Articles by JCS

COST OF WORKERS’ COMP

THE HIGH COST OF WORKERS’ COMPENSATION CASES

By

JCS

For business owners in Georgia, the State Board of Workers’ Compensation statistics on back injuries and costs alone are frightful. In 1999, there were 2,959 cases of low back injuries that cost the program over 28 million dollars, which equates to nearly $10,000 per case.[1]

While these figures are certainly shocking, there is a better solution, albeit under-utilized in our state. For example, of the 2,959 cases in the Workers’ Compensation program, only 81 were chiropractic cases costing $79,760, which equates to less than $1,000 per case.[2]  A Utah Study also compared medical versus chiropractic care and showed that patients of chiropractors returned to work sooner after an injury and that chiropractic care was one-tenth as expensive as standard medical care in total workers’ compensation costs.[3]

Very impressive and reliable research now has shown chiropractic care is not only a valid non-invasive clinical approach, but it is also more cost-effective than the current medical management of low back problems. Moreover, a Gallup Poll found nine out of ten chiropractic patients felt that their treatment was effective and met or exceeded their expectations.[4]

NEW SOLUTION TO AN OLD PROBLEM

Low back pain in the U.S. overall is a huge expense in the range of $50-75 billion dollars annually. As you may know, 8 of 10 adults will have an acute low back problem during their lifetime, back problems are the leading on-the-job injury and back pain is the leading cause of disability for people under the age of 45.[5]

New solutions are eagerly being sought to decrease the cost and improve clinical outcomes for this epidemic. In fact, the most recent comparative studies have shown that the traditional medical management of low back pain has added to the problem with unnecessary drugs, expensive MRI exams, and ineffective back surgery. There is also compelling evidence to support chiropractic’s conservative management incorporating spinal manipulation as an effective alternative for the majority of these problems.

Dr. Gordon Waddell, renowned orthopedist and spine researcher, states:

 Low back pain has been a 20th century health care disaster. ..Medical care certainly has not solved the everyday symptom of low back pain and even may be reinforcing and exacerbating the problem… Medical care for low back pain in the United States is specialist-oriented, of high technology, and of high cost, but 40% of American patients seek chiropractic care for low back pain instead.”[6]

 

Richard Deyo, M.D., noted researcher in the area of the spine, published an article in the Scientific American (Aug. 1998) titled “Low-Back Pain.”[7] 

“Calling a [medical] physician a back-pain expert, therefore, is perhaps faint praise--medicine has at best a limited understanding of the condition. In fact, medicines’ reliance on outdated ideas may have actually contributed to the problem.”

 

THE FAILURE OF BACK SURGERY

Not only has Dr. Deyo concluded there are many “outdated ideas” about the cause and treatments of back pain, other researchers have repeatedly shown the poor results from back surgery.

A recent study (Aug. 2000) by Dr. E. Berger published in Surgical Neurology emphatically showed the high rates of permanent disability from spinal fusions. One thousand workers’ compensation patients who had undergone lumbar spinal surgery were divided into two groups; one group consisted of 600 patients with a single operation and was evaluated on average 51 months after surgery. The second group consisted of 400 with multiple operations and was evaluated 38 months postoperatively.

The results of this study were stunning, to say the least. 71% of the single-operation group had not returned to work more than 4 years after the operation, and 95% of the multiple-operations had not returned to work. In none of these cases was there a neurological deficit that precluded gainful employment—the failure to return to work being blamed on chronic postoperative pain.[8] In fact, Failed Back Surgery Syndrome is now a diagnostic code.

THE “SLIPPED DISK”: A CATCHALL DIAGNOSIS

The reason why many experts deem back surgeries ineffective and unnecessary rests with the new evidence that shows disk abnormalities are not the primary cause of back pain. Many spine researchers have invalidated the standard medical diagnosis of a “slipped disk” found on MRI exams, which remains unknown to most patients with low back pain.

Dr. Deyo criticizes the over-reliance on MRI imaging for “misleading” and “incidental findings” of disk abnormalities.

