By Robin E. Kobayashi, J.D., LexisNexis Legal & Professional Operations
Musculoskeletal disorders (MSDs), including most commonly sprains and strains, accounted for a whopping 33 percent of all workplace injury and illness cases as well as one-third of all the days-away-from-work cases in 2013 according to the U.S. Dept. of Labor, Bureau of Labor Statistics. What’s more, workers who sustained an MSD injury needed an average of 11 days to recuperate before they could return to work compared to 8 days for all other types of injury cases. Nursing assistants, laborers, and freight, stock, and material movers had the highest rates of MSD injuries.
Given the high rate of MSD injuries in the workplace and the associated high costs of treatment, studies from 2011 and 2012 examined the use of on-site chiropractic services and found that these services contributed to lowered overall costs. Supporting the value of on-site chiropractic services is a 2014 study published in the Journal of Occupational and Environmental Medicine that compared the impact of on-site and off-site chiropractic care on health care utilization, specifically, radiological procedures and clinical care.
How the 2014 Study Was Set Up
The study focused on Cerner Corporation, a self-insured company in Kansas City, MO, specializing in health information technology and care delivery strategies. Cerner’s on-site health centers provide wellness, prevention, pharmacy services, and primary care, including chiropractic care, to all employees enrolled in Cerner’s health plan.
The 36-month retrospective study examined 876 employees who received chiropractic care at their place of employment (the on-site group) and 759 employees who received chiropractic care at an off-site community-based chiropractic office (the off-site group).
The study assessed utilization for radiological procedures (i.e., MRI, ultrasound, CT scan, and other radiograph procedures) and clinical utilization (i.e., claims for chiropractic services, physical therapy, or further medical care—inpatient, outpatient, or ER visits).
Key Findings And Facts
Overall the on-site group had much lower health care utilization than the off-site group.
For example, 55.5% of the off-site group received radiology services compared to 38.2% of the on-site group. In addition, repeat radiology services were much higher in the off-site group (20.5%) than the on-site group (10.1%). The authors of the study suggest that chiropractors who were unaffiliated with Cerner’s health plan were more likely to refer patients out of the clinic, thereby increasing costs in the system.
With respect to utilization of outpatient services, 47.3% of the off-site group had outpatient utilization compared to 30.2% of the on-site group. In addition, repeat outpatient services were much higher in the off-site group (29.5%) compared to the on-site group (18.5%). This pattern repeated with utilization of ER—19.0% for the off-site group compared to 13.1% for the on-site group. However, the authors of the study warned that they did not collect comorbidities or patient histories for their study, so it’s unclear whether these statistics were impacted by underlying characteristics of each group.
The study also found that the average number of chiropractic services and physical therapy visits per member were significantly higher with the off-site group. The authors of the study queried whether care packages advertised by community care centers might explain this big gap in utilization between the on-site and off-site groups.
CHIROPRACTIC PERSPECTIVE: David C. Radford, D.C., M.S. urges conservative care first, based on nearly 40 years of experience treating spine cases. He worked in the Spine Center at Lutheran Hospital for several years in the Department of Neurology and Neurosurgery, where many patients had successful non-surgical care. In support of his opinion he pointed out a recent prospective population-based cohort study by B.J. Keeny et al. that was published in the journal Spine May 15, 2013. The authors found that patients who saw a chiropractic physician first for acute occupational lower back demonstrated reduced odds of spine surgery. It was reported that those injured workers whose first provider was a chiropractor had a 1.5% chance of surgery versus those who saw a surgeon first, where their odds were 42.7% for spine surgery within three years. Baseline variables associated with surgery (P < 0.05) in the multivariate model included higher Roland-Morris Disability Questionnaire scores, and greater injury severity. The area under the receiver operating characteristic curve of the multivariate model was 0.93 (95% confidence interval, 0.92-0.95), indicating an excellent ability to discriminate between workers who would versus those who would not have surgery. The authors concluded that there was a very strong association between surgery and first provider type seen for the injury even after adjustment for other important variables.
According to Denise M. Goodman, MD, MS et al. in the April 24, 2013 Journal of the American Medical Association, “Many treatments are available for low back pain. Often exercises and physical therapy can help. Some people benefit from chiropractic therapy or acupuncture.” She also states that “sometimes medications are needed, including analgesics (painkillers) or medications that reduce inflammation. Surgery is not usually needed but may be considered if other therapies have failed.”
Dr. Radford pointed out that today, doctors of chiropractic medicine are very well trained to triage spine patients rapidly and accurately. When a patient has red flags indicating a serious injury or an obvious surgical case, they can help move the patient through what can sometimes be a cumbersome system. He said spine care is often a team effort; injured workers should feel confident starting care with a chiropractic physician.
The study did not determine whether the care received by the on-site and off-site groups improved their MSD symptoms. The authors of the study wondered whether the higher utilization seen in the off-site group may have been due to a lower quality of care in community care centers. Nor did the study examine cost savings. While the study did not analyze direct and indirect cost savings to Cerner’s health care plan, the authors believed it could be inferred that lower utilization of health care services would result in direct cost savings.
© Copyright 2015 LexisNexis. All rights reserved. Reprinted with permission.
Author Robin E. Kobayashi, J.D., Workers’ Compensation Practice Area Lead at LexisNexis. She is the site coordinator for the LexisNexis Legal Newsroom Workers’ Compensation Law. She has been a Sr. Legal Editor at LexisNexis specializing in workers’ compensation law for over 28 years. She also serves as the Editor-in-Chief of theLexisNexis Workers’ Compensation eNewsletters and the Co-Editor-in-Chief of Workers’ Compensation Emerging Issues Analysis, a 50 state survey of workers’ comp legislation and trends. Contact: Robin.E.Kobayashi@lexisnexis.com