Pran Manga, PhD
Masters Program in Health Administration,
University of Ottawa,
Ottawa, Ontario, Canada
For much of its history, chiropractic care has been both an alternative therapeutic paradigm and separate from or marginal to the mainstream health care system. Over the past decade, the situation has changed somewhat in that chiropractic care is gradually being integrated within a variety of health care delivery organizations. According to Triano et al,1 by the application of evidence-based health care and good business, there is a surge in cooperation and integration among chiropractors, allopathic physicians, allied health care providers, ancillary therapists, and respective support staff. There is, however, no quantification of the level of integration. Integration may also be more true of the United States than elsewhere. The overall position of chiropractic care as alternative and separate still predominates. This situation does not serve the interests of the chiropractic profession nor the public well. There is a persuasive economic case for a radical shift in the role of chiropractic care to one that may succinctly be described as alternative and mainstream. The chiropractic profession must preserve its identity and its unique therapeutic paradigm and continue to be seen as an alternative to other health care professions, especially medical doctors. However, it should also become mainstream and thus widely available and accessible to the public by being integrated into the wide variety of health care delivery organizations that collectively constitute the health care system.
There are considerable and persuasive economic and related arguments for this integration. Fundamentally, the integration of chiropractic care into the health care system is the solution to a set of 3 interrelated problems: (1) very high direct health care costs and indirect costs for the treatment of neuromusculoskeletal (NMS) conditions and injuries, (2) inadequate and inequitable access to effective and safe services offered by chiropractors, and (3) poor or worrisome health outcomes of medically managed NMS diseases, illnesses, or injuries. The desired integration can lead to improved health outcomes, significantly reduce health care costs, and improve accessibility to needed health services on the part of several socioeconomic groups who, under the current public and private insurance coverage guidelines, do not have adequate access to care.
From the Full-Text Article:
Cost-effectiveness and alternative providers of health care
Health care needs consist of the incidence and prevalence of diseases, illnesses, injuries, disabilities, and risks to health (Fig 1).
It is these needs that generate a demand for a wide range of health care services. Such services are offered by a number of health care professions, some of which are uniquely competent to respond to some of the needs of the public. However, for many of the needs (eg, NMS conditions), two or more professions may be more or less competent to offer the needed care. Under such situations, the proper objective of the insurance plan and health care system authorities should be to bring about the most cost-effective pairing of specific health care needs and health care providers. The organization and design of the health care system should accommodate this cost-effective pairing or at least not frustrate or vitiate it.
A fundamental health care delivery issue
For a proper matching of needs and care giver, it is essential to include and aggregate all relevant treatment costs for the entire episode of illness or injury. It so happens that chiropractic management of all NMS conditions is highly own-labor intensive (ie, the doctors of chiropractic provide mostly hands-on therapy), whereas medical management is a lot more complex and costly, involving one or more (and frequently repeat) prescription drugs, referrals to other care givers (eg, specialists and physiotherapists), diagnostic tests, diagnostic imaging, and sometimes hospitalization. Consequently, the cost of chiropractic care is likely to be all inclusive and accurate, whereas the cost of medical management of NMS cases is more likely to be understated. The literature on the cost of medical and chiropractic management of low back pain show that payments to chiropractors for their own services constitute more than 80% of the costs per episode. In the case of medical management the payments to medical doctors comprise only about 23% of the costs per episode.  In a recent study  on how such comparative cost studies should be performed and a review of the economic literature, not a single study measured the direct health care costs of an episode of NMS disorder fully. However, a few studies came close to doing so. The cost of medical management of NMS disorders is invariably understated because of methodological errors of the studies, even when only conventional components of costs are considered. No study included or even considered the costs of iatrogenic complications of medical management of NMS disorders. 
The other key parameters for the purposes of matching needs with care giver are, of course, the effectiveness and safety of different therapies and the preference for and patient satisfaction with the alternative care givers.
The quantitative importance of NMS disorders
There are good epidemiologic and actual practice reasons for the focus on NMS conditions in Fig 1. About 90% of chiropractic care in Canada is for patients with NMS disorders, with 67% for back pain, 6% for headaches, and 16% for arthritis and rheumatism. About 33% of patients with back pain would eventually be treated by chiropractors.  Although the precise figures for other jurisdictions would differ from these, NMS is by far the dominant area of chiropractic services and practice.
