What Recent Claims Studies Reveal About Chiropractic Care

Doctors of chiropractic (DCs) and their patients have long known that chiropractic care delivers relief from low back pain (LBP) and neck pain while helping to reduce spending on expensive medical procedures, imaging, and drugs. A group of 4 significant studies, which all have been submitted for peer review and are currently available in their unreviewed form on the preprint server medRxiv,^1-4 further validate these doctors’ findings and patients’ experiences. The research team found when DCs are the first provider seen by an individual with LBP or neck pain they are the most likely to deliver guideline-concordant care and were associated with the lowest total episode cost of any type of health care provider. One of the most recent studies shows that no matter when a DC becomes involved in an episode of LBP, they are the type of health care provider most likely to resolve the LBP. However, DCs are often the last doctor to be consulted even though they specialize in managing neuromusculoskeletal conditions.

Among DCs, physical therapists (PTs), and licensed acupuncturists (LAcs), individuals with low back pain initially seeking treatment from a DC are most likely to receive 1 to 3 visits, are associated with the lowest total cost, and have the lowest rate of exposure to pharmaceuticals or imaging. At all levels of visit frequency, DCs delivering chiropractic manipulative therapy were associated with the lowest median episode cost compared to PTs and LAcs.

Costly Conditions and Low-Value Care

The studies were led by David Elton, DC, former VP of Musculoskeletal R&D at Optum Labs (a subsidiary of UnitedHealth Group). Across the 4 unique papers, the team utilized its massive claims database primarily to investigate the links between the type of health care provider initially contacted, service utilization, and total episode cost for management of LBP and neck pain.

Three of the studies focused on LBP because it causes the highest disease burden among musculoskeletal conditions. In 2016, for example, combined LBP and neck pain costs were estimated at $134 billion, collectively making them the most expensive medical disorders in the country, with commercial and public insurers funding more than 90% of spending.

In the US, 67% of individuals with LBP seek care annually, making it the second-most common reason for visiting a primary care provider. Neck pain also has a high prevalence and incidence, as well as high years lived with disability.

Yet, despite the prevalence of the 2 conditions, and availability of high-quality clinical practice guidelines, management of LBP and neck pain remains highly variable and a common source of low-value care. Guidelines recommend that if there are no red flags of significant pathology, care should progress from first-line, nonpharmacological, and noninterventional approaches to selective use of pharmacologic and interventional procedures if patients don’t respond to the initial approaches. First-line treatments include spinal manipulation – typically called a chiropractic adjustment -- heat, massage and acupuncture. There are fewer guidelines for treatment of neck pain, but they follow the same approach of conservative modalities first.

The Importance of Initial Health Care Provider Contact

The overriding theme across all of Dr Elton’s recent papers is that the first provider the patient visits to manage their pain can cause a significant impact on guideline adherence, additional service utilization and costs. What is missing from these papers is outcomes data, which is understandable given each study is limited to an analysis of insurer claims data and a review of earlier studies. Yet the patterns researchers discovered across hundreds and thousands of claims -- and the services that patients received when they do not receive guideline-concordant care first -- enable them to draw solid conclusions when evaluated in the context of previous research.

For all the studies, Dr Elton’s team examined different size cohorts representing a US nationwide sample of claims submitted for LBP and neck pain episodes completed from 2017 through 2019.

In the first submitted study, researchers found a medical primary care or specialist physician was initially contacted in 62% of episodes while a nonprescribing health care provider, such as a DC or PT, was initially contacted in 32.5% of episodes. Similarly, in a later study, Dr Elton’s team reported that when a DC or PT was not the first provider sought, they tended to be the fourth provider the patient visited using their health plan, which meant they received numerous other services and prescriptions during the episode. However, in 84% of LBP episodes where patients visited a DC first, they visited no other providers afterward using the health plan included in the database.

As far as care quality, the studies show nonprescribers were associated with early use of guideline-recommended, first-line services. The most frequently provided first-line services were chiropractic manipulation (40.2% of episodes), active care (21.5%) and passive therapy (18.9%). The most frequent second-line services were radiographs (26.5%), skeletal muscle relaxants (19.2%), and prescription NSAIDs (18.3%). The lowest-value and least frequent services offered were opioids (11.6%) and spinal injections (5.0%). Of the total episodes, 4.2% included spinal surgery.

