Ten modifiable health risk factors are linked to more than one-fifth of employer-employee health care spending.

An underlying premise of the Affordable Care Act provisions that encourage employers to adopt health promotion programs is an association between workers' modifiable health risks and increased health care costs. Employers, consultants, and vendors have cited risk-cost estimates developed in the 1990s and wondered whether they still hold true. Examining ten of these common health risk factors in a working population, we found that similar relationships between such risks and total medical costs documented in a widely cited study published in 1998 still hold. Based on our sample of 92,486 employees at seven organizations over an average of three years, $82,072,456, or 22.4 percent, of the $366,373,301 spent annually by the seven employers and their employees in the study was attributed to the ten risk factors studied. This amount was similar to almost a quarter of spending linked to risk factors (24.9 percent) in the 1998 study. High risk for depression remained most strongly associated with increased per capita annual medical spending (48 percent, or $2,184, higher). High blood glucose, high blood pressure, and obesity were strongly related to increased health care costs (31.8 percent, 31.6 percent, and 27.4 percent higher, respectively), as were tobacco use, physical inactivity, and high stress. These findings indicate ongoing opportunities for well-designed and properly targeted employer-sponsored health promotion programs to produce substantial savings.

Chiropractic in North America: toward a strategic plan for professional renewal--outcomes from the 2006 Chiropractic Strategic Planning Conference.

OBJECTIVE: This report describes the process, participation, and recommendations of a set of consensus conferences on strategy for professional growth that emphasized elements of public trust and alignment between the chiropractic profession and its stakeholders. METHODS: In February and August 2006, an invitational group of leaders in the chiropractic profession convened an ad hoc Chiropractic Strategic Planning Conference. Public notice was given and support solicited through the Foundation of Chiropractic Education and Research. A series of international and interdisciplinary speakers gave presentations on the shifting of external social dynamics and medical culture, illuminating opportunities for the profession to extend its privilege and service. A systematic round-robin discussion was followed by group breakout sessions to develop recommendations on priorities for the profession to respond to challenges and opportunities. Recommendations were reviewed by the group as a whole and voted to consensus requiring more than 70% agreement. RESULTS: Participants determined a series of recommendations within 5 key domains for improving health professions practice: education, research, regulation, workplace, and leadership. CONCLUSION: The action steps proposed by the Strategic Planning Committee are first steps to provide better service to the public while making use of the inherent strengths of the profession.

Health and medical economics applied to integrative medicine.

Cost-benefit analyses (CBA) of every aspect of health and medical care are a necessity to address both the clinical effectiveness and cost effectiveness of health and medical care for the purpose of allocating limited practitioner, organizational, governmental, and monetary resources while maintaining the highest quality outcomes. In response, there are an array of approaches that emphasize the full continuum of prevention, restructuring primary care, involvement of the workplace and communities, and adoption of innovative strategies and interventions ranging from genomic assessments to complementary and alternative medicine (CAM). Among these approaches is an integrative medicine (IM) model that is consistent with these national objectives and that uniquely and explicitly includes "evidence-based global medical strategies" in its definition. All of these strategies require rigorous, appropriate, state-of-the art medical economic analyses. Since few if any IM models have been rigorously evaluated in terms of CBA, it is possible to draw upon the cost-effectiveness research focused on a limited number of CAM modalities as well as from the work-site/corporate clinical and cost outcomes research to suggest the evidence-based foundation from which a true healthcare system will evolve.

How can chiropractic become a respected mainstream profession? The example of podiatry.

BACKGROUND: The chiropractic profession has succeeded to remain in existence for over 110 years despite the fact that many other professions which had their start at around the same time as chiropractic have disappeared. Despite chiropractic's longevity, the profession has not succeeded in establishing cultural authority and respect within mainstream society, and its market share is dwindling. In the meantime, the podiatric medical profession, during approximately the same time period, has been far more successful in developing itself into a respected profession that is well integrated into mainstream health care and society. OBJECTIVE: To present a perspective on the current state of the chiropractic profession and to make recommendations as to how the profession can look to the podiatric medical profession as a model for how a non-allopathic healthcare profession can establish mainstream integration and cultural authority. DISCUSSION: There are several key areas in which the podiatric medical profession has succeeded and in which the chiropractic profession has not. The authors contend that it is in these key areas that changes must be made in order for our profession to overcome its shrinking market share and its present low status amongst healthcare professions. These areas include public health, education, identity and professionalism. CONCLUSION: The chiropractic profession has great promise in terms of its potential contribution to society and the potential for its members to realize the benefits that come from being involved in a mainstream, respected and highly utilized professional group. However, there are several changes that must be made within the profession if it is going to fulfill this promise. Several lessons can be learned from the podiatric medical profession in this effort.

