Behind the Paper: The Rationale and Impact of Expanding Access to Chiropractic Care

by: Dr. Ronald Farabaugh and Dr. Zac Cupler

Editor’s note: Dr. Ronald Farabaugh will be presenting at the 2024 ICS Chicagoland Fall Convention. For more information or to register click here.

In our recent systematic review, we explored the comparative costs of chiropractic versus medical management of spine-related musculoskeletal pain. The motivation behind this research stems from the critical need to address the rising healthcare costs associated with spinal pain, which in the United States alone are estimated at $134.5 billion annually [1]. The opioid crisis has underscored the need for innovation and reconfiguration of care pathways for spine-related musculoskeletal pain and brings into question the correct clinical expertise to serve on the frontlines of this societal concern. This article delves into the “why” behind our paper, emphasizing the importance of broadening access to non-pharmacological care practitioners like chiropractors and its potential impact on healthcare utilization and costs.

The Problem: Medicalization of spine-related musculoskeletal pain and limited access to guideline-recommended non-pharmacological care

Healthcare systems often favor medical management over non-pharmacological care pathways, inadvertently leading to the medicalization of spine-related musculoskeletal pain and overutilization of invasive and costly medical interventions. Low-value options such as x-rays in the first 6 weeks of an episode of atraumatic acute low back pain are common. Patients with spine-related musculoskeletal pain frequently encounter barriers to accessing chiropractic care, despite its alignment with guidelines for numerous recommended front-line options for management [2]. This limited access not only affects patient outcomes but also escalates healthcare costs for patients and payers.

The Solution: Cost-effective and guideline-recommended chiropractic care

Our systematic review highlights the substantial benefits of chiropractic care as an initial treatment option for spine-related pain. By facilitating broader access to chiropractors, patients can experience significant reductions in the use of expensive and guideline discordant downstream healthcare services for spine-related musculoskeletal pain. The evidence from our systematic review supports the following key points:

1. Reduced Advanced Imaging: Patients who consult chiropractors early in their episode of care are less likely to undergo advanced imaging procedures such as magnetic resonance imaging. This reduction indirectly reduces the risk of spine surgery and interventional procedures.
2. Decreased Spine Surgery: Chiropractic care early during care is associated with fewer surgical procedures for spine-related musculoskeletal pain. A reduction in spine surgeries lowers immediate healthcare costs but also mitigates the risks and long-term costs associated with surgical complications.
3. Fewer Opioid Prescriptions: Patients who receive chiropractic care for spine-related musculoskeletal pain are less likely to be prescribed opioids and have lower risk of

opioid-related complications, including opioid-use disorder, overdose, and self-directed harm.

• Fewer Injections: Chiropractic care as a first-line care pathway for spine-related musculoskeletal pain reduces the likelihood of costly interventional procedures.
• Reduced Emergency Department Visits: Patients are less likely to frequent the emergency room for spine-related musculoskeletal pain when their entry point for spine- related musculoskeletal pain is the chiropractor. This is benefit to the health care system by removing non-emergency conditions from the emergency department and optimizes emergency medicine expertise, diagnostic resources, and available beds.
• Shorter Hospitalization Days: Patients with spine-related musculoskeletal pain managed initially by chiropractors experience fewer hospitalization days, which translates to fewer iatrogenic complications and lower overall healthcare expenditures.

The Impact: Cost Savings and Improved Outcomes

The implications of expanding access to chiropractic care as a frontline care pathway consistent with guideline recommendations are profound. By prioritizing non-pharmacological care, healthcare systems can achieve significant cost savings while improving patient outcomes. The reduction in costly downstream services not only alleviates financial burdens on the healthcare system but also enhances the quality of life for patients by minimizing exposure to guideline discordant medication, intervention, and surgeries, and their associated risks.

Supporting Evidence

The evidence supporting these findings is consistent, though limited largely by the retrospective nature of most included studies. For instance, a study by Weeks et al. [3] demonstrated that chiropractic care for chronic low back pain among older adults was associated with lower costs and reduced use of medical services compared to medical management. Similarly, Whedon et al.

[4] found that chiropractic care significantly reduced the likelihood of opioid prescription fills, highlighting its role in combating the opioid epidemic.

Conclusion

Our systematic review underscores the value of patients engaging in care delivered by chiropractors early in the episode of spine-related musculoskeletal pain. There is a critical need to broaden access to chiropractic care and optimize care pathways for patients with spine-related musculoskeletal pain. By overcoming barriers (i.e., fee-for-service models, co-pays, limited insurance coverage, limited chiropractors within large health care systems, etc.) to non- pharmacological care, we can reduce the overreliance on costly, invasive, and guideline discordant medical care, ultimately leading to substantial cost savings and improved patient outcomes. As healthcare systems continue to grapple with rising costs and the opioid crisis, chiropractic care offers a viable and effective solution that warrants greater integration into mainstream healthcare.

Expanding access to chiropractic care is not just a cost-saving measure; it is a patient-centered approach that aligns with guideline recommendations practices for managing spine-related

musculoskeletal pain. It is time for policymakers, healthcare system leaders, and providers to recognize the value of chiropractic care and ensure that patients have access to the full spectrum of effective and non-pharmacological treatment options.

References

1. Dieleman et al. US health care spending by payer and health condition, 1996–2016. JAMA. 2020;323(9):863–84.
2. Qaseem et al. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline from the American College of Physicians. Ann Intern Med. 2017 Apr 4;166(7):514-530. doi: 10.7326/M16-2367. Epub 2017 Feb 14. PMID: 28192789.

• Weeks WB, Goertz CM. Cross-sectional analysis of per capita supply of doctors of chiropractic and opioid use in younger Medicare beneficiaries. J Manipulative Physiol Ther. 2016;39(4):263-266.
• Whedon JM, Toler AWJ, Goehl JM, Kazal LA. Impact of chiropractic care on use of prescription opioids in patients with spinal pain. Pain Med. 2018;19(7):1337-1344.