Wide Cost Variation

The costs across these high- and low-value services were compared in one analysis by splitting a sample size of 616 766 patients who received surgery and 600 390 who did not. Although the surgery cohort contained only 16000 more patients than the nonsurgical, their care cost was over a half-billion dollars ($533 million) more. On a care episode basis, when a patient contacted a DC first, the median care episode cost $165, but when a neurosurgeon was contacted first, the median cost climbed to $1512.

That is because, as we learn in a study published later in the year, patients who visited a DC for one to 3 appointments had the lowest costs and used the fewest number of second- and third-line services afterward, such as pharmacological therapies or imaging. The same pattern emerged for PT and acupuncture appointments as well, but after that third appointment, costs tended to increase significantly even though patients did not utilize many second- or third-line services. Regardless of the number of visits, however, DCs delivering chiropractic manipulative therapy produced the lowest median episode cost ($194) compared to PT ($692).

The studies reinforce previous research demonstrating that the delivery of guideline-concordant management is not only less costly, but more effective and resulting in fewer cases of acute LBP and neck pain leading to chronic pain. A study published in JAMA Network Open, for example, found that of patients with acute LBP visiting medical primary care practices, half received at least one nonconcordant recommendation within the first three weeks of the first visit.⁵ Of the more than 5300 patients studied, 1544 received prescriptions for non-recommended medications, including 999 who received opioids.

Even after controlling for patient characteristics (eg, obesity) and clinical characteristics (eg, baseline disability), increasing numbers of nonconcordant management approaches increased the likelihood of having chronic LBP at 6 months.

Expanding Value-Based Care Access

Given these clinical and financial outcomes, employers, health insurers and health care policy leaders should drive systemic changes to increase the likelihood of individuals seeking and receiving guideline-concordant, high-value care for LBP and neck pain. This could mean increasing the frequency of initial contact with a DC or other nonprescribing health care provider by using incentives such as offering no out-of-pocket spending for choosing such a provider first. Encouraging primary care and specialists to recommend or refer patients to providers who offer nonpharmacological treatment when indicated would also reduce low-value care and costs.

As payers, employers and policymakers search for ways to increase the value of care for musculoskeletal disorders and improve outcomes, they should look to chiropractic care.

About the Author

Sherry McAllister, DC, is president of the Foundation for Chiropractic Progress (F4CP). A not-for-profit organization with nearly 35,000 members, the F4CP informs and educates the general public about the value of chiropractic care delivered by doctors of chiropractic (DC) and its role in drug-free pain management. Learn more or find a DC at www.f4cp.org/findadoc.

References

1. Elton D, Kosloff TM, Zhang M, Advani P, et al. Low back pain care pathways and costs: Association with the type of initial contact health care provider. A retrospective cohort study. medRxiv (Cold Spring Harbor Laboratory). Published online June 18, 2022. doi:https://doi.org/10.1101/2022.06.17.22276443
2. Elton D, Zhang M. Neck pain care pathways and costs: Association with the type of initial contact health care provider. A retrospective cohort study. medRxiv. Published online July 22, 2022. Cold Spring Harbor Laboratory. doi:10.1101/2022.07.18.22277777. Accessed November 2, 2023. https://www.medrxiv.org/content/10.1101/2022.06.17.22276443v3
3. Elton D, Zhang M. Low back pain service utilization and costs: Association with number of visits of chiropractic manipulation, active care, manual therapy or acupuncture. A retrospective cohort study. medRxiv. Published online October 30, 2022. Cold Spring Harbor Laboratory. doi:10.1101/2022.10.28.22281664. Accessed November 2, 2023. https://www.medrxiv.org/content/10.1101/2022.10.28.22281664v2.full
4. Elton D, Zhang M. Low back pain care pathways – is the last provider seen more important than the first: A retrospective cohort study. medRxiv. Published online October 30, 2022. Cold Spring Harbor Laboartory. doi:10.1101/2022.10.27.22281624. Accessed November 2, 2023. https://www.medrxiv.org/content/10.1101/2022.10.27.22281624v1
5. Stevans JM, Delitto A, Khoja SS, et al. Risk factors associated with transition from acute to chronic low back pain in US patients seeking primary care. JAMA Network Open. 2021;4(2):e2037371. doi:10.1001/jamanetworkopen.2020.37371