OUTCOMES, ACCESS, AND COST THE CHIROPRACTIC ANSWER: COPAY PARITY - PowerPoint PPT Presentation

OUTCOMES, ACCESS, AND COST THE CHIROPRACTIC ANSWER: COPAY PARITY NC C HIRO PRA C TIC A SSO C IA TIO N Dr . Joe Sir a g usa – E xe c utive Dir e c tor www.nc c hiro .o rg drjo e @ nc c hiro .o rg 919-832-0611 e xt. 104

WHY SHOULD SHP CHIROPRACTIC CO-PAYS BE LOWERED? • Chiro pra c tic Ca re is sa fe , no n-d rug , no n-surg e ry c a re fo r pa tie nts, pro vid e d b y Do c to rs o f Chiro pra c tic who a re lic e nse d b y the sta te o f NC. • Chiro pra c tic Ca re is c o st-e ffe c tive c o mpa re d to sta nd a rd me d ic a l c a re fo r se le c te d c o nd itio ns. • Chiro pra c tic c a re , whe n pro pe rly inc e ntivize d b y lo we r c hiro pra c tic c o -pa ys c a n po te ntia lly sa ve pa tie nts a nd e mplo ye rs mo ne y, inc re a se pa tie nt c ho ic e a nd pro vid e re lie f to me d ic a l prima ry c a re o ffic e s.

CHIROPRACTIC OVERVIEW • Prima ry po rta l o f e ntry into the he a lth c a re syste m • Autho rity to e xa mine , d ia g no sis, tre a t, ma na g e , re a sse ss a nd re fe r b y the NC Bo a rd o f Chiro pra c tic E xa mine rs • Chiro pra c to rs prima rily tre a t spine re la te d c o mpla ints suc h a s lo w b a c k a nd ne c k pa in

WHY COPAY PARITY? • Pa tie nts d e se rve c ho ic e o f pro vid e r fo r b a c k a nd ne c k c o nd itio ns. • T he le g isla ture pa sse d a no n-d isc rimina tio n sta tute (90-157.1 F re e Cho ic e b y Pa tie nt Gua ra nte e d ) to e nsure tha t pa tie nts ha d the ir c ho ic e o f pro vid e rs. • Curre ntly, c hiro pra c tic c o pa ys a re no t c o nsiste nt with the spirit a nd inte nt o f tha t la w.

EXAMPLE OF A PLAN WITH PCP $30 COPAY VS. DC (SPECIALIST) $70 COPAY Pr ima r y Ca r e Doc tor of Chir opr a c tic Ide ntic a l Ba c k Pa tie nt Physic ia n Visit Visit $128 $68 T o ta l Co st o f Visit $30 $70 Pa tie nt’ s Co pa y $98 $0 Insure r Pa ys (Pha nto m Be ne fit) 5

RELIEF FOR THE PRIMARY CARE SYSTEM • Pa tie nt c ho ic e with c hiro pra c tic c o pa y pa rity will a llo w pa tie nts to c ho o se a d o c to r o f c hiro pra c tic witho ut pe na lty o f hig he r c o pa ys, a nd will o pe n up c a pa c ity in prima ry c a re o ffic e s.

CHIROPRACTIC CO-PAY PARITY • Co pa y pa rity wo uld pro hib it he a lth pla ns fro m re q uiring tha t c o nsume rs pa y a hig he r c o -pa y fo r c hiro pra c tic visits whe n c o mpa re d to a PCP visit fo r a c o mpa ra b le c o nd itio n • Co pa y pa rity d o e s NOT ma nd a te c hiro pra c tic o r PCP c o -pa y a mo unts

SOUTH DAKOTA LANGUAGE HB 1146 • "No he a lth insure r ma y impo se a ny c o pa yme nt o r c o insura nc e a mo unt o n a n insure d fo r se rvic e s re nd e re d b y a d o c to r o f c hiro pra c tic lic e nse d pursua nt to c ha pte r 36-5 tha t is g re a te r tha n the c o pa yme nt o r c o insura nc e a mo unt impo se d o n the insure d fo r the se rvic e s o f a prima ry c a re physic ia n o r pra c titio ne r fo r the sa me o r a simila r d ia g no se d c o nd itio n e ve n if a d iffe re nt no me nc la ture is use d to d e sc rib e a c o nd itio n."