"Early or frequent use of these tests [CT scans and MRI] is discouraged, however, because disk and other abnormalities are common among asymptomatic adults. Degenerated, bulging, and herniated disks are frequently incidental findings, even among patients with low back pain, and may be misleading.”[9]

 The U.S. Public Health Services’ guideline also recognizes the “irrelevant findings” of disk abnormalities on MRI exams as the cause of low back pain:

“Degenerative discs, bulging disk and even herniated discs are part of the aging process for the spine and may be irrelevant findings: they are seen on imaging tests of the lumbar spine in a significant percentage of subjects with no history of low back problems. Therefore, abnormal imaging findings seen in a patient with acute low back problems may or may not be related to that individual’s symptoms.[10]

 This points out the single-most prevalent cause of misdiagnosis in low back pain problems—that is, the use of costly MRI images to show disk abnormalities to convince patients that some sort of disk problem is the cause of their pain. In fact, as Dr. Deyo, the U.S. guideline, and other researchers have repeatedly shown, disk abnormalities are not the cause of most back pain and often appear in perfectly pain-free patients.  As Dr. Deyo mentioned, “Detecting a herniated disk on an imaging test therefore proves only one thing conclusively: the patient has a herniated disk.”[11] Indeed, you don’t “slip disks” but you do “slip joints.”

FEDERAL GUIDELINE RECOMMENDS SPINAL MANIPULATION FIRST

Due to this epidemic of low back pain, the controversy surrounding surgery and MRI exams, and the huge costs to treat it, the U.S. Public Health Service conducted the most extensive study ever done consisting of a two-year study of nearly 4,000 articles from the National Library of Medicine, which led to a 1994 federal guideline on “Acute low back problems in adults,” released by the Agency for Health Care Policy and Research (AHCPR). [12]

The 23-member expert panel’s recommendations shocked the medical profession for many reasons, such as their recommendation of spinal manipulation as a “Proven Treatment” for acute low back problems in adults. This guideline states:

“This treatment (using the hands to apply force to the back to ‘adjust’ the spine) can be helpful for some people in the first month of low back symptoms. It should only be done by a professional with experience in manipulation [chiropractors].”[13]

 

This federal guideline on acute low back pain also did not recommend treatments commonly used by many practitioners to treat low back pain.

A number of other treatments are sometimes used for low back symptoms. While these treatments may give relief for a short time, none have been found to speed recovery or keep acute low back problems from returning. They may also be expensive. Such treatments include: Traction, TENS, Massage, Biofeedback, Acupuncture, Injections into the back, Back corsets, Ultrasound.

             This guideline also did not endorse the use of strong pharmaceutical pain pills or muscle relaxants for back pain. Instead, the guideline recommends over-the-counter NSAIDs for temporary pain relief. [14] Plus, the guideline warns medications have serious side effects and can damage internal organs with their prolonged use. Nor do they correct the underlying cause.

The most surprising recommendation in this federal guideline focused on failure of back surgery. The expert panel found back surgeries were based on misleading tests and generally had ineffective outcomes. Their guideline states:

“Even having a lot of back pain does not by itself mean you need surgery. Surgery has been found to be helpful in only 1 in 100 cases of low back problems. In some people, surgery can even cause more problems. This is especially true if your only symptom is back pain.”[15]

A COST-EFFECTIVE CONSERVATIVE APPROACH PROVEN SUPERIOR TO TRADITIONAL MEDICAL METHODS

There are now 36 randomized controlled trails of manipulation for low back pain, and these show early patient benefits in terms of pain relief, improved activity levels and patient satisfaction. “Chiropractic manipulation is successful because it addresses the under-lying problem, restricted joint function, rather than symptoms only,” according to David Chapman-Smith, Esq., editor of The Chiropractic Report. [16]

Modern evidence-based management of patients with acute low back pain indicates that most patients have mechanical or functional problems rather than disk pathology. That is, dysfunctional or misaligned spinal joints cause the pain and reflex spasm associated with low back pain. Joint Complex Dysfunction is now considered the most accurate explanation of mechanical low back pain.[17] Considering there are 137 joints in the human spine, one can easily understand that most low back pain stems from joint problems and, thus, why spinal manipulation and conservative management of the underlying cause of joint dysfunction has been shown to be effective to help solve this epidemic.

