Roger Wilhelm, D.C.

A Comparison With Other Disciplines
For Satisfaction, Costs, and Effectiveness

Consumer Reports is a monthly consumer advocacy magazine with a circulation of about 4,000,000 subscribers. Its first issue appeared in January 1936.

Consumer Reports publishes reviews and comparisons of consumer products and services based on reporting and results from its in-house testing laboratory. Its annual testing budget is approximately $21 million US.

Consumers Reports prides itself on its objectivity. Consumer Reports does not print outside advertising, accept free product samples, or permit the commercial use of its reviews for selling products. Its publisher states that this policy allows the magazine to “maintain our independence and impartiality.”

Consumer Reports states that all tested products are purchased at retail prices by its staff, that no free samples are accepted from manufacturers, and that this avoids the possibility of bias from bribery or from being given “better than average” samples.

Consumers Reports web page address is www.consumersreports.org. This web page states:

• “Expert Unbiased Product Ratings & Reviews.”

• “Information that empowers consumers to make the best purchasing decision.”

• “We are a non-profit organization that is supported by the subscriptions to our web site and magazine.”

• “To maintain our independence, we do not accept any outside advertising and any free test samples.”

• Consumer Reports offers:

Scientific tests and ratings of thousands of products every year.

More than 100 experts working in 7 major areas:

• Appliances
• Cars
• Baby & Kids
• Electronics
• Foods
• Health & Family
• Recreation & Home Improvement

In May 2009, Consumers Reports published an article titled:

Relief for your aching back
What worked for our readers

This survey by Consumers Reports
produced the following findings:

• About 80 percent of United States adults have been bothered by back pain at some time in their lives.

• The Consumer Reports Health Ratings Center surveyed more than 14,000 subscribers who experienced lower-back pain in the past year but never had back surgery.

• “More than half said the pain severely limited their daily routine for a week or longer.”

• 88 percent said their back pain recurred throughout the year.

• In many of those surveyed, their lower-back pain interfered with their sleep, thwarted their efforts to maintain a healthy weight, and it hampered their sex life.

• “When back pain goes on and on, many people go to see a primary-care doctor. While this visit may help rule out any serious underlying disease, a surprising number of the lower-back-pain sufferers we surveyed said they were disappointed with what the doctor could do to help.”

• “Although many of our respondents who saw a primary-care doctor left dissatisfied, doctors can write prescriptions and give referrals for hands-on treatments that might be covered by health insurance.”

• The percentage of people highly (completely or very) satisfied with their back-pain treatments and advice varied by practitioner visited. The chart below summarizes who helped the most:

• “Our survey respondents tried an average of five or six different treatments over the course of just a year.”

• In all those surveyed, 23 different treatments types were used.

• “Hands-on treatments were rated by lower-back-pain sufferers as very helpful. Survey respondents favored chiropractic treatments (58 percent), massage (48 percent), and physical therapy.”

• “Prescription medications (available to subscribers), which one-third of our respondents said they took, were rated as beneficial by 45 percent of them.”

• “Almost 70 percent said they took an over-the-counter medication, but only 22 percent said the drugs were very helpful.”

• Lower-back pain is the fifth most common reason people go to a doctor.

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Chiropractic Services for the Treatment of Low Back and Neck Pain and the Improvement in the Value of Health Benefits Plans

On October 12, 2009, Mercer Health and Benefits released a study titled:

Do Chiropractic Services for the Treatment of Low Back and Neck Pain Improve the Value of Health Benefits Plans?

An Evidence-Based Assessment of Incremental Impact on Population Health and Total Health Care Spending

As noted, Mercer Health and Benefits produced this analysis. A Google Internet search of Mercer states:

“Mercer is a leading global provider of consulting, outsourcing and investment services. Mercer works with clients to solve their most complex benefit and human capital issues, designing and helping manage health, retirement and other benefits. It is a leader in benefit outsourcing. Mercer’s investment services include investment consulting and multi-manager investment management. Mercer’s 18,000 employees are based in more than 40 countries. The company is a wholly owned subsidiary of Marsh & McLennan Companies, Inc., which lists its stock on the New York, Chicago and London stock exchanges.”

Physicians Niteesh Choudhry, MD, PhD, and Arnold Milstein, MD, MPH, authored this Mercer report.

Dr. Niteesh Choudhry is from Harvard Medical School where he is an Assistant Professor of Medicine and an Associate Physician in the Division of Pharmaco-epidemiology and Pharmaco-economics. He is also associated with the Hospital Program at Brigham and Women's Hospital. Dr. Choudhry’s research focuses on patterns of use and adherence to medications for common chronic conditions, such as coronary artery disease, hyperlipidemia and diabetes.

