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John weeks' integrator blog: researchers from Harvard and employer group find chiropractic 'highly cost-effective' versus MD treatment.

The first sentence of this report states a blunt fact of life in the US: "Low back pain and neck pain are extremely common conditions that consume large amounts of health care resources." Checking in with the state of one's own back or neck places many of us with the 26% who have low back pain and 14% who have neck pain in a given three-month period. Half of us with chronic low back seek chiropractic care. $85 billion a year is spent on low back pain alone.


So, is chiropractic effective and, more specifically, cost effective compared with other care?

Two top researchers, Niteesh Choudhry, MD, PhD, and Arnold Milstein, MD, filed a 15-page report on October 12, 2009, that attempts to resolve that medicopolitical question that has rattled around US health care for the last 20 years since the American Medical Association was forced, by dint of the Wilk v. AMA antitrust lawsuit, to allow chiropractic into the public debate as something other than quackery. Choudhry is a professor in pharmacoeconomics from Harvard Medical School, and Milstein a consultant with Mercer Health and Benefits and medical director for the influential Pacific Business Group on Health. The report is prosaically titled "Do Chiropractic Services for the Treatment of Low Back Pain and Neck Pain Improve the Value of Health Benefit Plans? An Evidence-Based Assessment of Incremental Impact on Population Health and Total Healthcare Spending."

The team reviewed all the effectiveness literature and cost-effectiveness literature on the question. The authors analyze leading studies that have created confusion in the US on the issue, showing in each case certain "methodological limitations." For instance, a UCLA study which concluded that chiropractic was not cost-effective did not include surgical costs. They then turn to Europe for "high-quality" cost effectiveness studies with a randomized group. The conclusions are mixed, interesting, and educational for those not familiar with methods in cost analysis in the real world.

* Effectiveness: Chiropractic is more effective than other modalities for treating low back and neck pain.

* Total cost of care per year: For low back pain, chiropractic care increases total annual per patient spending by $75 per year over "medical physician care." For neck pain, chiropractic care reduces annual spending $302 per year compared with medical physician care. The cost of care for neck pain is lowered when chiropractic is combined with exercise (and better than exercise alone).

* Cost-effectiveness: If both cost and effectiveness are considered together, chiropractic is "highly cost-effective" and "represents a good value" relative to medical physician care and "widely-accepted cost-effectiveness thresholds." The authors then note that they were not able to incorporate data on pharmacy costs but project that, had they been able to do so, "our estimate of chiropractic's comparative cost effectiveness is likely to be understated."

Ultimately, the audience for this report is health-care purchasers--employers and government agencies--especially amidst the current health-care reform debate. Choudhry and Milstein conclude:
  Using data from high-quality, controlled (European Union) trials
  and contemporary US-based average unit prices payable by
  commercial insurers, we project that insurance coverage
  for chiropractic physician care for low back pain and neck pain
  for conditions other than fracture and malignancy is likely to
  drive improved cost-effectiveness of care.

A health services researcher, who chose not to speak on the record, offered this blunt perspective on the study when contacted by the Integrator:
  I didn't seen anything glaringly ridiculous, so the conclusions
  may be reasonable. I think a good health economist would be
  in a better position to comment. Finding chiropractic care
  (or anything else) more cost-effective than conventional medical
  care is in itself, not that impressive, given how
  un-cost-effective conventional medical care is.

The study was funded by the Foundation for Chiropractic Progress (F4CP), an organization established to publicize and advance positive perspectives on chiropractic. The organization recently Invested $1 million in a major Beltway-focused advertising campaign. F4CP sent out an October 21, 2009, release that advertised these study outcomes.

Comment: If credibility is created by biting the hand that feeds you, this study deserves some recognition for concluding that the cost per patient for low back pain by chiropractic physicians is higher than medical physician care. This consultant's conclusion was of course significantly softened by the overall outcome. The study will certainly have its merits for the positioning chiropractic in health-care reform.

This study is also instructive in other ways. First, there is the review of the limits of various methods selected in various costs studies, which leads to the dissembling and often misleading conclusion that studies of cost-effectiveness of X are conflicting. Second, the combination of higher cost but greater cost-effectiveness may be the equation that helps many therapies and practices in labor-intensive (rather than drug-intensive) health care, including complementary and alternative practices, extract the sword from the stone in the cost debate. Finally, the approach of these researchers underscores that for whole-practice approaches, we are often best off to look at the whole system of cost rather than to compare modality cost versus modality cost.

One thing we know for certain after this study is that F4CP will insure that policymakers and benefits purchasers know about it, and that future wanderers into the debate over chiropractic physician/medical physician costs will now have another report with which they'll need to contend.


In the context of the note in the most recent Integrator Round-up over changing terms by which the chiropractic, er, uh, chiropractic medical profession describes itself, it is interesting that these researchers chose to use chiropractic physician in the comparison with medical physician services.

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This article is reprinted courtesy of John weeks, publisher-editor of a free subscription newsletter, The Integrator Blog News and Reports ( Weeks, a Townsend Letter columnist for many years, also produces regular columns, based on Integrator material, for Integrative Practitioner Online ( and Integrative Medicine: A Clinician's Journal (

by John Weeks
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Author:Weeks, John
Publication:Townsend Letter
Article Type:Reprint
Geographic Code:1USA
Date:Apr 1, 2010
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