Another recent article by Dr. Deyo in The New England Journal of Medicine (Feb. 2001) also acknowledges that most back pain is “mechanical” in nature, i.e., joint dysfunction. According to his article, “Differential Diagnosis of Low Back Pain,” Dr. Deyo showed that “mechanical low back or leg pain” constituted 97% of these cases, of which “lumbar strain, sprain” accounted for 70% of these cases; “nonmechanical spinal conditions [disk problems] accounted for “about 1%”; “visceral disease” [referred pain from a diseased organ] accounted for 2%.”[18]

Dr. Deyo also mentions chiropractic as a popular solution, “Chiropractic is the most common choice, and evidence accumulates that spinal manipulation may indeed be an effective short-term pain remedy for patients with recent back problems.”[19]

 CONCLUSION:

Many spine researchers and the U.S. Public Health Service agree that chiropractic care is less costly and clinically superior to medical management. Medical economist, Pran Manga, PhD, from the Ontario (Canada) Ministry of Health concludes in his extensive study into this low back pain problem that chiropractic care is the best solution:

 “Chiropractic care is a cost-effective alternative to the management of neuromusculoskeletal conditions by other professions. It is also safer and increasingly accepted by the public, as reflected in the growing use and high patient retention rates. There is much and repeated evidence that patients prefer chiropractic care over other forms of care for the more common musculoskeletal conditions… The integration of chiropractic care into the health care system should serve to reduce health care costs, improve accessibility to needed care, and improve health outcomes.[20]

 Since acute low back pain is the leading on-the-job injury, it behooves the employer and employee to understand the clinical effectiveness and cost-savings with the utilization of chiropractic care for this costly epidemic. Injured workers have the legal right to seek chiropractic care, and employers have the choice to send them for the safest, least costly and most effective form of care for most back problems—chiropractic spinal care.

REFERENCES:



[1] Georgia Board of Workers Compensation as of 10/20/2000

[2] Georgia Board of Workers Compensation as of 10/20/2000

[3] Javis, DB et al., “Cost per case comparison of back injury claims of chiropractic versus medical management for conditions with identical diagnostic codes,” Journal of Occupational Medicine, August 1991, pp. 8437-52.

[4] The Gallup Organization. Demographic Characteristics of Users of Chiropractic Services (Princeton, NJH: The Gallup Organization, 1991)

[5] Bigos S, et al., “Acute Low Back Problems in Adults, Clinical Practice Guideline No. 14,” U.S. Public Health Service, U.S. Dept. of Health and Human Services, AHCPR Pub. No. 95-0642, Rockville, MD: Dec. 1994.

[6] Waddell G. Low back pain: A twentieth century health care enigma. Spine 1996 Dec 15; 21 (24):2820-5

[7] Deyo, RA. Low -back pain., Scientific American, pp. 49-53, August 1998.

[8] Berger E. Later postoperative results in 1000 work related lumbar spine conditions. Surg. Neurol 2000 Aug:54(2)101--6

[9] Deyo, RA. Low -back pain., Scientific American, pp. 49-53, August 1998.

[10] Bigos S, et al., #5.

[11] Deyo, RA, #7

[12] Bigos S. et al. Patient Guide, Acute Low Back Problems in Adults, Consumer Version, Clinical Practice Guideline, AHCPR Pub. No 95-0644 Dec. 1994.

[13] Bigos S. et al. #12.

[14] Bigos S. #12.

[15] Bigos S. #12.

[16] Smith, D,  Managing patients with low back pain. The Chiropractic Report, Jan 1997, vol 11 no.1

[17]Seaman, D. Joint complex dysfunction, a novel term to replace subluxation/subluxation complex. Etiological and treatment considerations. J. Manip Physiol Ther 1997, 20:634-44.

[18]Deyo RA, Weinstein JN. Low back pain. N Engl J Med 2001 Feb 1;344(5):363-70

 

[19] Deyo, RA. Low -back pain., Scientific American, pp. 49-53, August 1998.

[20] Manga P. “Economic case for the integration of chiropractic services into the health care system.”

 J Manipulative Physiol Ther 2000 Feb;23(2):118-22.

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