NORTH CAROLINA SB 561 5 SE CT ION 1. G.S. 58-50-30(a 3) re a ds a s re writte n: • 6 "(a 3) Whe ne ve r a ny he a lth b e ne fit pla n, sub sc rib e r c o ntra c t, o r po lic y o f insura nc e issue d • 7 b y a he a lth ma inte na nc e o rg a niza tio n, ho spita l o r me dic a l se rvic e c o rpo ra tio n, o r insure r • 8 g o ve rne d b y Artic le s 1 thro ug h 67 o f this Cha pte r pro vide s c o ve ra g e fo r me dic a lly ne c e ssa ry • 9 tre a tme nt, the insure r sha ll no t impo se a ny limita tio n o n tre a tme nt o r le ve ls o f c o ve ra g e if • 10 pe rfo rme d b y a duly lic e nse d c hiro pra c to r a c ting within the sc o pe o f the c hiro pra c to r's pra c tic e • 11 a s de fine d in G.S. 90-151 unle ss a c o mpa ra b le limita tio n is impo se d o n the me dic a lly ne c e ssa ry • 12 tre a tme nt if pe rfo rme d o r a utho rize d b y a ny o the r duly lic e nse d physic ia n. An insure r sha ll no t • 13 impo se a s a limita tio n o n tre a tme nt o r le ve l o f c o ve ra g e a c o -pa yme nt a mo unt c ha rg e d to the • 14 insure d fo r c hiro pra c tic se rvic e s tha t is hig he r tha n the c o -pa yme nt a mo unt c ha rg e d to the • 15 insure d fo r the se rvic e s o f a duly lic e nse d prima ry c a re physic ia n fo r a c o mpa ra b le me dic a lly • 16 ne c e ssa ry tre a tme nt o r c o nditio n." •

J OEL STEVANS, DC P O S T D O C TO R A L FELLO W S C H O O L O F H EA LTH & R EH A B ILITA TIO N S C IEN C ES U N IV ER SITY O F P ITTS BUR G H

BACK PAIN - KEY STATISTICS • L o w b a c k pa in is ub iq uito us • 80% will e xpe rie nc e it in the ir life time • 40% will e xpe rie nc e it a nnua lly • 14% will se e k tre a tme nt a nnua lly • $90 b illio n a nnua lly in dire c t me dic a l c o st • 2 nd le a d ing sympto ma tic re a so n fo r physic ia n visits • Mo st c o mmo n re a so n fo r visits to o rtho pe d ic surg e o ns a nd ne uro surg e o ns • 3 rd mo st c o mmo n re a so n to und e rg o surg e ry • 5 th mo st fre q ue nt c a use o f ho spita liza tio n • $50 b illio n a nnua lly in a b se nte e , disa b ility, a nd lo st pro duc tivity • Mo st c o mmo n c a use o f lo st wo rk pro d uc tivity • 2 nd le a d ing c a use o f lo st wo rk time (1 st c o mmo n c o ld ) • Mo st fre q ue nt re a so n fo r d isa bility a mo ng wo rking a d ults 11

KEY CONCERN IN HEALTH BENEFIT PLANS • OptumHe a lth, a Unite d He a lthc a re c o mpa ny, re po rts: • Ortho pe dic pro b le ms a re the mo st c o stly c o nditio n c a te g o ry • Spine pro b le ms a c c o unt fo r 46% o f the se c o sts • Blue Shie ld o f CA re po rts b a c k pro b le ms a re third hig he st b y a llo we d c o sts • UPMC He a lth Pla n re po rts tha t o nly c a nc e r a nd c a rd io va sc ula r c o nd itio ns c o st mo re tha n b a c k pa in 12