Musculoskeletal disorders are ranked first in prevalence as the cause of chronic health problems, long-term disabilities, and consultations with a health professional and ranked second for restricted activity days and use of both prescription and nonprescription drugs. No other body systems ranked invariably within the top 2 ranks for the morbidity indices examined. 
The prevalence of NMS conditions has increased over the years. Changing demographics are likely to sustain this trend. NMS conditions are common among working-age men and women, as well as the elderly. They also tend to be more prevalent among the lowest and lower-middle income populations.5 Back problems and arthritis are the first and second most common causes for long-term activity limitations among the population aged 15 years and over.  A very recent study noted that the majority of the household population aged 55 years and over (72% of men and 78% of women, 4.3 million people altogether) reported having at least one chronic condition in 1994–1995. The relatively high prevalence of musculoskeletal problems is consistent with the results of earlier Canadian surveys.  In Canada and the United States, those with inadequate incomes, especially women, are more likely to be hospitalized for NMS conditions. Admission rates were almost twice as high among the poor as for those who were not poor. 
Growing use of alternative therapies
There are numerous studies showing the rising use of alternative therapies. The popularity and value of such non-medical care is further underscored by the fact that 70% of the expenditure for such care was borne by the patients themselves out-of-pocket, with insurers and governments paying the remaining 30%. By contrast, only 17% of the total medical services expenditure was paid out-of-pocket.  There is a significant growth in the use of chiropractic care in the United States and Canada. There is a growing recognition and acceptance of chiropractic care by the public, despite high and rising levels of copayments.
Virtually everywhere there are significant differences in the use rate of chiropractic care by income class. The lower-middle class and the poor compare unfavorably with the upper-middle class, even though the former groups have a higher prevalence of NMS disorders. The elderly consume proportionately less chiropractic services than the nonelderly population. Ethnic and visible minorities too are relatively less likely to access and use chiropractic care.
Insurance coverage of chiropractic care has increased over the years, despite the strong and concerted opposition to such reforms by the medical and physiotherapy professions. It has been shown empirically that chiropractic care is subject to very high price and cross-price elasticities of demand.  This means that high copayments for chiropractic care very significantly deter its use and shift the object of care seeking from chiropractors to medical doctors. It is crucially important to note that the use rate of chiropractic care increased despite a huge increase in the level of copayments payable by patients for chiropractic visits. This illustrates that the public preferred to see chiropractors despite a strong financial deterrence. If this financial deterrence is greatly reduced to the point where it becomes relatively insignificant, evidence suggests that we can expect to see a very large increase in the proportion of the public visiting chiropractors, especially for NMS conditions and injuries, for which chiropractic care has been shown to be safer and more effective than medical management of these conditions.
Evidence of lower health care costs
Space does not allow for even a cursory presentation and discussion of the empirical studies on the comparative costs of chiropractic and medical management of NMS conditions. The overall conclusions of a recent review3 were that the vast majority of studies and the methodologically better studies showed that chiropractic costs were significantly lower than medical costs for back problems. The rare studies that purported to find the opposite were particularly weak in terms of method, concepts, data, statistical analysis, or generalizability. Regrettably, these studies were also given much prominence and publicity. In two very recent studies by Smith and Stano  and Stano and Smith,  the health insurance payments (costs) and patient use patterns for episodes of common lumbar and low back conditions managed by chiropractors and medical doctors were compared. The analysis was particularly important in that patients could very well commence and then obtain all the care needed for their conditions from either a chiropractor or a medical doctor. The data used by Smith and Stano are derived from fee-for-service claims information of large corporations with a population of about 2 million beneficiaries. The total patient count was 7077, involving 8018 episodes of care initiated by clearly identified chiropractic or medical physicians. The authors analyzed 9 high-frequency NMS ICD-9-CM trigger codes that are typically used by both medical doctors and doctors of chiropractic as the first diagnostic code, as well as being used to initiate an episode of care.
The average total insurance payments for a medically managed episode is $1020, virtually double the $518 for the average chiropractic episode. For outpatient costs, the average payment for medically managed episodes is $598 compared with $447 for chiropractic episodes, a difference of 34%. Much of the higher total payments for medically managed episodes are due to inpatient hospital costs. Note that these differences are underestimated because “some reporting plans exclude prescription drug payments.”  In an earlier article Stano describes in detail the data sources used in this study, and the possible bias in the cost estimates is acknowledged. “We do know, however, that medical care is under reported in this database (eg, prescription drugs, physical therapy), due to the decentralized delivery of medical services and the difficulties relating to the documentation of that care.”  Interestingly, these studies have not been criticized in the literature.