Dr. Choudhry attended McGill University and then received his M.D. and did his residency training in Internal Medicine at the University of Toronto. He served as Chief Medical Resident for the Toronto General and Toronto Western Hospitals and was also Director of the Medical Clerkship Program at the Toronto General Hospital. He did his Ph.D. in Health Policy at Harvard University, with a concentration in statistics and the evaluative sciences, and was a Fellow in Pharmaceutical Policy Research at Harvard Medical School. He practices inpatient general internal medicine at Brigham and Women's Hospital and is actively involved in resident education.

Dr. Arnold Milstein is from Mercer Health and Benefits in San Francisco, California where he is the Medical Director at Pacific Business Group on Health, the largest employer health care purchasing coalition in the US, where he is the National Health Care Thought Leader. His work focuses on improving managed care programs for large purchasers and government.

Dr. Milstein's 40 book chapters and published articles have centered on managed care program design. Dr. Milstein is Mercer’s chief physician and national thought leader, and he earned the Elliott M. Stone Award of Excellence in Health Data Leadership from the National Association of Health Data Organizations (NAHDO) at its annual meeting in Alexandria, VA, on October 15, 2009. The NAHDO stated:

“Through this award, NAHDO honors Dr. Milstein’s strong advocacy of public comparative health care provider performance and public reporting. Dr. Milstein has successfully advocated for quality and pay-for-performance initiatives at the Centers for Medicare and Medicaid Services. As a national thought leader, his support of the state health care data reporting programs and their missions to provide health care data for policy and market purposes has been, and will continue to be, essential to the success and advancement of these databases.”

The National Association of Health Data Organizations (NAHDO) is a national, not-for-profit membership organization dedicated to improving health care through the collection, analysis, dissemination, public availability, and use of health data. NAHDO provides leadership in health care information management and analysis, promotes the availability of and access to health data, and encourages the use of these data to make informed decisions and guide the development of health policy. NAHDO provides information on current issues and strategies to develop a nationwide, comprehensive, integrated health information system, sponsors educational programs, provides assistance, and serves as a forum to foster collaboration and the exchange of ideas and experiences among collectors and users of health data. By doing so, NAHDO works to increase the state of knowledge.

Business Insurance magazine selected Dr. Milstein as “one of the 20 people who has made a difference in employee benefits management in the past 20 years.” Last year's New England Journal of Medicine's series on employer sponsored health insurance described him as a “pioneer” in employer efforts to advance quality.

In October 2006 Dr. Milstein was elected to the Institute of Medicine. He is a member of the Medicare Payment Advisory Commission. Since January 2002, Dr. Milstein has also served on the Strategic Advisory Council of the National Quality Forum.

Dr. Milstein’s work focuses on health care purchasing strategy, the psychology of clinical performance improvement and clinical innovations that reduce total health care spending. Among his many accomplishments in the quality field have been co-founding both the Leapfrog Group and the Consumer-Purchaser Disclosure Project. He heads performance measurement activities for both initiatives and is a Congressional MedPAC Commissioner.

Dr. Milstein holds a medical degree from Tufts University and a master's degree in health services planning from the University of California, Berkeley. He received a bachelor's degree in economics from Harvard University. He is an Associate Clinical Professor at the University of California, San Francisco Medical Center and a Worldwide Partner at Mercer.

Tom Elliott, president of Mercer’s global health and benefits business and a member of the firm’s global executive committee made these comments pertaining to Dr. Milstein:

“As the leader in providing innovative health care solutions to employers, Mercer takes great pride in celebrating the accomplishments of Arnie Milstein, who has had such a profound impact on how health care is delivered in the US. At a time when there is greater pressure than ever to deliver quality health care and at the same time control costs, we need innovative leaders who challenge employers, providers, health plans and policy makers to change their business models. Accurate and transparent data is essential in order to improve the delivery and efficacy of health care. Dr. Milstein has been a driving force behind improving the efficiency of the delivery system and his work has certainly influenced the national initiative to bridge the quality gap.”

The New England Journal of Medicine’s series on employer-sponsored health insurance described Dr. Milstein as a “pioneer” in national efforts to advance quality of care. He was selected for the highest annual award of the National Business Group on Health for distinguished innovation in health care cost reduction and quality gains. He was elected to the Institute of Medicine of the National Academy of Sciences and is a faculty member at University of California, San Francisco, Institute for Health Policy Studies.

