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Cost effectiveness

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General Cost Effectiveness Data

In 2012 a major study was undertaken to identify early predictors of lumbar spine surgery within 3 years after occupational back injury. In this landmark study the researchers found that 42.7% of workers who first saw a surgeon had surgery, in contrast to only 1.5% of those who saw a chiropractor. Furthermore, reduced odds of surgery were observed for those under age 35, women, and Hispanics. [1]

While this study did not directly study cost the implications are clear. Early intervention with conservative practitioners such as chiropractic physicians should be considered and implemented in all payor and governmental guidelines.

We now know that the training of chiropractic physicians (see Clinical Compentancy Article) is at least as good, arguably better, than medical physicians in relation to musculoskeletal conditions. The question is: Do patients realize a better outcome when consulting chiropractic physicians? The answer to this question was provided in a 1999 study when a large Chicago HMO began to utilize doctors of chiropractic (DCs) in a primary care provider role. The DCs focused on assessment and evaluation of risk factors and practiced with a non-pharmaceutical/non-surgical approach. Insurance claims and patient surveys were analyzed to compare clinical outcomes, costs and member satisfaction with a normative control group. During the 4-year study, this integrative medical approach, emphasizing a variety of complimentary and alternative medical (CAM) therapies, resulted in lower patient costs and improved clinical outcomes for patients. The patients who went to DCs as their primary care providers had 43 percent decreases in hospital admissions, 52 percent reductions in pharmaceutical costs and 43 percent fewer outpatient surgeries and procedures. [2]

In a follow-up study published in 2007 Sarnat and Winerstein discovered even better results. As reported in the abstract: "Results: Clinical and cost utilization based on 70274 member-months over a 7-year period demonstrated decreases of 60.2% in-hospital admissions, 59.0% hospital days, 62.0% outpatient surgeries and procedures, and 85% pharmaceutical costs when compared with conventional medicine IPA performance for the same health maintenance organization product in the same geography and time frame." [3]

Imagine the cost savings if the entire nation were to embrace wellness care and the utilization of doctors of chiropractic? Imagine if every person were to realize an 85% reduction in drug-intake? The cost savings to our country could be enormous. Simple logic dictates that if we were to encourage conservative care the costs associated with the two main cost-drivers in the system, drugs and surgery, would plummet.

A retrospective claims analysis found that Tennessee Blue Cross/Blue Shield beneficiaries initiating care with chiropractic physicians had lower treatment costs for low back pain episodes than those initiating care with medical physicians. [4]

A 2011 systematic review found that guideline-endorsed acupuncture, cognitive behavioral therapy, exercise, interdisciplinary rehabilitation, and spinal manipulation were all cost-effective for patients with sub-acute or chronic LBP. There was insufficient evidence for the cost-effectiveness of spinal manipulation for acute LBP. [5]

A 2012 systematic review found spinal manipulation was cost-effective for neck and back pain, used either alone or combined with other therapies. [6]

Impact Of Chiropractic Benefits on Payors

Clearly chiropractic users ingest substantially less drugs than the average person who does not utilize chiropractic services. But what impact does the inclusion of a chiropractic benefit have on an insurer? The answer to that question was provided by a 2004 study published in Archives of Internal Medicine. A 4-year retrospective review of claims from 1.7 million health plan members were analyzed to determine the cost effects of the inclusion of a chiropractic benefit in an HMO insurance plan. The data revealed that members with a chiropractic benefit had lower overall total annual health care costs. Back pain patients with chiropractic coverage also realized lower utilization of plain radiographs, low back surgery, hospitalizations and MRI’s. Back pain episode-related costs were also 25 percent lower for those with chiropractic coverage ($289 vs. $399). [7]

In another study, the claims of 8 million members insured by a managed health plan were evaluated to determine how patients utilize chiropractic treatment when they have a chiropractic benefit. They found that patients use chiropractic as a direct substitution for medical care, choosing chiropractic 34 percent of the time. Having a chiropractic benefit rider did not increase the number of patients seeking care for neuromusculoskeletal complaints. [8]

In a Canadian study the author explores the effects of the integration of chiropractic care into the health care system. The author indicates that greater use of chiropractic care would lead to reduced costs and improved outcomes. As support, the author points to studies which demonstrate that chiropractic is effective for neuromusculoskeletal disorders and the evidence that patients often prefer chiropractic care over a medical approach. [9].

American Medicare

What financial impact does chiropractic inclusion have on the American Medicare program? One study by Muse and Associates, published in the Journal of the American Chiropractic Association in 2001 examined cost, utilization and effects of chiropractic services on Medicare costs. The study compared program payments and service utilization for Medicare beneficiaries who visited DCs and those who visited other types of physicians. The results indicated that chiropractic care could reduce Medicare costs. The Muse report specifically stated, “…these results strongly suggest that chiropractic care significantly reduces per beneficiary costs to the Medicare program currently and could potentially save even more in the future.” Medicare beneficiaries who had chiropractic care had an average Medicare payment of $4,426 for all Medicare services. Those who had other types of care had an average of $8,103 Medicare payment for all Medicare services. The per claim average payment was also lower with chiropractic patients, having an average of $133 per claim compared to $210 per claim for individuals who did not have chiropractic care.


