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TEXAS SENATE PUBLIC HEARING

Testimony for Workers’ Compensation Select Interim Committee

Norwalk, Iowa, Thursday, April 29, 2004—Anthony Rosner, Ph.D., LL.D. (Hon.), Director of Research and Education at the Foundation for Chiropractic Education and Research, delivered testimony at a public hearing of the Texas Senate Select Committee on Workers' Compensation in Austin, TX on April 29, 2004. His appearance, at the invitation of Parker Chiropractic College, was to present data supporting the cost-effectiveness of chiropractic services in refutation to implications from the data of the Workers Compensation Research Institute (WCRI) suggesting that chiropractic services are a major driver of significant increases of workmen's compensation benefits in Texas. Among the alleged points of contention were the high number of chiropractic visits per episode compared to other states.

Dr. Rosner has taken issue with numerous documents relating to chiropractic health care and workers’ compensation benefits released by the WCRI since November 2001, offering testimony at that time in the Pennsylvania state legislature and releasing an extended report through the Congress of Chiropractic State Associations (COCSA) late last year. Among the arguments he has offered in opposition to the WCRI reports are that: (i) the sampling frame of chiropractors chosen must be truly representative of all practitioners within the state and presented with detailed information as to the distribution of costs, number of visits, and numbers of procedures applied within that sampling frame; (ii) details of the actual comparative outcomes of claimants through different providers must be furnished; (iii) bundling and billing of all services provided must be clearly spelled out; (iv) the case mix between providers compared must be more clearly matched in severity; and (v) the actual sum of benefits paid out to chiropractors (less than 5%) for back pain is but a minuscule fraction of the 16-33% of workers' compensation expenditures for back pain, refuting the contention that chiropractors have been a major cost burden to workers’ compensation benefits.

It is hoped that Dr. Rosner's presentation will persuade members of the Texas Senate Committee to conduct a balanced and impartial review of healthcare costs within the workers’ compensation system, consistent with the approach of the International Association of Industrial Accidents Boards and Commissions which Dr. Rosner recently joined at its All-Committee meeting in Kissimmee, Florida.

The complete testimony is given below.  In addition, his complete 30-page report refuting the details of recent reports from the WCRI can be obtained from the Congress of Chiropractic State Associations at www.cocsa.org.

Dr. Rosner's Testimony

Thursday, April 29, 2004, 1:00 pm

Good afternoon, Mr. Chairman--I am pleased to introduce myself as the Director of Research and Education from the Foundation for Chiropractic Education and Research, a nonprofit foundation that in its 60-year history has provided both financial support and oversight for over $10M worth of pilot projects and stipends for postgraduate study in areas pertaining to the theory and practice of chiropractic healthcare. My background includes a Ph.D. in biochemistry from Harvard, clinical laboratory directorship at a Harvard teaching hospital and an affiliate of the Mayo Clinic, and extensive grants administration and development. I am here at the request of the Parker College of Chiropractic in Dallas.

I want to thank the Senate Select Committee on Workers' Compensation for hearing my testimony and particularly for its intention to more closely review some aspects of cost analysis which lurk behind healthcare costs and benefits, which appear to have eluded too many but thankfully not all individuals in policymaking positions. I fear that part of this problem are some flaws in the interpretation of data from the Workmens' Compensation Research Institute^1-3--flaws which have suggested that chiropractic services have become a major cost driver of benefits in Texas within recent years. I ask the Committee's indulgence in focusing upon a few of these flaws in its deliberations.

1. Sampling frames have to be clearly identified: In the state of California, in which similar trends have been presented by the California Workers' Compensation Research Institute,³ it has been suggested that the large number of visits observed can be attributed to just 3-5% of chiropractors who are responsible for 80% of the costs.⁴ Until we see a complete set of data allowing us to verify that the sampling frame of chiropractors chosen is truly representative of all practitioners within the state of Texas AND what the distribution of the costs, number of visits, and numbers of procedures is within this sampling frame, we cannot draw any meaningful conclusions.

2. Data on actual comparative outcomes in comparison years is lacking: There is no indication in the WCRI data what the comparative levels of disability were at the workplace when the worker returned to his or her place of employment. Should the worker have returned in a shorter period of time and/or performed at a higher efficiency in the more recent years, the increase in WC payments would have been offset by higher worker productivity with lower costs for replacement training and long-term rehabilitation. This simply has to do with good medicine rather than simply closing the books on a claim at an arbitrary time point without validation.

3. Bundling and billing of services is problematical: Bundling of all germane costs for an episode of care remains elusive--whether for ancillary issues such as the actual costs of all medications, laboratory or hospital services or for indirect costs such as [i] workdays lost by patient, [ii] retraining for replacement labor, [iii] caregiver to assist in domestic duties, [iv] iatrogenic events associated with treatment, and [v] legal [malpractice] settlements and premiums. Previous studies have never fulfilled all these criteria,⁵ although a recent report from CIGNA comes closer than most.⁶ A report from a leading healthcare economist commissioned by the Ontario Provincial Government has concluded that, in a typical patient's visit to the office of an M.D., 20% of medical services lie within the office visit itself while 80% of the charges are billed to ancillary services. For visits to the chiropractor's office, these two percentages are almost diametrically opposed--as most costs are contained within the chiropractor's office.^7,8 The data from the WCRI studies^1,2 bear no resemblance to these proposed ratios and raise further questions as to precisely how they were calculated. The caveat is to avoid splitting up the actual treatments for non-D.C. patients into separate categories when in fact they are linked to the same episode and must consequently be bundled. Finally, surgical costs were omitted in one report² while drug costs, a notorious driver of the high costs of healthcare,^9-12 seem vastly underestimated as suggested by postings of $7 or "insignificant" amounts per episode in the state of Connecticut.²

