults: Are we utilizing healthcare resources wisely? Pain Medicine 2006; 7(2): 143-150.

9. Friedly J, Chan L, Deyo RA. Increases in lumbosacral injection in the Medicare population, 1994 to 2001. Spine 2007; 32(16): 1754-1760.

10. Deyo RA, Mirza SK. Trends and variations in the use of spine surgery. Clinical, Orthopedics and Related Research 2006; 443: 139-146.

11. http://swbc.georgia.gov/vgn/images/portal/cit_1210/21/6/12724921At_A_Glance04.pdf. [ Full-Text Link ]

12. Hooper P. Dynamic Chiropractic 1994; 12(25).

13. Eccleston SM, Zhao X. The anatomy of workers' compensation medical costs and utilization: Trends and interstate comparisons, 1996-2000. Cambridge, MA: Workmen's Compensation Research Institute WC- 03-04, 2003.

14. Victor RA, Wang W. Patterns and cost of physical medicine: Comparison of chiropractic and physician-directed care. Cambridge, MA: Workmen's Compensation Research Institute, WC-02-07, 2002.