1 The Chiropractic Profession s Role in Helping to Meet Vermont's Health Care Reform Goals Better care Better health Lower costs
2 Chiropractic Abstract: Chiropractic is now more than a century old, and it is licensed throughout the United States and Canada and recognized in more than 60 countries worldwide. Doctors of Chiropractic receive training that is focused on the treatment of NMS conditions through manual and physical procedures, such as manipulation, massage, exercise, and nutrition. Most patients present to chiropractors with low back pain, neck pain, whiplash, and headaches. Numerous studies and expert panel reviews have supported the use of chiropractic and manipulation for these complaints. Satisfaction with chiropractic care for low back pain typically is good. Chiropractic, in general, offers safe and cost-effective procedures for selected musculoskeletal problems. Prim Care Jun;29(2):
3 Chiropractic "The practice of chiropractic" means the diagnosis of human ailments and diseases related to subluxations, joint dysfunctions, neuromuscular and skeletal disorders for the purpose of their detection, correction, or referral in order to restore and maintain health, including pain relief, without providing drugs or performing surgery; the use of physical and clinical examinations, conventional radiologic procedures and interpretation, as well as the use of diagnostic imaging read and interpreted by a person so licensed and clinical laboratory procedures to determine the propriety of a regimen of chiropractic care; adjunctive therapies approved by the board, by rule, to be used in conjunction with chiropractic treatment; and treatment by adjustment or manipulation of the spine or other joints and connected neuromusculoskeletal tissues and bodily articulations. Vermont Statute 26 VSA Chapter 10
4 Chiropractic Education By law, licensed chiropractors are entitled to use the titles Doctor of Chiropractic, D.C., or Chiropractic Physician. Government inquiries, as well as independent investigations by medical practitioners, have affirmed that today s chiropractic training is of equivalent standard to medical training in all pre-clinical subjects (Chapman-Smith, 1988). A doctor of chiropractic s training generally requires a minimum of 7 academic years of college study and a clinical rotation before entering private practice. https://www.nbce.org/links/publications/practiceanalysis/
5 Curriculum Requirements 1- Meeker W, Haldeman H. Chiropractic: A Profession at the Crossroads of Mainstream and Alternative Medicine. Annals of Internal Medicine 2002, Vol 136, No American Physical Therapy Association Fact Sheet, Physical Therapist Education Programs. January 2007.
6 What Happens During a Visit to a Chiropractor? Consultation Review of current health problems, past injuries and illnesses, lifestyle, diet, sleep habits, exercise, mental stresses, use of alcohol, drugs, or tobacco. Physical Examination Examination procedures include standard physical, orthopedic and neurological testing as well as joint and muscular evaluations. Diagnostic and laboratory testing may be utilized. Referral and co-management with other medical professionals as needed. Treatment Chiropractic is most associated with, but not limited to, spinal manipulation. Chiropractic treatments may include a range of adjunctive therapies such as physical modalities, manual treatment of muscular, ligamentous and extremity problems as well as counseling on diet, exercise, home care and lifestyle management.
7 Chiropractic: Evidence Based Spine Care In 2007 the American College of Physicians and the American Pain Society released a joint guideline related to the diagnosis and treatment of low back pain. According to their review of the literature, spinal manipulation was recommended for both acute and chronic low back pain. Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 2007;147:
8 Chiropractic: Evidence Based Spine Care Acute and chronic chiropractic patients experienced better outcomes in pain, functional disability, and patient satisfaction; clinically important differences in pain and disability improvement were found for chronic patients. Haas et al (2005), Journal of Manipulative and Physiological Therapeutics
9 Neck Pain In a study funded by NIH s National Center for Complementary and Alternative Medicine to test the effectiveness of different approaches for treating mechanical neck pain received either spinal manipulative therapy (SMT) from a doctor of chiropractic (DC), pain medication (over-the-counter pain relievers, narcotics and muscle relaxants) or exercise recommendations. After 12 weeks, about 57 percent of those who met with DCs and 48 percent who exercised reported at least a 75 percent reduction in pain, compared to 33 percent of the people in the medication group. After one year, approximately 53 percent of the drug-free groups continued to report at least a 75 percent reduction in pain; compared to just 38 percent pain reduction among those who took medication. -- Bronfort et al. (2012), Annals of Internal Medicine
10 The Cost of Chronic Pain
11 Chronic pain affects at least 116 million American adults more than the total affected by heart disease, cancer, and diabetes combined. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research
12 Commonly Reported Pain Conditions When asked about four common types of pain, respondents of a National Institute of Health Statistics survey indicated that low back pain was the most common (27%), followed by severe headache or migraine pain (15%), neck pain (15%) and facial ache or pain (4%). Back pain is the leading cause of disability in Americans under 45 years old. More than 26 million Americans between the ages of experience frequent back pain. National Centers for Health Statistics, Chartbook on Trends in the Health of Americans 2006, Special Feature: Pain.
13 Economist Evaluation Pran Manga,PhD an economist at the University of Ottawa, was commissioned twice by the Provincial Government of Ontario to assess the effectiveness and cost-effectiveness of chiropractic management of low back pain. His assessment of the comparative cost data in his first report led him to conclude the following: There is an overwhelming body of evidence indicating that chiropractic management of low back pain is more costeffective than medical management. We reviewed numerous studies that range from very persuasive to convincing in support of this conclusion. The lack of any convincing argument or evidence to the contrary must be noted and is significant to us in forming our conclusions and recommendations (Manga et al., 1993, p. 11).
