Do I Need a Referral for Chiropractic Care?

Do I Need a Referral for Chiropractic Care?

So, I think I?m somewhat of an introvert, but the reality is, I really like people. Moreover, I really like helping people, which is the main reason I became a doctor of chiropractic. Over the last twenty years, I?ve seen the profession grow tremendously, not necessarily related to the number of practicing chiropractors or even the number of people who are seeing a chiropractor at any one time ? currently around 8% of the population. The growth I?ve seen is tied to QUALITY. What has driven that growth in quality? Data. As they say, ?the data doesn?t lie.? There have been enough clinical studies over the last twenty years that now, manipulation and exercise are recommended as appropriate treatments in mainstream medical guidelines for spine related conditions.1-4 Clinical guidelines are the highest level of evidence ? basically, it?s telling physicians what the preponderance of high-quality evidences suggests to get the best outcomes for patients. When an individual, especially a physician, says, ?I don?t believe in chiropractic,? or ?physical therapy isn?t necessary?, they clearly don?t know the evidence.

And now, in the age of big data and business intelligence (BI), we?re learning even more about the COST impact of healthcare decisions. Optum Health, a division of UnitedHealthcare ? the largest private insurer in the country, has been collecting and mining data for many years. From 2007-2014, I sat on their Chiropractic Professional Advisory Committee, and they shared not only their data with us, but the important insights derived from this data. Recently, Dr. David Elton, SVP Clinical Programs, Optum Physical Health, presented the most recent spine care data on an Optum Health Education Webinar.

Here?s what we know from millions and millions of data points from across the country:
-Of all healthcare costs, orthopedic condition costs make up the largest piece of the pie.

-Of those orthopedic costs, non-operative spine care makes up the largest portion of the orthopedic costs. Yes, surgery is expensive, but there are a lot less people who get surgery compared to those who don?t. The numbers of patients who don?t get surgery are enormous and therefore the sheer volume of patients who suffer with non-operative spine care costs a whopping $194,560,793 in Maryland alone!

-Key drivers of cost are inefficient and ineffective care ? Unnecessary imaging, injections, and opioid use making up a big portion of these costs and ineffective care.

-The key take home? If we want to reduce cost and improve outcomes, then ?The first provider seen by a patient with a SRD may be the most important decision that is made,? according to Elton and their millions of data points. ?Patients with Spine Related Disorders keep looking until they find a provider who has the time, knowledge and skills to help them, and ideally this is the first provider seen.? So, it?s all about making the right decision the FIRST time when it comes to treating and rehabilitating non-operative spine care conditions.

-So, who is the right provider? Well according to the clinical guidelines, and according to the cost data, it?s a provider who provides the following treatments ? an evidence based doctor of chiropractic :

  • Manipulation/spinal adjustments
  • Exercise Prescription
  • Massage/Soft tissue treatment
  • Patient education

-According to the cost data, if you see an evidence-based doctor of chiropractic, one who provided the above treatments, at the beginning of the episode as the first provider seen, the total cost of care averaged $636. The main reason? Less use of expensive imaging and less need for opioids and other prescription medications. When manipulation/spinal adjustments are never introduced during the course of care (ie the PCP or other providers are managing the care), the average episode costs are $1,300! So basically, without the use of manipulation/spinal adjustments, costs DOUBLE. Equally important, when patients enter the chiropractic portal of entry FIRST, the total cost of care is the lowest compared to any healthcare provider portal of entry.

-Further, the cost impact is even more significant as case complexity rises. In other words, the more complex the case, the better the cost savings when patients are seen by an evidence-based doctor of chiropractic.

-Lastly, according to Optum?s data, when patients start with their PCP, costs rise DRAMATICALLY after day three of the episode, without the introduction of manipulation and exercises (?97xxx? on the graph). Why? Imaging (orange) and injection (yellow) and prescription drug (green) costs go up. Pretty simple. No introduction of evidence-based conservative care (manipulation and rehab exercises) means patients don?t get better. So more drugs, more imaging and higher costs are the results. Note that the manipulation and exercise costs remain virtually constant even with delayed introduction of those services. So, we can dramatically reduce costs with early intervention of evidence-based chiropractic by being the portal of entry provider for these conditions .5

picIn this new era of healthcare reform, the operative word is value. Patients demand value because they are paying more for their healthcare ? they want (and deserve) their healthcare dollar spent to go a lot further. Employer costs are rising, and they want their healthcare dollar spent to go further as well. Our PCP referral partners also want total costs to go down. New healthcare delivery models are incentivizing our PCP?s to get better outcomes at lower costs. Our PCP referral source partners that are saving money on total spine condition episode costs will be eligible to reap financial rewards by participating in the shared savings plan delivery models ? Accountable Care Organizations and Patient Centered Medical Homes.

The days of ?beliefs? are gone. When millions of data points from the largest private insurer in the country, UnitedHealthcare, point to non-operative spine care patients needing to see an evidence-based doctor of chiropractic first for better outcomes at a lower cost, then patients must be armed with this knowledge to make better decisions on who to see, and when to see the right doctor. So when I meet those folks who say, ?my back hurts?, or ?my neck hurts?, and they ask, ?Do I need a referral??, I simply state, ?Unless your insurance policy requires it, the overwhelming evidence suggests that if you start with us first, you?ll get the desired clinical result at a substantially lower cost.?

Dr. Jay Greenstein, DC
CEO, Sport and Spine Rehab
[email protected]


1 Chou and Huffman. Annals of internal medicine (2007); 492-504.
2 Chou, et al. Annals of internal medicine (2007); 478-491.
3 Delitto, et al. J Orthop Sports Phys Ther. (2012); 42(4): A1-A57.
4 Childs, et al. J Orthop Sports Phys Ther. (2008); 38(9): A1-A34.
5. Elton et al. Leveraging Data to Improve the Quality and Affordability of Spine Care, Optum Health Education (2015)

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