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Tuesday, March 8th, 2011Chiropractors are notorious for “keeping their patients coming back.” Many advise everyone to have their spine checked for “subluxations” and “adjusted” throughout life. Many chiropractors advise people whose symptoms have stopped to keep coming back for “preventative maintenance. Some chiropractors are networked with attorneys (and even medical doctors) to provide unnecessary tests and treatment to injured works and auto accident victims. Partly as a result, in many states, workers’ compensation programs has become so expensive that employers have asked their state legislature to limit the amount of chiropractic coverage.
In 1992, Florida Trend magazine published a cover story on “why chiropractors get blamed for fueling the cost of workers’ compensation.” The author concluded that, “Workers’ compensation is fraught with abuse, but no other players in the system rile business more than the chiropractors.” A spokesman for the American Insurance Association even said that, “Sometimes I think of workers’ comp as the chiropractic full-employment act.” Some health-insurance companies called for limits on chiropractic treatment, and some wanted chiropractors out of the WC system altogether. The main complaints were about exaggerated diagnoses, overtreatment, and aggressive marketing aimed at patient retention from cradle to grave. The author also noted:
Less scrupulous attorneys turn to chiropractors, hoping they will give injured workers the highest impairment rating and extend treatment for as long as possible. The chiropractors who play the game are then rewarded with a steady stream of clients provided by their unspoken lawyer/partners.
The payback for a lawyer comes in the medical expenses: The larger the expenses, the more the lawyer can expect, with legal fees paid by the insurer. . . . If a carrier disputes a claim . . . the lawyer can rack up hefty costs for time-consuming depositions and pre-trial appearances. Meanwhile, the chiropractor continues to provide treatment [1].
Two studies have focused attention on the problem in California. The first one, published by the Workers Compensation Research Institute of Cambridge, Massachusetts, analyzed 28,539 workers’ compensation cases involving back strains and sprains in California and four other states and concluded:
Chiropractic care could achieve the same outcome at lower costs if the number of visits were limited (see Figure A). Chiropractor-directed physical medicine care costs 30% more than physician-directed care and achieved the same outcomes as measured by duration of temporary disability. The higher number of visits that chiropractors use per case is the major driver behind the higher physical medicine payments. In Florida, chiropractic care achieved the same outcome at lower cost than physician-directed physical medicine care in Florida where reimbursement rules place strict limits on the number of chiropractic visits per case that will be reimbursed by workers’ compensation payors. The fact that treatment and billing practices by Florida chiropractors result in lower medical costs while achieving a similar duration of disability as physician-directed care may provide lessons that other states can draw from. Physical medicine services are most often used for back injuries, representing 41% of all injuries that receive such services. This is not surprising because back injuries — mostly strains and sprains — represent one-quarter of all workers’ compensation injuries, so they are disproportionately more likely to receive physical medicine services. In most cases, physicians manage care and arrange for physical medicine, either within or outside their organizations. Chiropractors are involved in about 13% of the cases, two-thirds of which are under the exclusive care of chiropractors. The average payment per workers’ compensation claim was 30% higher in chiropractor-treated cases in California, Connecticut and Texas to achieve the same duration of disability as they are in physician-directed care. That’s because chiropractor-treated claims involve more than double the number of visits, although the payment per visit is 19% to 24% lower. On average, chiropractors use 137% to 158% more visits that provide physical medicine services and 74% to 90% more visits for which office visits are billed. By contrast, in Florida, chiropractor-treated claims are 10% less expensive than similar physician-treated claims to achieve the same duration of disability. Medical costs per claim are 14% lower to achieve the same outcome. Florida chiropractors appear to treat and bill differently from chiropractors in other states. For example, Florida chiropractors treat with an average of eight visits per claim for claims with more than seven days of lost time from the job. Chiropractors in the other study states treat these cases with an average of 14 to 35 visits per claim. And Florida chiropractors are less likely to bill for office visit codes, and when they do, they bill for fewer visits. Part of the reason for the different results is that Florida law mandates absolute limits on the number of chiropractic visits per case — the lesser of 18 visits or eight weeks of treatment. Cases treated exclusively by chiropractors have much longer durations of physical medicine services. Nearly one-quarter have durations of 15 weeks or more. Only 35% have durations of 4 weeks or less. The shortest durations of physical medicine treatment involve cases in which physicians manage treatment. In these cases, physical medicine services are either provided internally, externally by physical therapists or through hospital providers. Between one-half and three-quarters receive two weeks or less of services and more than three-quarters receive four weeks or less. About 5% have durations of physical medicine services of 15 weeks or more. Cases treated by both chiropractors and physicians, either sequentially or concurrently, have the longest durations of treatment with 43% having durations of 15 weeks or more [2,3].