Musculoskeletal health not sexy, but still must be addressed
Muscular health, or more broadly musculoskeletal health, isn’t a very "sexy" problem. No blood is spilled and no one is likely to die. The problem is hard to see.
To make things worse, the worker/patient perspective on these painful problems can sometimes seem inconsistent from the vantage point of an employer-observer and even a health care provider caring for the problems. It would be so much simpler if there was a broken bone or a jagged laceration — set the fracture or stitch them up and let’s get back to work!
In addressing "muscular madness," we have learned a great deal about treating musculoskeletal problems. Thankfully, we have listened to the research and jettisoned the idea of bed rest. Similarly, we now appreciate that analgesics, muscle relaxants or tranquilizers are not a long-term answer.
Most important, we have learned that patients fare better when they transition to more active care (including exercise) as soon as possible. We have learned that these problems are very real and very costly to all parties involved.
However, what we haven’t come to grips with yet is that progress in addressing these problems will require changes in attitude, levels and types of care as well as payment considerations.
Patients and providers need to become teammates in addressing low-back pain/dysfunction. Providers need to enlist patients in the process of their recovery as guides, counselors, coaches and cheerleaders — services for which there are no appropriate CPT codes!
Patients need to be reminded at each and every step that their health and function is theirs and theirs alone. Non-engagement is recovery denied, or at least recovery delayed.
Providers and payers need to defer to conservative approaches, such as manipulation and rehabilitative procedures, provided by caregivers most skilled with these interventions. Surgeons need to restrain themselves from involvement until the need for their services is undeniable.
Payers and managed care organizations need to be realistic in allowing conservative care providers to deliver enough care to be successful before moving the patient further down the care and cost continuum.
The attitude changes also need to occur within the provider community. There is no lack of hubris among providers who treat low-back pain — each assumes his or her intervention is what the patient needs and that as soon everyone quits fiddling around with all this other stuff, then we can make real progress.
Every provider from the counselor to the orthopedic surgeon has had success in addressing low-back pain. Every provider from the counselor to the orthopedic surgeon also has failed in addressing low back pain. No one person or provider group has “the answer.”
Part of this new attitude is the willingness to conduct analyses that heretofore wouldn’t have been considered, let alone acted upon.
A recent example from Canada illustrates this point well. Researchers in Alberta compared the effectiveness of microdiskectomy and chiropractic care in a randomized, head-to-head trial, in a population of patients with low-back pain and sciatica in the presence of lumbar disk herniation whose symptoms had been resistant to at least three months of usual care — analgesics, physical therapy, massage, acupuncture and lifestyle modification.
The study concluded that 60% of patients benefited from spinal manipulation to the same degree that they benefited from the surgical intervention.
When this data is considered from a financial perspective, we see a staggering savings in direct costs of care alone. Applying the findings of this study to the U.S. environment yields potential savings of multiple billions of dollars annually.
Consider the following analysis. In 2002 Singhal et al reported that 200,000 microdiskectomy procedures were performed in the United States at a cost of $5 billion, or a per procedure cost of $25,000. In the Canadian study, patients under chiropractic care were seen an average of 21 times.
If we assume a U.S. cost of $100 per patient visit then the total cost of chiropractic care per patient would be $2,100. For each and every patient in whom the microdisckectomy could be avoided there would be a savings of $22,900.
As was indicated in the Canadian study, if 60% of the surgery indicated population avoided the procedure, the annual direct medical costs savings would be in the range of $2.75 billion.
The cost savings reflected in this study are not a fluke. A key element in responding to “muscular madness” must include a new look at our biases and a candid and sincere reappraisal of our strategies related to the source of the “madness.”
In 2009 an analysis completed by Arnold Milstein, M.D., MPH, then of Mercer Health and Benefits, and Niteesh Choudhry, M.D., PhD of Harvard Medical School, concluded that clinical and cost advantages were found with chiropractic management of low-back pain and neck pain.
"When considering effectiveness and cost together, chiropractic physician care for low back pain and neck pain is highly cost effective, represents a good value in comparison to medical physician care and to widely accepted cost-effectiveness thresholds," they wrote.
In 2010, the Center for Health Value Innovation, a membership organization of employers and insurance plan sponsors that shares actionable health data, strategies and tools for better business performance, appointed an expert panel that applied the findings of Milstein and Choudhry in a valued-based benefits design analysis.
In part, the panel concluded:
"As the country experiences innovation and adoption in health reform, the opportunity arises to expand the continuum of care services in order to apply the right mix of resources for each individual. Chiropractic intervention is one area in which new analysis may define the placement in the care continuum. This will be especially important in the transformational years of patient-centered care with low numbers of primary care physicians to serve as medical home quarterbacks. Care that causes early engagement of both the patient and clinician coupled with shared accountability for the outcome is the most desirable of relationships. Chiropractic may be able to support and enhance this relationship."
For health care reform to be effective and worth the effort, it will require a fresh look at all options, not just the ones that are most familiar. For savings to be achieved and clinical effectiveness to be increased the status quo will need to be disrupted. This illustration related to low back pain is a clear example that can be quickly and easily re-thought in a manner that will yield savings in the billions of dollars annually. —E.B.N.
Gerard Clum, D.C. is the president of Life Chiropractic College West, and a board member of the Foundation for Chiropractic Progress.