The Value of Adding Chiropractic Care to Worksite Health Clinics

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Alexander Barker
6 years ago
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1 4 th National Association of Worksite Health Centers Annual Forum September 8, 2016, Milwaukee, Wisconsin Curt A. Krause, DC, MS Cerner Healthe Clinic LinkedIn Profile: Slide 1: Slide 2: Slide 3: Slide 4: Introductory slide Why bring chiropractic care on-site? What s the benefit to the company to the employee? How is it integrated with other health care services? What do chiropractors do and what things should be considered when hiring a chiropractor? Chiropractic care saves money The driving factor in healthcare today is the general question of, How do we lower the cost of healthcare while still providing high quality care? Plans with chiropractic care coverage saw a 1.6% decrease in total annual health care costs at health plan level Back pain patients with chiropractic care coverage had lower utilization of x-rays, MRI, hospitalizations and spinal surgeries Those w/ DC care had lower costs per episode of back pain Legorreta, A.P., Metz, R.D., Nelson, C.F., Ray, S., Oster Chernicoff, H., DiNubile, N.A. Comparative analysis of individuals with and without chiropractic coverage: Patient characteristics, utilization, and costs. Archives of Internal Medicine: (Oct); 164;18: Patient Centered Medical Home (PCMH) Becoming the new standard for delivery of care Patients are wanting to receive care from a clinic, a care team, where they and their stories are known, respected, and integrated across health care disciplines A family medicine residency program concluded that team care was critical to providing high quality care More and more PCMH are integrating healthcare disciplines outside of primary care. Chiropractic becoming more and more common With the annual economic cost of back pain reaching $ Billion annually. No better time for PCPs and DCs to collaborate their care A good resource to learn more information is the white paper The Role of Chiropractic Care in the Patient Centered Medical Home published by the Foundation for Chiropractic Progress, July 2011

2 Slide 5: Slide 6: Areas of Collaboration Cerner took 1 st place as the Healthiest Employer as named by Kansas City Business Journal in 2015 It did so by transitioning from reactive medicine to preventative healthcare Incentivizes engagement with wellness programs and preventative care activities allowing associates to earn premium reduction in their health plan premiums and HRA contributions 72% of a cohort of 1900 maintained or reduced their key health risk factors Commitment to preventative healthcare is primary focus of Cerner Healthe Clinics and is the reason we have such an interdisciplinary PCMH for our members making collaboration critical Cerner Team Care: Primary Care: including NPs, Visit Navigators & Care Coordinators ATCs, PTs, & Fitness Specialists Health Coaches & Dietitians Behavioral Health Specialists Maternity Programs & Coordinators Pharmacists Primary Care Each member of the care team in the PCMH should practice to the full scope of their license so that the PCP does not have to spend time rendering care when it can be provided as effectively and more efficiently by another member of the team At Cerner Care Teams huddle on a monthly basis to coordinate care How do Chiropractors and chiropractic care fit with Primary Care? Chiropractors are portal of entry physicians with a broad scope of practice, while other providers are much more limited in their scope Because of the broad scope of practice chiropractors are unique partners with PCPs decreasing their workload, while communicating significant findings of shared patients In addition to being experts in spinal biomechanics and musculoskeletal health, chiropractors have the training and capabilities to examine, diagnose, and co-manage other health related conditions. Chiropractors are able to order any advanced diagnostic testing. Whereas other providers are not or can with significant limitations depending on state law.

3 It s important to keep these factors in mind when hiring a potential Doctor of Chiropractic for your clinic. Additionally, some general criteria to consider when hiring are: 3-5 yrs of experience Excellent Diagnostician Able to create effective care plans based upon the diagnosis evidenced based outcomes Experience working in an integrative clinic Has outstanding patient service Holds Advanced Certification Slide 7: Slide 8: PTs, ATCs, & Fitness Specialist Chiropractors & ATCs huddle on a bi-monthly basis to coordinate care at Cerner Chiropractors: Can be a bridge from the clinic to the certified athletic trainers Can coordinate care with the PT s and co-manage patients Can work with fitness specialist as patients engage in more physical activities to ensure that they are engaging in activities that are not beyond their capabilities, while providing supportive care as issues might arise Health Coaches & Dietitian A major complicating factor of back pain is the co-morbidity of obesity Excess weight is a chronic strain on the spine and other joints Health Coaches and dietitians can address this significant complicating factor As nutrition improves so too does healing and response to care Chiropractors can provide guidance as patients become more active and provide supportive care as necessary