Using a return-on-investment estimation model to evaluate outcomes from an obesity management worksite health promotion program.

OBJECTIVE: Certain modifiable risk factors lead to higher health care costs and reduced worker productivity. A predictive return-on-investment (ROI) model was applied to an obesity management intervention to demonstrate the use of econometric modeling in establishing financial justification for worksite health promotion. METHODS: Self-reported risk factors (n = 890) were analyzed using chi2 and t test methods. Changes in risk factors, demographics, and financial measures comprised the model inputs that determined medical and productivity savings. RESULTS: Over 1 year, 7 of 10 health risks decreased. Of total projected savings ($311,755), 59% were attributed to reduced health care expenditures ($184,582) and 41% resulted from productivity improvements ($127,173), a $1.17 to $1.00 ROI. CONCLUSIONS: Using an ROI model to project program savings is a practical way to provide financial justification for investment in worksite health promotion when risk reduction data are available.

A diagnosis-based clinical decision rule for spinal pain part 2: review of the literature.

BACKGROUND: Spinal pain is a common and often disabling problem. The research on various treatments for spinal pain has, for the most part, suggested that while several interventions have demonstrated mild to moderate short-term benefit, no single treatment has a major impact on either pain or disability. There is great need for more accurate diagnosis in patients with spinal pain. In a previous paper, the theoretical model of a diagnosis-based clinical decision rule was presented. The approach is designed to provide the clinician with a strategy for arriving at a specific working diagnosis from which treatment decisions can be made. It is based on three questions of diagnosis. In the current paper, the literature on the reliability and validity of the assessment procedures that are included in the diagnosis-based clinical decision rule is presented. METHODS: The databases of Medline, Cinahl, Embase and MANTIS were searched for studies that evaluated the reliability and validity of clinic-based diagnostic procedures for patients with spinal pain that have relevance for questions 2 (which investigates characteristics of the pain source) and 3 (which investigates perpetuating factors of the pain experience). In addition, the reference list of identified papers and authors' libraries were searched. RESULTS: A total of 1769 articles were retrieved, of which 138 were deemed relevant. Fifty-one studies related to reliability and 76 related to validity. One study evaluated both reliability and validity. CONCLUSION: Regarding some aspects of the DBCDR, there are a number of studies that allow the clinician to have a reasonable degree of confidence in his or her findings. This is particularly true for centralization signs, neurodynamic signs and psychological perpetuating factors. There are other aspects of the DBCDR in which a lesser degree of confidence is warranted, and in which further research is needed.

Effects of a managed chiropractic benefit on the use of specific diagnostic and therapeutic procedures in the treatment of low back and neck pain.

OBJECTIVE: The aim of this study was to measure the effects of a managed chiropractic benefit on the rates of specific diagnostic and therapeutic procedures for the treatment of back pain and neck pain. DESIGN: This study is a retrospective analysis of claims data from a managed-care health plan over a 4-year period. The use rates of advanced imaging, surgery, inpatient care, and plain-film radiographs were compared between employer groups with and without a chiropractic benefit. RESULTS: For patients with low back pain, the use rates of all 4 studied procedures were lower in the group with chiropractic coverage. On a per-episode basis, the rates in the group with coverage were reduced by the following: surgery (-32.1%); computed tomography (CT)/magnetic resonance imaging (MRI) (-37.2%); plain-film radiography (-23.1%); and inpatient care (-40.1%). On a per-patient basis, the rates were reduced by the following: surgery (-13.7%); CT/MRI (-20.3%); plain-film radiography (-2.2%); and inpatient care (-24.8%). For patients with neck pain, the use rates were reduced per episode in the group with chiropractic coverage as follows: surgery (-49.4%); CT/MRI (-45.6%); plain-film radiography (-36.0%); and inpatient care (-49.5%). Per patient, the rates were surgery (-31.1%); CT/MRI (-25.7%); plain-film radiography (-12.5%); and inpatient care (31.1%). All group differences were statistically significant. CONCLUSION: For the treatment of low back and neck pain, the inclusion of a chiropractic benefit resulted in a reduction in the rates of surgery, advanced imaging, inpatient care, and plain-film radiographs. This effect was greater on a per-episode basis than on a per-patient basis.

Chiropractic as spine care: a model for the profession.