In 1998 noted economist, Pran Manga, lead a study which consider the effects of chiropractic care on the Ontario Health Insurance plan. This study demonstrates the ways in which individuals in Ontario are deterred from the use of chiropractic care because it is not covered under OHIP. The authors indicate that greater chiropractic coverage under OHIP would result in a greater number of individuals visiting chiropractors and going more often. The study shows that despite increased visits to DCs, this would result in net savings in both direct and indirect costs. Direct savings for Ontario's healthcare system could be as much as $770 million and at the very least $380 million.[10].

DC vs MD

A 1997 study compared care rendered by chiropractic physicians to that of medical physicians. A 1997 study compared the health insurance payments and patient utilization patterns of individuals suffering from recurring low back pain who visited doctors of chiropractic or medical doctors. Insurance payments were higher for medically initiated episodes. Those who visited chiropractors paid a lower cost and were also more satisfied with the care given. Because of this, the study suggests that chiropractic care should be given careful attention by employers when using gate-keeper strategies. [11].

Another study compared health insurance payments and patient utilization patterns for episodes of care for common lumbar and low back conditions treated by chiropractic and medical providers. Using 2 years of insurance claims data, this study examines 6,183 patients who had episodes with medical or chiropractic first-contact providers. Researchers found that total insurance payments were substantially greater for episodes with a medical first-contact provider. The mean total payment when DCs were the first providers was $518, whereas the mean payment for cases in which an MD was the first provider was $1,020. [12].

A 1995 retrospective study of 7077 patients compared costs of care for treatment of common low back conditions when a chiropractor was the first provider versus when a medical doctor (MD) was the first provider. Total payments for inpatient procedures were higher for MD initiated treatment and especially for episodes that lasted longer than a single day. Outpatient payments were much higher for MD initiated treatments as well. Payments were nearly twice as great for the medically initiated cases and their outpatient payments were nearly 50% higher. The authors’ statistical estimates indicate that the costs of care for common low back disorders using a chiropractor as first-contact provider are substantially lower than episodes in which a medical physician is the first- contact provider. The author concluded that chiropractic care could help to control health care spending. [13].


  1. Keeney, BJ et al (2012 Dec 12). "Early Predictors of Lumbar Spine Surgery after Occupational Back Injury: Results from a Prospective Study of Workers in Washington State". Spine. Retrieved 2/17/2013. 
  2. Sarnat, R; Winterstein, J (2004). "Clinical and Cost Outcomes Of An Integrative Medicine IPA". JMPT 27: 336-347. Retrieved 5/31/2012. 
  3. Sarnat, R; Winterstein, J (2007). "Clinical Utilization and Cost Outcomes From An Integrative Medicine Independent Physician Association: An Additional 3-Year Update". JMPT 30: 263-269. Retrieved 5/31/2012. 
  4. Liliedahl, RL et al (Nov-Dec 2010). "Cost of care for common back pain conditions initiated with chiropractic doctor vs medical doctor/doctor of osteopathy as first physician: experience of one Tennessee-based general health insurer.". JMPT 33(9): 640-643. Retrieved 11/19/2013. 
  5. Lin, CW et al (Jul 2011). "Cost-effectiveness of guideline-endorsed treatments for low back pain: a systematic review.". Eur Spine J 20(7): 1024-1038. Retrieved 11/19/2013. 
  6. Michaleff, ZA et al (Oct 2012). "Spinal manipulation epidemiology: systematic review of cost effectiveness studies". J Electromyogr Kinesiol 22(5): 655-662. Retrieved 11/19/2013. 
  7. Legorreta, A; Metz, D; Nelson, C; Ray, S; Chernicoff, H (2004). "Comparative Analysis Of Individuals With And Without Chiropractic Coverage". Archives of Internal Medicine Jan;30: 1985-1992. 
  8. Metz, D; Nelson, D; LaBrot, T; Pelletier, K (2004). "Chiropractic Care: Is It Substitution Care Or Add-On Care In Corporate Medical Plans?". Journal of Occupational and Environmental Medicine 46: 847-855. 
  9. Manga, P (2000 February). "Economic Case for the Integration of Chiropractic Services into the Health Care System". Journal of Manipulative and Physiological Therapeutics 23 (2): 118-122. Retrieved 5/31/2012. 
  10. Manga, P (1998). Enhanced Chiropractic Coverage Under OHIP (Ontario Health Insurance Plan) As A Means For Reducing Health Care Costs, Attaining Better Health Outcomes And Achieving Equitable Access To Health Services. 
  11. Stano, M (1997 January). "Costs And Recurrences Of Chiropractic And Medical Episodes Of Low Back Care". Journal of Manipulative and Physiological Therapeutics 20 (1): 5-12. Retrieved 6/3/2012. 
  12. Smith, M (1996 March). "Chiropractic And Medical Costs Of Low Back Care". Journal of Managed Care 34 (3): 191-204. Retrieved 6/5/2012. 
  13. Stano (1995). "The Economic Role of Chiropractic Further Analysis of Relative Insurance Costs for Low Back Care". Journal of the Neuromusculoskeletal System 3 (3): 139-144.