John Weeks February 2013 Integrator Round-up covering the topic of Economics

Back Surgery Incidence at a Fraction for Those Who First Visit Chiropractors

A press release from the Foundation for Chiropractic Progress highlights a recent study of data from the state of Washington: Early Predictors of Lumbar Spine Surgery after Occupational Back Injury: Results from a Prospective Study of Workers in Washington State. Concluded the authors: “Reduced odds of surgery were observed for those under age 35, women, Hispanics, and those whose first provider was a chiropractor.” And: “42.7% of workers who first saw a surgeon had surgery, in contrast to only 1.5% of those who saw a chiropractor.” Finally: “There was a very strong association between surgery and first provider seen for the injury, even after adjustment for other important variables.”

Comment: The cost-savings from “CAM” such as was found in the recent Medical Expenditures Panel Survey (MEPS) study is typically via foregoing expensive tests and procedures. It remains astonishing that more plans and employers do not directly establish programs that push users toward chiropractors. Culture, power dynamics and loyalties rather than evidence would seem to be shaping decision processes. The chiropractic profession would serve itself by clarifying and even certifying those chiropractors who wished to be “primary care for back pain.” They will need to assure that patients would be able to appropriately access non-chiropractic practitioners of yoga, of acupuncture, of massage or other treatment, including surgery, when manual manipulation is not the most appropriate or only treatment suggested. 


Money in Medicine: “Economic Impact” of Teaching Hospitals IncreasesIs This a Good Thing?

On January 7, 2013 the e-news of the Association of American Medical Colleges (AAMC) featured a notice entitled: “Medical Schools, Teaching Hospitals Generate Billions for Economy.” The synopsis of a recently completed economic impact analysis by the consulting concluded that the nation’s medical schools and teaching hospitals “infused $587 billion into the economy while supporting nearly 3.5 million jobs in 2011, reflecting a 15 percent increase over the impact institutions had on the economy the last time the analysis was conducted in 2008.

Comment: Should medicine be bragging that it is growing as an industry? Shouldn’t it only brag if it has been so successful in creating a healthy population that it needs to retrain hospital-based professionals and technicians as community workers because we are getting a handle on the growth of major conditions and limiting the waste and harm in our tertiary care environments? This release brings to mind the Congressional and community battles over closures of military bases. The debate is not about mission and need, if it ever way, but rather about protecting the industry, and jobs. Former Centers for Medicare and Medicaid administrator Don Berwick, MD has been particularly outspoken about these ethical issues. He asks medicine to consider how these “billions for the healthcare economy” are taking social investment from education, transportation and the environment. Paul Grundy, MD, MPH, IBM’s global director for health, is more blunt about such boasting. He calls these economically-bloated academic health centers “milking machines.” Asks Grundy of the academics in medicine: “What happened to you guys?” The AAMC’s advocacy reeks with a corruption that is all the worse for the apparent lack of consciousness. 


Growth in Bucks Spent on CAM Practitioners Flattens

A team led by researchers out of Dartmouth and the Rand Corporation concluded in widely-covered study published in Health Affairs that services of complementary and alternative medicine providers have “plateaued” at $9-billion, or 3% of total ambulatory care. (See US Spending On Complementary And Alternative Medicine During 2002-08 Plateaued, Suggesting Role In Reformed Health System.) The authors suggest that the flattening may be connected to the increase in co-payments for services of chiropractors and others. They suggest that, given this small contribution to cost, attempts to cut expenses in medicine through targeting elimination of coverage of complementary and alternative healthcare services will have little impact on the overall economic burden of the medical system on the economy. The researchers conclude that for some conditions and disciplines, such as chiropractic management of low back pain, the system may actually save money through more coverage in delivery contexts such as accountable care organizations where the incentive structure favors keeping people healthy.

Comment: How do we explain the flattening of investment in these services, even as costs continue to expand in other areas? Is there a natural limit to conditions or populations that may benefit from CAM? Antagonists might propose that there is a happy limit to gullibility and the placebo’s impact. The unfortunate reality is that neither the mainstream delivery system nor the research establishment that enables it have much interest in exploring how, and when, these providers may actually create cost-savings compared to regular care. (Note that the Implementation and Dissemination program above is not a call for new research.)

Why is this? If fewer procedures and surgeries are needed, the economic impacts of the academic health centers swing into decline. (See Teaching Hospitals Generate Billions for Economy, above.) Few people or institutions willingly engage the suicidal act of funding their own undoing. Ultimately the responsibility for making a case for cost savings from “CAM” and integrative health will not come from those whose interests are opposed. The leadership must be from those who need the data, namely the public, payers such as employers, the elected officials who represent them, and perhaps most of all the integrative health and medicine community. To date, these have done more complaining about what the system is not doing than organized advocacy for what needs to be done. They have not spoken up, except in rare instances, to directly urge the NIH and NCCAM to do the kind of research that is needed. Leadership is needed.