BACKGROUND: More than 100 years after its inception the chiropractic profession has failed to define itself in a way that is understandable, credible and scientifically coherent. This failure has prevented the profession from establishing its cultural authority over any specific domain of health care. OBJECTIVE: To present a model for the chiropractic profession to establish cultural authority and increase market share of the public seeking chiropractic care. DISCUSSION: The continued failure by the chiropractic profession to remedy this state of affairs will pose a distinct threat to the future viability of the profession. Three specific characteristics of the profession are identified as impediments to the creation of a credible definition of chiropractic: Departures from accepted standards of professional ethics; reliance upon obsolete principles of chiropractic philosophy; and the promotion of chiropractors as primary care providers. A chiropractic professional identity should be based on spinal care as the defining clinical purpose of chiropractic, chiropractic as an integrated part of the healthcare mainstream, the rigorous implementation of accepted standards of professional ethics, chiropractors as portal-of-entry providers, the acceptance and promotion of evidence-based health care, and a conservative clinical approach. CONCLUSION: This paper presents the spine care model as a means of developing chiropractic cultural authority and relevancy. The model is based on principles that would help integrate chiropractic care into the mainstream delivery system while still retaining self-identity for the profession.

The selection effects of the inclusion of a chiropractic benefit on the patient population of a managed health care organization.

OBJECTIVE: The aim of this study is to measure the selection effects of the inclusion of a chiropractic benefit on a managed care health plan. DESIGN: An analysis of enrollment data from a managed care health plan over a 4-year period was conducted. Employers could select the managed care plan with or without a chiropractic care benefit. Comparisons of demographic and comorbid characteristics were made between employees who had the chiropractic benefit and those who did not, and between individuals who self-selected chiropractic care and those who self-selected medical care. RESULTS: The cohort with chiropractic coverage was younger with fewer subjects in the older age group (>65 years; 6.5% vs 9.6%) and more subjects in the younger age group (0-17 years; 31.9% vs 26.2%). The mean age of the group with coverage was 32.9 compared with 35.5 in the group without coverage. Comparing self-selected chiropractic patients to self-selected medical patients, there were fewer subjects older than 65 years in the chiropractic group (4.9% vs 9.2%) and fewer subjects aged 0 to 17 years (9.4% vs 19.4%). In 6 of the 8 comorbid conditions studied, the rates were lower in the cohort with chiropractic coverage compared with the group without coverage. The rates of comorbid conditions in self-selected chiropractic patients were lower in all 8 categories compared with self-selected medical patients. CONCLUSION: The inclusion of a chiropractic benefit in a health plan produces a modest favorable selection processes resulting in a slightly younger patient population with fewer comorbidities. At the level of patient self-selection, chiropractic patients are considerably younger and healthier than comparable medical patients.

Comparative analysis of individuals with and without chiropractic coverage: patient characteristics, utilization, and costs.

BACKGROUND: Back pain accounts for more than $100 billion in annual US health care costs and is the second leading cause of physician visits and hospitalizations. This study ascertains the effect of systematic access to chiropractic care on the overall and neuromusculoskeletal-specific consumption of health care resources within a large managed-care system. METHODS: A 4-year retrospective claims data analysis comparing more than 700 000 health plan members with an additional chiropractic coverage benefit and 1 million members of the same health plan without the chiropractic benefit. RESULTS: Members with chiropractic insurance coverage, compared with those without coverage, had lower annual total health care expenditures ($1463 vs $1671 per member per year, P<.001). Having chiropractic coverage was associated with a 1.6% decrease (P = .001) in total annual health care costs at the health plan level. Back pain patients with chiropractic coverage, compared with those without coverage, had lower utilization (per 1000 episodes) of plain radiographs (17.5 vs 22.7, P<.001), low back surgery (3.3 vs 4.8, P<.001), hospitalizations (9.3 vs 15.6, P<.001), and magnetic resonance imaging (43.2 vs 68.9, P<.001). Patients with chiropractic coverage, compared with those without coverage, also had lower average back pain episode-related costs ($289 vs $399, P<.001). CONCLUSIONS: Access to managed chiropractic care may reduce overall health care expenditures through several effects, including (1) positive risk selection; (2) substitution of chiropractic for traditional medical care, particularly for spine conditions; (3) more conservative, less invasive treatment profiles; and (4) lower health service costs associated with managed chiropractic care. Systematic access to managed chiropractic care not only may prove to be clinically beneficial but also may reduce overall health care costs.

Chiropractic care: is it substitution care or add-on care in corporate medical plans?

An analysis of claims data from a managed care health plan was performed to evaluate whether patients use chiropractic care as a substitution for medical care or in addition to medical care. Rates of neuromusculoskeletal complaints in 9e diagnostic categories were compared between groups with and without chiropractic coverage. For the 4-year study period, there were 3,129,752 insured member years in the groups with chiropractic coverage and 5,197,686 insured member years in the groups without chiropractic coverage. Expressed in terms of unique patients with neuromusculoskeletal complaints, the cohort with chiropractic coverage experienced a rate of 162.0 complaints per 1000 member years compared with 171.3 complaints in the cohort without chiropractic coverage. These results indicate that patients use chiropractic care as a direct substitution for medical care.