4 Slide 9: Behavioral Health Specialist Stress Continuum When patients are in distress they will often have musculoskeletal symptoms 2 Types of patients: o Anxiety being expressed in somatic dysfunction o Chronic pain generating depression Behavioral health specialists can teach techniques and provide tools to better manage their stress levels ultimately helping the root cause of their pain Chiropractors can help provide correction for any corresponding musculoskeletal dysfunction Slide 10: Maternity Programs & Coordinators Chiropractors coordinate with nurse maternity navigators and patients who are pregnant Members are educated on the benefits of chiropractic care in regard to pain management and general mobility issues They are also educated about evidence which suggests that those moms under chiropractic care have shorter labors Chiropractors also participate on expert panel discussions We do see children and adolescents as well Slide 11: Cost of Pain Steadily climbing over the years Examples include: Loss of productivity costs $62 Billion Annually (Foundation for Chiropractic Progress Reassessing the Value of Healthcare Treatment Options ) 15 million physician visits annually exceeding $50 Billion in costs (Koebbe, CJ, et. al. Lumbar Microdiscectomy: A Historical Perspective and Current Technical Conditions, Neurosurg Focus: 2002;13(2)) LBP causes 80% of injured workers to miss 8 weeks of work following back injury (Koebbe, CJ, et. al. Lumbar Microdiscectomy: A Historical Perspective and Current Technical Conditions, Neurosurg Focus: 2002;13(2)) Slide 12: Chiropractic Care Saves Money What we find in research is that Chiropractic care saves money in many different ways Generally, less expensive than other types of care Decrease in utilization of other healthcare services such as imaging, hospital or urgent care visits Generally, more effective than other types of services Prevents spinal surgeries

5 Slide 13: Worksite Studies Less radiological procedures overall which included: MRI, US, and x-rays Less outpatient and ER visits Concluded that on-site chiropractic care is associated with lower health care utilization Krause, CA; et. al. Value of Chiropractic Services at an On-Site Health Center; JOEM: August 2012 Volume 54 - Issue 8 - p Kindermann, S.L; et. al. Impact of Chiropractic Services at an On-Site Health Center; JOEM: Sept Volume 56 Issue 9 p Slide 14: Chiropractic Care is Cost Effective Health plans with and without coverage for chiropractic services were compared. Those with coverage saw less utilization of advanced imaging, plain film x-rays, surgery and inpatient care (Nelson, CF et. al., Effects of a managed chiropractic benefit on the use of specific diagnostic and therapeutic procedures in the treatment of low back and neck pain, JMPT: 2005 Oct;28(8):564-9.) Cost analysis of care DC vs Complex Medical Management for LBP w/ neurological symptoms, w/o neurological symptoms, and w/ other, over a 3-year period revealed that chiropractic care was 6x less expensive (Foundation for Chiropractic Progress Reassessing the Value of Healthcare Treatment Options ) 2.75 Billion annual savings vs miscrodiscectomies (McMorland, G., et. al. Manipulation or microdiskectomy for sciatica? A prospective randomized clinical study. JMPT: 2010 (Oct); 33 (8): ) A decrease by 60.2% in-hospital admissions, 59.0% hospital days, 62.0% outpatient surgeries and procedures, and 85% pharmaceutical costs when treated by CAM (which included chiropractors) when compared to traditional/conventional medical management (Sarnat, RL, et. al. Clinical utilization and cost outcomes from an integrative medicine independent physician association: an additional 3-year update. JMPT 2007 May;30(4):263-9) Slide 15: Chiropractic Care Has Higher Patient Satisfaction In a final report to congress on the Medicare Demonstration Project for Chiropractic Services, dated 2010, 87% of patients rated their satisfaction with care an 8 or higher on a 10-pt scale, with 56% giving a perfect 10 60% stated that they had complete resolution or a lot of relief with care 94% patient satisfaction rate while pain levels decreased significantly from 7.6/10 before treatment and 1.9/10 after treatment. (Haneline, MT, Symptomatic Outcomes and Perceived Satisfaction Levels of Chiropractic Patients with a Primary Diagnosis Involving Acute Neck Pain, JMPT: May 2006, Vol 29, Issue 4) 2009 Consumer Reports survey found that 59% of patients were completely satisfied or very satisfied with chiropractic care 58% stated that their care helped a lot with the pain Satisfaction with other forms of care: 55% PT, 53% Acupuncturist, 44% Physician Specialist, 34% PCP