BACK PAIN – COST DRIVERS Pr e vale nc e (Millions) Phar mac y E xpe nditur e s (Billions) 25 $5 20 $4 15 $3 10 $2 5 $1 0 $0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Spine Inje c tion Rate s pe r 100,000 Spine F usion Sur ge r y Rate s pe r 100,000 5000 80 4000 60 3000 40 2000 20 1000 0 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 1998 1999 2000 2001 20022003 2004 2005 2006 2007 2008 E p id ural F a c e t Sac ro iliac L umba r Ce rvic al T ho rac ic 13

EVIDENCE BASED LBP GUIDELINES Ac ute & Sub Ac ute Chr onic Pa tie nt E duc a tio n Pa tie nt E duc a tio n No nna rc o tic Ana lg e sic No nna rc o tic Ana lg e sic NSAIDS NSAIDS Prima ry Spine Ca re Spina l Ma nipula tio n Sho rt-te rm Opio ids Spina l Ma nipula tio n Ba c k e xe rc ise s Spine Inje c tio ns Be ha vio ra lthe ra py Surg e ry Multidisc iplina ry Re ha b ilita tio n Spe c ia lty Spine Ca re Spine Inje c tio ns Surg e ry 14

AMBULATORY EXPENDITURES BY PROVIDER TYPE 15

AMBULATORY EXPENDITURES PCP VS SPECIALIST 16

EPISODE COSTS FOR NON-SURGICAL BACK PAIN OptumHe a lth (adjuste d) $1,400 $1,200 $1,000 $800 $600 $400 $200 $0 DC PCP Spe c ia list 17

SPREADING THE WORK LOAD Distribution of Porta l of E ntry Provide r for Ba c k Proble ms (1.5 million e pisode s) 26% 40% 34% Chiro p ra c to r Prima ry Ca re Physic ia n Me dic a l Spe c ia list 18

ALIGNING EVIDENCE & POLICY • UPMC Insura nc e Se rvic e s Divisio n po lic y fo r Surg ic a l Ma na g e me nt o f L o w Ba c k Pa in • “Spina l surg e ry will b e c o nsid e re d me d ic a lly ne c e ssa ry…whe n me mb e rs ha ve fa ile d c o nse rva tive ma na g e me nt…” • Co nse rva tive Ma na g e me nt inc lud e s the fo llo wing : 1. No n-Pha rma c o lo g ic T he ra py 2. Pha rma c o lo g ic T he ra py 3. E a rly re fe rra l to c hiro pra c to r o r physic a l the ra pist 19

WHY IS COST SHARING IMPORTANT? • Co st sha ring de c re a se s ne c e ssa ry & unne c e ssa ry se rvic e s • Inc re a sing c o st-sha ring fo r so me , b ut no t a ll, se rvic e s c o uld c a use pe o ple to sub stitute mo re e xpe nsive fo rms o f c a re • Re spo nse s to c o st-sha ring ma y diffe r b y inc o me e ve n a mo ng g ro ups tha t a re no t lo w-inc o me • Pe o ple in po o r he a lth o r with c hro nic c o nditio ns ma y b e mo re se nsitive to c o st-sha ring tha n he a lthy pe o ple 20

COST SHARING RESTRICTS CHIROPRACTIC ACCESS • Ra nd o mize d c o ntro lle d tria l to e va lua te e ffe c ts o f c o st sha ring o n he a lth c a re q ua lity & c o sts • F a milie s a ssig ne d d iffe re nt b e ne fit d e sig ns & le ve ls o f c o st sha ring (e .g ., 25%, 50% c o insura nc e ) • T he o d d s o f a c c e ssing c hiro pra c tic pro vid e rs we re 71% lo we r a t 25% c o insura nc e c o mpa re d to fre e c a re • Co nc lusio n: c hiro pra c tic c a re is ve ry se nsitive to c o st sha ring …mo re tha n o ve ra ll a nd o the r o utpa tie nt e xpe nse s 21