This biographical information on Dr. Niteesh Choudhry and Dr. Arnold Milstein shows that there are none more qualified to present an evidence-based assessment on the value to Health Benefits Plans of chiropractic services.

This report by Drs. Choudhry and Milstein is twelve pages in length and cites 18 references from the National Library of Medicine PubMed database. A complete copy of the report can be accessed at www.f4cp.org.

The Executive Summary of the report makes the following points:

1) “Low back and neck pain are extremely common conditions that consume large amounts of health care resources.”

2) “Chiropractic care, including spinal manipulation and mobilization, are used by almost half of the US patients with persistent back-pain seeking out this modality of treatment.”

[This is an important point. It indicates that patients seek chiropractic treatment primarily for the management of chronic spinal musculoskeletal conditions. It is established that these chronic problems are both expensive and problematic because they do not spontaneously resolve and those suffering from these chronic complaints tend to seek the help from multiple healthcare providers].

3) “The peer-reviewed scientific literature evaluating the effectiveness of US chiropractic treatment for patients with back and neck pain suggest that these treatments are at least as effective as other widely used treatments.”

4) “Chiropractic care is more effective than other modalities for treating low back and neck pain.”

5) Pertaining to the total cost of care per year:

A) “For low back pain, chiropractic physician care increases total annual per patient spending by $75 compared to medical physician care.”

B) “For neck pain, chiropractic physician care reduces total annual per patient spending by $302 compared to medical physician care.”

Importantly, these authors indicate that chiropractic care is known to reduce the need for drug treatment. Additionally, the cost of medical physician care noted above did not include the cost of drug spending. Consequently, the authors state:

“Because we were unable to incorporate savings in drug spending commonly associated with US chiropractic care, our estimate of its comparative cost effectiveness is likely to be understated.”

“When considering effectiveness and costs together, chiropractic physician care for low back and neck pain is highly cost-effective, represents a good value in comparison to medical physician care and to widely accepted cost- effectiveness thresholds.”

6) “Our findings in combination with existing US studies published in peer-reviewed scientific journals suggests that chiropractic care for the treatment of low back and neck pain is likely to achieve equal or better health outcomes at a cost that compares very favorably to most therapies that are routinely covered in US health benefit plans.”

7) “The addition of chiropractic coverage for the treatment of low back and neck pain at prices typically payable in US employer-sponsored health benefit plans will likely increase value-for-dollar by improving clinical outcomes and either reducing total spending (neck pain) or increasing total spending (low back pain) by a smaller percentage than clinical outcomes improve.”

•••••••••

In their paper, Drs. Choudhry and Milstein note that low back and neck pain are extremely common conditions in the United States, and they consume large amounts of health care resources, noting:

• About 26% of the US adult population report back pain in a year.

• About 14% of the US adult population report neck pain in a year.

• The lifetime prevalence of back pain is approximately 85%.
• Low back pain accounts for 2% of all physician visits.

• The United States annual spending for spine-related problems is about $85 billion.

• About 50% of US patients with persistent back pain will seek out chiropractic care.

Drs. Choudhry and Milstein note that vast scientific literature has evaluated the cost effectiveness of chiropractic treatment for patients with common types of back and neck pain, which support these conclusions:

“Chiropractic care is at least as effective as other widely used therapies for low back pain.”

“Chiropractic care when combined with other modalities, such as exercise, appears to be more effective than other treatments for patients with neck pain.”

In this study, Drs. Choudhry and Milstein assessed whether chiropractic care was cost-effective by applying the widely-accepted standard “quality-adjusted life years,” or QALYs to existing studies that compared chiropractic services to medical physical services and physical therapy services. “Quality-adjusted life years,” or QALYs are “a standard means assessing both the length and quality of a patient’s life.” Studies show that treatments with cost-effectiveness ratios below $50,000 to $100,000 per QALY are considered to be cost effective.

Once again, when comparing the cost-effectiveness of chiropractic care to physician care for the treatment of low back and neck pain, the authors stress “prescription drug expenditures were not included in our analysis.” This is important because the authors note that prescription drug use is 9% higher in patients treated only by a medical physician compared to patients treated only by a chiropractor. They cite a 2006 study from the journal Spine showing the following pertaining to prescription drug use (1):

Use of Drugs for Back Pain

Consequently, the authors state:

“Thus, had our analysis included prescription drug costs it likely would have increased our estimate of the relative cost-effectiveness of chiropractic care.”

RESULTS FOR LOW BACK PAIN:

• In the treatment of low back pain, medical physician-only care was the least costly ($2,355), but it was also the least effective treatment.