6 Slide 16: Chiropractic Care Prevents Spinal Surgery Studies have shown that seeing a chiropractor first reduces the amount of spinal surgeries 42.7% had surgery when seeing a surgeon first 1.5% had surgery when seeing a chiropractor first o Keeney, BJ. Et. al. Early Predictors of Lumbar Spine Surgery after Occupational Back Injury: Results from a Prospective Study of Workers in Washington State. Spine (Phila Pa 1976) May 15; 38(11): Failed Back Surgery Syndrome only clinical intervention that has a named diagnosis for its failure Failure rate around 75% Associated with increased disability, opiate use, & poor return to work and significant work loss o Nguyen, TH. Et. al. Long-term Outcomes of Lumbar Fusion Among Workers Compensation Subjects: A Historical Cohort Study. Spine: 15 February Volume 36 - Issue 4 - p Microdiscectomies may have a higher success rate: 91% at 6 months 86% after 10 yrs (Findlay, GF. Et. al. A 10-Year Follow-Up of the Outcome of Lumbar Microdiscectomy. Spine: 15 May Volume 23 - Issue 10 - p ) 75-80% more realistic: (Harold, AL. Et. al. Prospective multiple outcomes study of outpatient lumbar microdiscectomy: should 75 to 80% success rates be the norm? J Neurosurg Jan;96(1 Suppl):34-44) 5-10 percent will have recurrent disc herniation's (Kim, MS. Et. al. Recurrence Rate of Lumbar Disc Herniation After Open Discectomy in Active Young Men. Spine: 1 January Volume 34 - Issue 1 - pp 24-29) Costs of Surgery: Microdiscectomies: $25K per procedure or $5 Billion annually (Foundation for Chiropractic Progress Reassessing the Value of Healthcare Treatment Options ) Fusions: $80-150K per surgery depending on the reference o Excludes recovery and further treatment Rate of Surgery o Microdiscectomies: 300,000 lumbar annually (Koebbe, CJ, et. al. Lumbar Microdiscectomy: A Historical Perspective and Current Technical Conditions, Neurosurg Focus: 2002;13(2)) o Fusions: 413,000 annually (Rajaee, SS. Et. al. Spinal fusion in the United States: analysis of trends from 1998 to Spine (Phila Pa 1976) Jan 1;37(1):67-76.)

7 Slide 17: Chiropractic Care is More Effective Chiropractic care was revealed to be more effective in reducing pain vs placebo and muscle relaxants (Hoiriis, KT. Et. al. A randomized clinical trial comparing chiropractic adjustments to muscle relaxants for subacute low back pain. JMPT: 2004 Jul-Aug;27(6): ) Chiropractic care was revealed to be more effective in the short term, as well as up to a year vs traditional medical management. Chiropractic had a particular advantage in cases of sciatica past the knee. (Haas, M. Et. al. A practice-based study of patients with acute and chronic low back pain attending primary care and chiropractic physicians: two-week to 48-month follow-up. JMPT: 2004 Mar-Apr;27(3):160-9.) Chiropractic care was revealed to be more successful in treating nonspecific NP when compared to PT or continued care by a PCP. Success was defined as complete recovery or much improved NP. (Hoving, JL. Et. al. Manual therapy, physical therapy, or continued care by a general practitioner for patients with neck pain. A randomized, controlled trial. Ann Intern Med May 21;136(10):713-22) 68.3% DC 50.8% PT 35.9% PCP Stop Chasing Pain. Instead Chase Dysfunction Care is much less effective and costlier when we chase symptoms Slide 18: Summary Primary care is transitioning into the Patient Centered Medical Home and Chiropractors are increasingly becoming part of those care teams Chiropractors are uniquely qualified and positioned to partner with PCPs in caring and co-managing many of their patients as well as collaborating with all aspects of the care team and worksite programs Chiropractic care saves money by lowering health care utilization and preventing surgeries while achieving better outcomes and maintaining high patient satisfaction Slide 19: Why not bring chiropractic care on-site? What if adding chiropractic care to your onsite clinic prevented just 1 microdiscectomy and 1 spinal fusion? That would save your insurance plan $175,000 in just surgical costs alone. What if adding chiropractic care to your onsite clinic reduced your number of microdiscectomies and spinal fusions by 41.2%? What would that be worth to your company or organization? What if you could spend 6x less in treating LBP by adding chiropractic care to your onsite clinic? What would that be worth to your company or organization? Slide 20: What is your next step?

8 Special thank you to the Foundation for Chiropractic Progress for the invitation to speak on their behalf and to the National Association of Worksite Health Centers for hosting.

Comparative Analysis of Individuals With and Without Chiropractic Coverage Patient Characteristics, Utilization, and Costs

Comparative Analysis of Individuals With and Without Chiropractic Coverage Patient Characteristics, Utilization, and Costs 1 Archives of Internal Medicine. October 11, 2004;164:1985-1992 Antonio P. Legorreta,