4. Data on case severity and case mix are conspicuously lacking: Other than a general weighting of different states, there is no primary data evident which adequately defines the allocation of case mix and severity between provider groups or years being compared. Regarding back pain alone, one must ask for instance whether the incidence of specific conditions or injuries [such as herniated disc] changed from earlier to later periods. Should the more difficult cases such as herniated disc have appeared more frequently in later years, they would be expected to require the more exhaustive treatment periods and assortments of procedures reported.

5. Data on permissible scopes of practice in the comparison years are lacking: The increase in the number of procedures reported may have to do with changes in the permissible scope of practice during that period. Also, the number of procedures/case for other healthcare professions should be reported for comparison.

6. WC benefits paid to chiropractors represents a minuscule proportion of the total: From the WCRI's own sampling frame of 12 representative states, the actual distribution of medical payments per claim to chiropractors is a paltry 4% of the total, substantially less than the 31% given to physicians, the 10% allocated to PT/OTs, or the 36% earmarked for hospitals.¹ In Georgia, chiropractors workers' compensation cost recoveries were just 0.8% of the benefits disbursed to physicians in 1997 and 1998,^13,14 while low back pain costs have been estimated to consume between 16-33% of workers' compensation distributions.¹⁵

These are but a few of the issues with recent reports from the WCRI^1-3 which I have described elsewhere addressing the WCRI in particular¹⁶ and workmens' compensation issues in general.¹⁷ Accordingly, chiropractic interventions which produce tangible results, a commitment to research and documentation of the highest recognized quality,^18-20 high patient satisfaction, and cost-effectiveness should be given full consideration for optimal involvement in workmens' compensation benefits. In this presentation I request that the Senate Committee members display a commitment to working with us to both carefully study and achieve these goals with regard to establishing truly cost-effective healthcare over the long term.

REFERENCES:

¹Eccleston SM, Zhao X. The anatomy of workers' compensation medical costs and utilization: Trends and interstate comparisons, 1996-2000. Cambridge, MA: Workmen's Compensation Research Institute WC-03 04, 2003.

²Victor RA, Wang W. Patterns and cost of physical medicine: Comparison of chiropractic and physician-directed care. Cambridge, MA: Workmen's Compensation Research Institute, WC-02-07, 2002.

³California Workers' Compensation Institute, Bulletin 03-06, March 20, 2003.

⁴Walen W. e-mail sent to Dynamic Chiropractic, September 19, 2003 and printed in the same publication, 2003; 21(22): 38.

⁵Branson RA. Cost comparison of chiropractic and medical treatment of common musculoskeletal disorders: A review of the literature after 1980. Topics in Clinical Chiropractic 1999; 6(2): 57-68.

⁶Schaffer WA, Margoshes B. The disability and HealthCare connection..How strong is the link. Report from CIGNA Corporation, 2004.

⁷Manga P. Economic case for the integration of chiropractic services into the health care system. Journal of Manipulative and Physiological Therapeutics 2000; 23(2): 188-122.

⁸Manga P. Enhanced chiropractic coverage under OHIP as a means for reducing health care costs, attaining better health outcomes and achieving equitable access to health services. Report to the Ontario Ministry of Health, 1998.

⁹Health Care and Financing Administration, as reported in the New York Times, October 29, 1999.

¹⁰National Institute for Health Care Management Research and Education Program, prepared by the Barents Group LLC, July 9, 1999.

¹¹Report from the Department of Health and Human Services, reported in the New York Times, January 8, 2002.

¹²Findlay S, National Institute of Health Care Management, as reported by Anjetta McQueen, The Boston Globe, May 8, 2001.

¹³www.ganet.org/sbwc/about/

¹⁴Smith JC. email notice of August 11, 2000.

¹⁵Hooper P. Dynamic Chiropractic 1994; 12(25).

¹⁶Rosner A. Workmens' compensation issues and chiropractic care: Response to Workmens' Compensation Research Institute Data. Report released to the Congress of Chiropractic State Associations, October 9, 2003.

¹⁷Rosner A. Workers' compensation costs and chiropractic: Taking a position on center stage. Journal of the International Association of Industrial Accidents, Boards and Commissions May 2004; In press.

¹⁸Hurwitz EL, Aker PD, Adams AH, Meeker WC, Shekelle PG. Manipulation and mobilization of the cervical spine: A systematic review of the literature. Spine 21(15): 1746-1760.

¹⁹Kjellman GV, Skagren EI, Oberg BE. A critical analysis of randomised clinical trials on neck pain and treatment efficacy: A review of the literature. Scandinavian Journal of Rehabilitative Medicine 1999; 31: 139-152.

²⁰Bronfort G, Assendelft WJJ, Evans R, Haas M, Bouter L. Efficacy of spinal manipulation for chronic headache: A systematic review. Journal of Manipulative and Physiological Therapeutics 2001; 24(7): 457-466.

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