Summary: Harvard’s Niteesh Choudhry, MD, PhD and Pacific Business Group on Health medical director Arnold Milstein, MD, MPH take on the most hard-fought “CAM” versus conventional question: Are the covered services of chiropractic physicians (as they are called by these researchers) in health plans for effective and cost-effective than those of medical physicians? The answers are mixed but with a very strong tilt in the direction of chiropractic, especially if the cost of drugs are factored in. There are implications here for how we belly up to the cost-effectiveness bar in other integrative practices. A health services researcher in the complementary and alternative medicine field offers a blunt comment that suggests comparative cost-effectiveness research should be at the top of our research agenda.
Harvard’s Niteesh Choudhry, MD, PhD, lead researcher
The first sentence of this report states a blunt fact of life in the United States: “Low back pain and neck pain are extremely common conditions that consume large amounts of health care resources.” Checking in with the state of one’s own back or neck places many of us with the 26% who have low back pain and 14% neck pain in a given 3 month period. Half of us with chronic low back seek chiropractic care. $85-billion a year is spent on low back pain alone.
So, is chiropractic effective and, more specifically, cost effective, compared to other care?
Two top researchers, Niteesh Choudhry, MD, PhD and Arnold Milstein, MD filed a 15-page report on October 12, 2009 which attempts to resolve that medico-political question which has rattled around US healthcare for the last 20 years since the American Medical Association was forced, by dint of the Wilk vs the AMA anti-trust lawsuit, to allow chiropractic into the public debate as something other than quackery. Choudrey is a professor in pharmacoeconomics from Harvard Medical School and Milstein a consultant with with Mercer Health and Benefits and medical director for the influential Pacific Business Group on Health. The report is prosaically titled:
Pacific Business Group on Health’s Arnold Milstein, MD, MPH co-authored the study
The team reviewed all the effectiveness literature and cost-effectiveness literature on the question. The authors analyze leading studies which have
created confusion in the United States on the issue, showing in each
case certain “methodological limitations.” For instance, a UCLA study
that concluded chiropractic was not cost-effective did not include
surgical costs. They then turn to Europe for “high-quality” cost
effectiveness studies with a randomized group. The conclusions are mixed, interesting and a teaching lesson for those
not familiar with methods in cost analysis in the real world.
- Effectiveness Chiropractic is more effective than other modalities for treating low back and neck pain.
- Total cost of care per year For low back pain, chiropractic care increases total annual per patient spending by $75 per year over “medical physician care.” For neck pain, chiropractic care reduces annual spending $302 per year compared to medical physician care. The cost of care for neck pain is lowered when chiropractic is combined with exercise (and better than exercise alone).
- Cost-effectiveness If both cost and effectiveness are considered together, chiropractic is “highly cost-effective” and “represents a good value” relative to medical physician care and “widely-accepted cost-effectiveness thresholds.” The authors then note that they were not able to incorporate data on pharmacy costs but project that, had they been able to do so, “our estimate of chiropractic’s comparative cost effectiveness is likely to be understated.”
Ultimately the audience for this report is healthcare purchasers – employers and government agencies – especially amidst the current healthcare reform debate. Choudhry and Milstein conclude: “
“Using data from high-quality, controlled (European Union) trials and contemporary US-based average unit prices payable by commercial insurers, we project that insurance coverage for chiropractic physician care for low back pain and neck pain for conditions other than fracture and malignancy is likely to drive improved cost-effectiveness of care.”
A health services researcher, who chose not to speak on the record, offered this blunt perspective on the study when contacted by the Integrator:
“I didn’t seen anything glaringly
ridiculous, so the conclusions may be reasonable. I think a good health
economist would be in a better position to comment. Finding chiropractic care
(or anything else) more cost-effective than conventional medical care is in
itself, not that impressive, given how un-cost-effective conventional medical
The study was funded by the Foundation for Chiropractic Progress, an organization established to publicize and advance positive perspectives on chiropractic. The organization recently invested $1-million in a major, Beltway-focused advertising campaign. FCER sent out an October 21, 2009 release which advertised these study outcomes.
Comment: If credibility is created by biting the hand that feeds you, this study deserves some recognition for concluding that the cost per patient for low back pain by chiropractic physicians is higher than medical physician care. This consultant’s conclusion was of course significantly softened by the over-all outcome. The study will certainly have its merits for the positioning chiropractic in healthcare reform.
This study is also instructive in other ways. First, there is the review of the limits of various methods selected in various costs studies, which leads to the dissembling and often misleading conclusion that studies of cost-effectiveness of X are conflicting. Second, the combination of higher cost but greater cost-effectiveness may be the equation that helps many therapies and practices in labor intensive (rather than drug intensive) healthcare, including complementary and alternative practices, extract the sword from the stone in the cost debate. Finally, the approach of these researchers underscores that for whole practice approaches, we are often best off to look at the whole system of cost rather than to compare modality cost versus modality cost.
One thing we know for certain after this study is that FCER will insure that policy makers and benefits purchasers know about it, and that future wanderers into the debate over chiropractic physician/medical physician costs will no0w have another report with which they’ll need to contend.
Post-script: In the context of the note in the most recent Integrator Round-up over changing terms by which the chiropractic, err, uh, chiropractic medical profession describes itself it is interesting that these researchers chose to use chiropractic physician in the comparison with medical physician services.