• Chiropractic care was more costly by $75 per patient ($2,431), but it was more effective and associated with better health outcomes. Incredibly, chiropractic care for back pain scored a cost effective ratio of $1,837 per QALY (quality-adjusted life year). Remember, studies of treatments with cost-effectiveness ratios below $50,000 to $100,000 per QALY are considered to be cost effective. This means that chiropractic care for back pain is an incredibly cost-effective means of improving QALY, indicating, “chiropractic care for low back pain is a very good value.”

• Physiotherapy-led exercise was more costly than medical physician-only care by $837, and more costly than chiropractic care by $762. Physiotherapy-led exercise was more effective than medical care but less effective than chiropractic care. Physiotherapy-led exercise for back pain scored a cost effective ratio of $49,210 per QALY (quality-adjusted life year). This means that chiropractic was less costly (by $762 per patient), more effective, and about 27 times superior in QALY than physiotherapy-led exercises.

• Combining physiotherapy-led exercise with chiropractic manipulation costs $2,507, which is more costly than chiropractic-only care (by $76), but less costly than physiotherapy-led exercises-only care (by $685), yet surprisingly it was less cost effective than chiropractic-only care. The combination of physiotherapy-led exercise with chiropractic manipulation for back pain scored a cost effective ratio of $4,591 per QALY (quality-adjusted life year). This is about 2.5 times more costly per QALY than chiropractic-only care. The authors concluded that even if the cost per chiropractic visit was $100, “chiropractic care is substantially more cost effective than exercise alone.”

RESULTS FOR NECK PAIN:

• Patients who received chiropractic care for neck pain “achieved better clinical outcomes at lower costs than medical physician care.”

• The cost of medical physician care for neck pain was $579 per patient. The cost of chiropractic care for neck pain was $277 per patient, $302 less than medical care.

• Compared to medical physician care for neck pain, chiropractic care would save $6,035 per QALY (-$6,035). If chiropractic care cost $100 per visit, the savings per QALY would still be $5,875 per patient.

• Exercise-only care for neck pain costs $952 per case, which is $373 more than medical-only care and $677 more than chiropractic-only care. Yet, exercise only care was less effective than chiropractic, costing $18,665 per QALY, or about 4 times more than chiropractic-only care (at -$6035).

• “If exercise therapy were provided by chiropractors instead of physical therapists, one-year costs would fall to $464, resulting in savings of $114 per [insurance] beneficiary.” As attractive as this is, the combination of exercise plus chiropractic manipulation was less effective and more costly than chiropractic-only care.

Drs. Choudhry and Milstein make the following concluding remarks:

“Using data from high-quality randomized controlled European trials and contemporary Unites States based average unit prices payable by commercial insures, we project that insurance coverage for chiropractic coverage for chiropractic physician care for low back and neck pain for conditions other than fracture and malignancy is likely to drive improved cost-effectiveness of United States care.”

“For neck pain it is also likely to reduce total United States health care spending.”

“These favorable results would likely occur within a 12-month timeframe.”

“In combination with the existing United States-based literature, our findings support the value of health insurance coverage of chiropractic care for low back and neck pain at average fees currently payable by Unites States commercial insurers.”

ENDING COMMENTS:

Consumer Reports is the largest nonprofit objective, independent, and impartial provider of expert unbiased product ratings and reviews available in the world today. Consumers Reports May 2009 survey of 14,000 low back pain sufferers showed that the provider with the highest satisfaction was chiropractic, with a completely or very satisfied response in 59% of the consumers surveyed.

The article by Mercer Health & Benefits is a unique analysis of the costs and effectiveness of chiropractic in the management of low back and neck pain as compared to medical care and physiotherapy-led exercise. The standard used by the authors was the cost per quality-adjusted life year, or QALY. The analysis showed chiropractic care to be extremely effective for the cost of the service. In the case of low back pain, the cost of chiropractic per quality-adjusted life year was $1,837, which the authors labeled as “extremely favorable.” In the case of neck pain, chiropractic care was the most cost effective service, and its improvement in the quality-adjusted life year showed that if chiropractic care is used in the management of neck pain there would be a savings of $6,035 per person per year.

When insurance companies evaluate the cost effectiveness of various benefits they cover, it seems prudent that they include chiropractic in the management of both low back and neck pain.

REFERENCE:

Hurwitz EL, Morgenstern H, Kominiske GF, Yu F, Chiang LM. A randomized trial of chiropractic and medical care for patients with low back pain: eighteen-month follow-up outcomes form the UCLA low back pain study. Spine 2006;31:611-21.