Very few studies show the opposite results. Carey et al  found outpatient costs per episode were lowest in a group-model health maintenance organization for primary care providers and highest for urban chiropractors and orthopedists. The reason for the high cost for chiropractic care was the larger number of visits for chiropractic episodes. Chiropractic-managed patients, however, reported a higher degree of satisfaction with their care than medically managed patients. The limitations of this study should be noted. The data for this study were drawn from a localized area in North Carolina with a very small sample. They also used charges rather than the actual payments to estimate costs. Payments are often substantially less than charges, and the discounting is typically larger for chiropractors than for medical doctors. Very importantly, only outpatient costs, and not total costs per episode, were considered in this study. Neither the mix of diagnosis nor the severity of the cases were known.
Shekelle et al  compared the total health care cost and some components thereof for services provided by different health care professions for episodes of low back pain. Although the article was published recently, the actual data used in the analysis came from a study undertaken 17 to 25 years ago. The design of the study and the process of establishing the various data series seemed to have overlooked referrals between the provider categories. The effects were to seriously understate the cost of medically managed back pain cases. They also found that chiropractic patients had the highest drug cost per episode but were unable to explain this surprising finding. The study acknowledged that because of the nature of the sampling, the results are not generalizable to the US population. The study found very large geographic variations in both the number of patients and the intensity with which they were treated. “The cause or causes of these variations in use are not known.”14 The sample size was too small, and the study did not include workman’s compensation cases.
Effectiveness, safety, patient satisfaction, and acceptance
There is an extensive body of literature demonstrating that chiropractic care for NMS disorders is effective, although there are studies that question or dispute this finding. Suffice it to say that there is not nearly as much nor as convincing evidence for the effectiveness of medical management of these conditions. Additionally, there is a strong and compelling consensus that chiropractic care is safer, and patient satisfaction is much higher than for other professions. 
All of these observations point to a clear need for greater integration of chiropractic care into the wider health care system. This will ensure gains in both efficiency (producing health care services at the lowest costs) and effectiveness (getting the best health outcomes per dollar spent). Furthermore, greater public or private insurance coverage will also mean greater access to chiropractic care, especially for population groups who are presently (financially) deterred from visiting chiropractors. This no doubt contributes to the high use among these groups of medical services, drugs, and hospital care. High out-of-pocket payment is a major deterrent to the use of chiropractic services. The patients are steered toward medical doctors, resulting in higher costs and often sub-optimal health outcomes. The lack of insurance coverage also militates against chiropractic being better and more fully integrated into the health care system.
Increasing insurance coverage for chiropractic care is consistent with the reallocation of resources for evidence-based front-line services in a community setting. This initiative substitutes community-based services for institutional care, emphasizes promotive and preventive health care, and de-emphasizes some of the costly interventions made with pharmaceuticals and surgery. It is consistent with the emphasis on primary health care and its effort to move away from a fee-for-service method of reimbursing physicians. It is also consistent with the current efforts of decreasing hospital capacity and having patients treated and managed on an ambulatory basis. The policy would be a powerful impetus to reform the worker’s compensation board processes and management of NMS disorders in the workplace. The extensive literature and clinical guidelines on back pain, neck pain, and headaches indicate a fundamental change in managing such conditions from a biomedical model (extensive use of diagnostic testing, drugs, bed rest, or physiotherapy) to a biopsychosocial model (use of early activities-exercise, patient education, spinal manipulation, some over-the-counter drugs if necessary, and restoration of function). Chiropractic care should be a front-line service rather than the default (ie, when all else fails) system of care it seems to be for many patients.
The integration of chiropractic care can take many forms, including extending hospital privileges to chiropractors, use in community health centers, interdisciplinary group practices and clinics, and partnerships across disciplinary boundaries. This integration of chiropractic care into health care organizations should be complemented by moving chiropractic colleges into universities; employment of chiropractors in Ministries of Health, Workers Compensation Boards, and public and private insurance corporations; and greater public funding for scientific research of chiropractic care. Although some of this is occurring already, it is far too little. At the same time, there is clear evidence of a resistance to change and reform. The case for the fuller integration of chiropractic care into the health care system will have to be made forcefully and repeatedly over the foreseeable future.