By David Kessler, D.C., M.H.A. CHCQM, SVP and medical director, Sedgwick Managed Care Ohio (MCO)
The Workers’ Compensation Research Institute (WCRI) recently published the findings of its study on the use of chiropractic care to treat injured workers in the United States suffering from lower back pain.
As a chiropractor by training and a longtime practitioner in the Ohio workers’ compensation and managed care arena, I was intrigued by this publication. The findings themselves are quite interesting and signal that further research on today’s physical medicine landscape is well warranted; however, their primary significance is, in my mind, to highlight the renewed role of chiropractic care in workers’ compensation.
The researchers found that average per-claim costs — both medical and indemnity — for low-back pain incurred on the job were lower for those treated exclusively by chiropractors, rather than other clinical specialists. Further, the injured workers studied who were treated exclusively by chiropractors were significantly less likely to be prescribed opioid drugs or to receive diagnostic imaging scans. (For detailed findings, refer to the study report.)
History and context
The 1990s were marked by rapidly rising healthcare costs. This spike, of course, strained workers’ compensation systems across the U.S. Multiple studies conducted during that decade found that chiropractic utilization was a significant driver of workers’ compensation healthcare spending — leaving many questioning its cost-effectiveness. This skepticism led a number of states to implement workers’ comp policy reforms and cost control measures limiting the use of chiropractic care in favor of other treatments viewed as more evidence-based and economical.
The results of the recent WCRI paint a far more encouraging picture of chiropractic care for injured workers than the findings of the 90s-era research.
What changed?
I believe there are a few factors contributing to the disparate findings.
- Patient empowerment: Historically, patients remained under chiropractors’ care for extended periods, and progress toward recovery was dependent on adjustments or manipulation administered in the office. (The traditionally prolonged duration of chiropractic treatment and cost increases that began in the ‘90s are other reasons why it fell out of favor.) Today’s outcomes-based chiropractor focuses more on evidence-based guidelines and structured treatment plans with functional goals that ultimately transition patients to self-care in order to hasten improvement and alleviate reliance on in-office care. They educate injured workers on stretching and strengthening exercises to perform at home, as well as strategies for safe return to work and prevention of further strain, such as appropriate biomechanics and lifting techniques.
- Continuing education: Many chiropractors now undertake training in complementary specialties and treatment approaches, such as sports injury management, orthopedics, neurology and more. This enables outcomes-based practitioners to leverage the knowledge and practices of other areas in physical medicine, as well as interdisciplinary care plans, and offers them additional tools to help injured workers achieve relief from back pain and greater productivity.
- Multidisciplinary care: Although the recent WCRI study primarily highlighted injured workers treated exclusively by chiropractors, some of the greatest successes I’ve seen of late were in complex cases that warranted an integrated model of care when patients did not achieve the anticipated evidence-based recovery measures after chiropractic treatment alone. There is a burgeoning trend of multidisciplinary clinics opening to treat high-severity musculoskeletal issues — where orthopedists, family physicians, nurse practitioners, neurologists, physical therapists, chiropractors, massage therapists, surgeons and other specialists work together to deliver holistic care under one roof. Rather than presuming that any one specialty has all the answers for a given individual, this integrated approach covers a variety of treatment protocols and allows for quality, collaborative care for complex injuries. However, enlisting multiple practitioners can increase the medical costs on a claim, so it should be done prudently and only when warranted by the severity and complexity of the case.
Opportunities in the WC arena
Many in the workers’ compensation, managed care and employer arena still hold onto longstanding perceptions of chiropractors as providing care for extended durations without evidence of measurable or functional benefits. As a result, they tend to shy away from including chiropractic care in injured workers’ treatment plans, for fear of increasing medical costs with little return on investment and potentially extending lost work time. While some continue to distrust the effectiveness of chiropractic treatment, millions of people achieve healing and pain relief under the care of evidence-based chiropractors. (The WCRI study pointed out that individuals with non-occupational back injuries are much more likely to seek chiropractic care than those injured on the job.)
In light of escalating concerns over addictive pain medications, long-term side effects and rising pharmacy and surgery costs, chiropractic care offers a non-invasive way to help injured workers improve their quality of life and their productivity. Some people respond well to chiropractic treatment, others may not, and particularly complex cases may require multiple treatment approaches. However, chiropractic intervention is an overall low-risk and comparatively low-cost treatment option that merits further consideration.
Workers’ comp in the U.S. may present a unique opportunity for optimal utilization of chiropractic care because of the system structure. Unlike individuals seeking treatment for non-occupational injuries, workers’ comp patients have a claims examiner, often a nurse case manager and others assisting in the coordination of their care. These professionals are trained in managing complex cases, asking the right questions, and facilitating communication and cooperation between treatment providers. Since occupational injuries are covered under workers’ comp, patients don’t have to worry about copays to multiple specialists and meeting medical plan deductibles. Instead, they and their claims team can focus on pursuing the right care from the right treatment providers at the right time.
I hope that WCRI’s publication opens the door to greater consideration of chiropractic care with physical medicine modalities in workers’ compensation cases and to a reexamination of the regulations currently limiting the access of injured workers in certain states to high-quality, evidence-based chiropractic care.