August 2007

Medicare folly

by Dr. Christopher Kent

Health care in the United States currently consumes about one in every six dollars spent in the United States, and will consume an estimated one in every five dollars by the year 2015. It is projected that by the end of the next decade, the government will be paying about half of the nation's medical costs. A report from the Centers for Medicare and Medicaid Services estimated that both government and private spending for health care will average $12,320 per person in 2015, almost double the 2005 figure of $6,683. The nation's health care bill could total more than $4 trillion in 10 years. [1] In 2005, Medicare provided coverage to 42.5 million people, spending $330 billion on benefits. [2] It is projected that Medicare Hospital Insurance program will become insolvent in 2019, and Medicare expenditures are projected to rise rapidly in coming decades as the baby‑boom generation retires and health care costs continue to rise. [3]

These exploding costs are directly related to the system's focus on urgent care, to the exclusion of strategies that address health problems before they become costly and difficult to treat. Coverage of early interventions could result in significant cost savings. Medicare currently limits coverage for early intervention services, such as care for asymptomatic vertebral subluxations, without weighing the long term financial and medical benefits of covering these services against their short term costs.

The Medicare Act provides for care of vertebral subluxation by chiropractors as a covered benefit under Medicare. Unfortunately, Medicare excludes coverage for chiropractic care of vertebral subluxation unless it is accompanied with another covered neuromusculoskeletal condition

The Act requires that services must be "reasonable and necessary for the diagnosis or treatment of an illness or injury, or to improve the functioning of a malformed body member." Vertebral subluxation is arguably an "illness or injury" in itself, and the purpose of its correction is to "improve the functioning" of the affected body member. Therefore, diagnosis and treatment of vertebral subluxation should be a covered service independent of any accompanying medical conditions.

Cost savings associated with chiropractic care

Current Medicare policy does not include coverage for the care of vertebral subluxations alone. However, research demonstrates that preventive chiropractic care results in significant cost savings in persons over 65 years of age. The limitations imposed on Medicare coverage for care of vertebral subluxations may be costing taxpayers a great deal of money. The economic significance of this problem amounts to billions of dollars.

Analysis of an insurance database compared 23 persons over 75 years of age receiving chiropractic care with 414 non‑chiropractic patients. Those receiving chiropractic care reported better overall health, spent fewer days in hospitals and nursing homes, used fewer prescription drugs, and were more active than the non‑chiropractic patients. Furthermore, the chiropractic patients reported 21% less time in hospitals over the previous 3 years. [4] 45% of Medicare's $278 Billion expenditures in 2003 were for hospital coverage. [5]

Another study surveyed 311 chiropractic patients, aged 65 years and older, who had received chiropractic care for five years or longer. To control for overall health status, patients in the study were asked to complete a general health survey. [6] Despite similar health status, chiropractic patients, when compared with US citizens of the same age, spent only 31% of the national average for health care services. The chiropractic patients also experienced 50% fewer medical provider visits compared with US citizens of the same age. [7]

A study by Muse & Associates examined the utilization, cost and effects of chiropractic services on Medicare program costs compared to similar data for beneficiaries treated by other provider types. 5.8 M beneficiaries were included. 1.5 M (26.8%) received chiropractic care. Despite averaging more claims per capita than non‑chiropractic patients, beneficiaries who received chiropractic care had lower average Medicare payments per capita for all Medicare services ($4,426 vs. $8,103), and had lower average payments per claim for Medicare services ($133 vs. $210). Aside from high levels of patient satisfaction and improved health behaviors, senior citizens receiving chiropractic care spent significantly less time in hospitals, reduced medical utilization, and spent much less on medical care than persons receiving chiropractic care. [8]

In contrast to the cost savings realized by persons receiving long‑term chiropractic care, the availability of chiropractic care limited to the treatment of musculoskeletal disorders (in addition to or independent of vertebral subluxations) achieves only a modest financial benefit. An analysis was performed comparing health plan members with such chiropractic coverage and members of the same health plan without chiropractic coverage. Having chiropractic coverage was associated with a 1.6% decrease in total annual health care costs. [9] The most significant health benefits and cost savings are seen in patients who were under long‑term care.

The problem in limiting such treatment to persons with a "dual diagnosis," and designating the treatment of asymptomatic vertebral subluxations as uncovered "maintenance therapy" means that Medicare beneficiaries are being denied clinical services which reduce overall health care costs and improve quality‑of‑life.

References

1. "U.S. Health Care Bill by 2015: $4 Trillion." abcnews.com. 2/22/06.

2. 2006 Medicare Trustees Report. CMS Office of Public Affairs. http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=1846

3. "Element of Medicare Trustee's Report Could Spell Trouble for Beneficiaries in Future Years." Center for Budget and Policy Priorities. 3/31/05. http://www.cbpp.org/3‑22‑05health.htm

4. Coulter ID, Hurwitz EL, Aronow HU, et al: "Chiropractic patients in a comprehensive home‑based geriatric assessment, follow‑up and health promotion program." Topics in Clinical Chiropractic 1996;3(2):46.

5. "The Medicare Program: A Brief Overview Research Report." Craig Caplan, AARP Public Policy Institute February 2005...

6. The survey method used was the SF‑36D, and a supplemental questionnaire. The SF‑36D gives the overall health status index of a patient, and further breaks down three primary attributes: functional status, well‑being, and overall evaluation of health. Normative data exists for 1,814 US patients over 65 years of age not receiving preventive chiropractic services. The SF‑36D scores of the chiropractic patients were not significantly different from the normative data scores.

7. Furthermore, 95.8% of the patients receiving five years or more of maintenance care believed it to be either considerably or extremely valuable. Rupert RL, Manello D, Sandefiir R: "Maintenance care: health promotion services administered to US chiropractic patients aged 65 or older, Part II." Journal of Manipulative and Physiological Therapeutics 2000;23(1):10.

8. Muse & Associates. "Utilization, cost, and effects of chiropractic care on Medicare program costs." Washington, DC. 2001.

9. Legorreta AP, Metz RD, Nelson CF, Ray S, Chernicoff HO, DiNubile NA: "Comparative analysis of individuals with and without chiropractic coverage: patient characteristics, utilization, and costs." Arch Intern Med 2004;164:1985‑1992.

(Dr. Christopher Kent, president of the Council on Chiropractic Practice, is a 1973 graduate of Palmer College of Chiropractic. The WCA's "Chiropractic Researcher of the Year" in 1994, and recipient of that honor from the ICA in 1991, he was also named ICA "Chiropractor of the Year" in 1998. He is director of research and a co‑founder of Chiropractic Leadership Alliance. An attorney as well as a chiropractor, Dr. Kent is a member of the California bar. With Dr. Patrick Gentempo, Jr., Dr. Kent produces a monthly audio series, "On Purpose," covering current events in science, politics and philosophy of vital interest to the practicing chiropractor. For subscription information call 800‑892‑6463.)