14 Economist Evaluation In his second report, Manga (1998) found the cost advantages for chiropractic care of matched conditions to be so dramatic that he concluded that doubling the utilization of chiropractic services from 10% to 20% may realize savings as much as $770 million in direct costs and $3.8 billion in indirect costs (p. 1).
15 A more recent evaluation of the cost-effectiveness of chiropractic care, the Mercer Report, came to the following conclusions (Choudry & Milstein, 2009): For low back pain, chiropractic physician care increases total annual per patient spending by $75 compared to medical physician care. For neck pain, chiropractic physician care reduces total annual per patient spending by $302 compared to medical physician care. When considering effectiveness and cost together, chiropractic physician care for low back and neck pain is highly cost-effective, [and] represents a good value in comparison to medical physician care and to widely accepted cost effectiveness thresholds. These researchers admitted that, because they were unable to capture and incorporate the costs of any prescribed drugs, their estimate of the comparative cost-effectiveness of chiropractic care was likely to be understated.
16 Patient Satisfaction Chiropractic patients were found to be more satisfied with their back care providers after four weeks of treatment than were medical patients. Results from observational studies suggested that back pain patients are more satisfied with chiropractic care than with medical care. Additionally, studies conclude that patients are more satisfied with chiropractic care than they were with physical therapy after six weeks. -- Hertzman-Miller et al (2002), American Journal of Public Health
17 Opiate Addiction Last year nearly twice as many people here died from heroin overdoses as the year before. Since 2000, Vermont has seen an increase of more than 770 percent in treatment for opiate addiction. Gov. Peter Shumlin.
19 Prescription Opioids, Gateway Drugs? Thirty-one (41%) felt that their addiction began with legitimate prescriptions. Prescription Opioid Use Among Patients Seeking Treatment for Opioid Dependence Journal of Addiction Medicine: June Volume 4 - Issue 2 - pp
20 Although prescription pain medications play a role in managing pain, the consequences of reliance upon prescription drugs can be serious. Dependence on and addiction to opioid drugs have physical, psychological, economic and social costs, and medications are not always effective in managing chronic pain. An evolving and reformed health care system must be open and responsive to nonconventional approaches to responding to chronic pain.
21 Vermont Medical Society 6. Discourage payment policies that encourage pill prescribing Follow the Money Current payment policies discourage: 1) use of evidencebased complementary and alternative medicine treatments; 2) team approach to caring for chronic pain patients; 3) case management; and 4) spending appropriate time with complex patients.
22 SAFE AND EFFECTIVE TREATMENT OF CHRONIC PAIN IN VERMONT Most people don t need to be on chronic pain medications. However, doctors went to medical school to help people and sometimes, due to lack of reimbursement for other alternative therapies and lack of time, writing a prescription to give the patient something to reduce their pain is sometimes the only and easier method to affect change. Different forms of therapy need to be equally accessible to all patients Doctors have an emotional response to their patients and because of the lack of resources and treatment modalities that are not covered by insurance; the emotional response is to give a pill to help Pain and addiction specialist
23 SAFE AND EFFECTIVE TREATMENT OF CHRONIC PAIN IN VERMONT One very big issue is how the insurance companies are actually driving a lot of the dependence on opioids. For example research shows that for chronic nonspecific low back pain, chiropractic manipulation, acupuncture, and massage are all helpful. Yet many insurance companies won t cover these. But they will cover the Percocet, which has not been proven to be helpful in research. Primary care physician
24 SAFE AND EFFECTIVE TREATMENT OF CHRONIC PAIN IN VERMONT A pressing issue in my practice is the painful burden and outright handcuffing of my ability to use several portions of a multidisciplinary pain treatment regimen, given the repeated, persistent and drastic cuts in payment for what I do. Controlled substances are given to patients by insurance payers without question, while pain alleviating, non- drug options such as procedures or physical therapies are denied coverage repeatedly, solely on the basis of expense. Is anyone among us really surprised that we have a prescription drug diversion issue now, given what I just stated. At times it has seemed to me that insurers want our patients addicted to medications; that this problem is something that is being created intentionally. Interventional pain specialist
25 Current Medicaid Coverage The current reimbursement of chiropractic services for the most vulnerable in Vermont is significantly limited. Spinal manipulation is the only reimbursable service. This is like limiting a PCP to only prescribing an antibiotic. Initial examination (Evaluation and Management visit) is noncovered. This is a significant barrier/financial disincentive for many Medicaid patients. Physical modalities, soft tissue treatments, physical rehab/exercise instructions are all non-covered services in a chiropractic office, yet they are a covered benefit when preformed by other providers.
26 Current Medicaid Coverage House Health Care Committee requested that DVHA look into the problem. The VCA provided an in depth paper reviewing the cost effectiveness of chiropractic care. We are still seeking consideration of H.487
27 Health Care Exchange Chiropractic physicians as well as other lower cost habilitative and rehabilitative providers are grouped in the same specialist category as surgeons, cardiologists and other high cost specialists on Exchange plans. MVP Bronze Plan specialist co-pay of $80.00 after the patient has met their deductible. Creates a financial disincentive for seeking cost effective, noninvasive, non-pharmacological treatments for pain management. We suggest a third provider distinction (habilitative and rehabilitative) with the same co-pay as primary care.
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