Chiropractors are involved in only a small fraction of workers’ compensation claims for low back pain in states where insurers or employers control the choice of medical provider, but a report released this week suggests that skepticism about uncontrollable costs may be unfounded.
A Workers’ Compensation Research Institute study found that medical care costs less and claimants return to work faster when low back pain treatment is provided only by chiropractors. Costs were also lower when chiropractors provided physical medicine services but other types of clinicians were responsible for assessment and management, but the difference was not as dramatic.
“This study will be useful for policy makers and stakeholders who want to re-evaluate the role of chiropractors, especially those who have embraced evidence-based practices and contributed to cost-effective care,” said the President and CEO of WCRI, John Ruser. in a press release.
WCRI researchers examined more than 2 million claims from 28 states with injuries dating from October 1, 2015 to September 30, 2017 to compare the costs and duration of claims for workers who were treated exclusively by chiropractors to workers who received no chiropractic care and workers who received services from chiropractors and other types of providers. Claims involving serious conditions requiring immediate care, such as tumors and fractures, have been excluded.
The average medical cost per claim for low back pain patients who were treated exclusively by a chiropractor for physical medicine and assessment and management was $1,366, 61% lower than the treatment cost of $3,522 for cases of low back pain who have not received any chiropractic treatment.
Compensation costs were also lower for workers whose low back pain was treated exclusively by a chiropractor: $492 compared to $3,604 for workers who received no chiropractic treatment.
For workers who received physical medicine services from a chiropractor and assessment and management services from other types of clinicians, medical costs averaged $3,001, 15% less than workers who were not receiving chiropractic care. Claims costs averaged $2,502, or 31% less.
Injured workers treated exclusively by chiropractors also used fewer medications and diagnostic imaging tests, the report said. By comparing a subset of claims with similar characteristics, the researchers found that only 1% of claimants treated by chiropractors were prescribed opioids, compared to 10.3% of claimants who were not treated by chiropractors. . In the chiropractic group, 4.3% of claimants underwent magnetic resonance imaging, compared to 18.9% for non-chiropractic claimants.
The report cautions readers that the data provide evidence for an association between chiropractic care and the outcomes that were noted, but not a causal relationship. Researchers cannot fully account for unobserved individual and system characteristics that likely influence chiropractic care choice and outcomes, the report says.
The use of chiropractic care varied widely by state. In Minnesota, 34% of low back pain cases received chiropractic care, 285 in Wisconsin, 25% in California and 20% in New York. At the other end of the spectrum, only 1% of low back pain claims in South Carolina, Georgia, Arkansas, New Jersey and North Carolina had chiropractic care.
WCRI said these states are among 16 study group states that allow employers or insurers to control the selection of the treating clinician. None of these Employer Choice states have seen more than an average of 11% of low back pain cases with chiropractic care. In contrast, Wisconsin allows employees to choose their medical provider while California, New York and Minnesota allow limited employee screening.
The report says that rapidly rising medical costs in the early 1990s caused employers to worry about the cost-effectiveness of chiropractic care. As a result, states began to impose new rules to control costs. Colorado, for example, adopted lower back guidelines that required demonstrable functional improvement after five visits and capped the total number of visits at 36. California allows no more than 24 chiropractic visits. In Oregon, the cap is 12.
Patients outside of workers’ compensation are much more likely to seek chiropractic care for lower back pain. WCRI said a 2017 study found that in non-professional settings, 31% of patients with back pain sought care from a chiropractor within 12 months of injury. Only a few of the 28 state workers’ compensation systems studied had a similar prevalence of chiropractic care for low back pain cases.
“Without up-to-date information on chiropractic care and associated costs and outcomes, it is conceivable that some employers and insurers may still be concerned about the cost-effectiveness of chiropractic care,” the report states. “The negative perception of chiropractic care by employers and insurers may also be partly due to the fact that some chiropractors can still provide extended maintenance care without measurable benefits in function and disability.”
The study is available here.
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