THE RISE OF COLLABORATIVE HEALTH SETTINGS

HOW DOCTORS OF CHIROPRACTIC ARE ESSENTIAL MEMBERS OF MODERN

MULTIDISCIPLINARY CARE TEAMS

THE

RISE

OF

CO

LLA

BO

RATI

VE

HEA

LTH

SET

TIN

GS

01

Since healthcare began, doctors were in charge. Like Generals in the military, the doctors made the decisions and designed the care plan while the other clinicians and patients followed it. Over the course of the 20th Century, however, healthcare delivery became more specialized and complex than one doctor could manage on his or her own; hence, the introduction of multidisciplinary care teams. The doctor still served as the leader, but consulted with and relied on multiple other doctors, clinicians, as well as patients, to design an optimal care plan.

Although healthcare had been team-oriented for much longer, the policy activity surrounding team-based care can be traced to at least the late 1990s with the Institute for Healthcare Improvement’s Chronic Care Model.1 Since then, care teams have continued to diversify to include other healthcare disciplines that were not typically included even in the 1990s, such as chiropractic.

Enter the opioid crisis.2 The epidemic of Americans misusing and abusing opioids in the United States has sent shockwaves across the healthcare industry. Doctors, government officials, public health leaders and other stakeholders sought new ways to stem the crisis starting at its source: prescriptions. By changing doctors’ prescribing habits, it was hoped fewer Americans would become dependent or addicted to prescription opioids, which would prevent them from seeking more potent and less expensive opioids, such as heroin.

The more these stakeholders studied the issue, the more they found that doctors of chiropractic (DCs) had a lengthy evidence-based history of managing acute, subacute and chronic pain without pharmaceutical interventions. Patients often prefer less invasive, more holistic options than drugs or surgery, which aligns with the Bulletin of the World Health Organization’s article highlighting that after educating patients about low back pain and urging them to remain active, the second-step care options generally include: therapies such as spinal manipulation, most often performed by a DC, as well as massage and exercise.3

In this context, a growing number of DCs are being included in collaborative, multidisciplinary care teams to help curb opioid prescriptions, but also to help patients achieve greater sustained pain relief and mobility. As recent research has shown, the involvement of DCs is having a profound effect on outcomes, as well as patient satisfaction. This white paper details recent cost and outcomes research and insight into how DCs, medical doctors and healthcare organizations can integrate on care teams.

INTRODUCTION

THE

RISE

OF

CO

LLA

BO

RATI

VE

HEA

LTH

SET

TIN

GS

02

TEAM-BASED CARE EFFECTIVE AND LESS COSTLY

Team-based care, especially across disciplines, has been shown to deliver improved patient outcomes.4 While this has been the chief reason for the shift from doctor-led to team-based care, cost is also a significant issue. The United States spends more on healthcare per capita than any other economically developed country.5 Recent evidence shows that this trend is unlikely to abate. National health expenditures are projected to grow at an average annual rate of 5.5 percent from 2018 through 2027 and represent 19.4 percent of gross domestic product in 2027.6

Among healthcare providers, physician subspecialties are often the most expensive members of the care team. According to data presented at a National Academy of Sciences, Engineering, and Medicine Workshop in December 2018, the type of drug-free care for low back pain (LBP) delivered by DCs appears to be less costly to the healthcare system than pursuing a medical care pathway.7 Findings presented by Optum, the health services subsidiary of UnitedHealth Group, showed that a conservative care approach involving chiropractic care or physical therapy for LBP costs the insurer approximately $619 per episode, while primary care costs $728 and care from a specialist costs $1,728. The insurer expects it could save $230 million and reduce opioid prescribing by 26 percent over two years if half of their members would first pursue a conservative approach for their LBP.8

Earlier research on spinal manipulation for back pain supports these findings and is highly relevant to chiropractic care considering DCs perform nearly 94 percent of all spinal manipulations.9 A 2011 study, for example, examined 26 studies concerning healthcare costs for LBP to identify the most cost-effective care.10 Most of the research found that a multidisciplinary approach involving non-pharmacological care, such as spinal manipulation, physical rehabilitation, exercise, acupuncture or cognitive-behavioral therapy were cost-effective in patients with subacute or chronic LBP.

A 2012 study compared spinal manipulation for neck and back pain to care from a medical doctor, exercise and physiotherapy.11 Researchers analyzed cost-effectiveness and cost-utility analysis and found spinal manipulation to be the most cost-effective treatment to manage neck and back pain when used alone or in combination with other techniques compared to primary care, exercise and physiotherapy.

Similarly, in 2016, researchers analyzed ten years of claims data related to LBP from one health insurer to compare utilization and charges from allopathic doctors (MDs), DCs and physical therapists (PTs).12 The study found that when care involved a referral for providers or services—in other words, a team approach—MD and DC care was on average $1,600 less care for uncomplicated LBP and $1,885 less for complicated LBP when compared to MD and PT care.

In all this research and more, chiropractic care alone or with medical care and other types of care is less expensive, often because patients experience pain relief sooner, with less expense, or managed to avoid more costly procedures and other types of healthcare services.

THE

RISE

OF

CO

LLA

BO

RATI

VE

HEA

LTH

SET

TIN

GS

03

Apart from cost, recent research has already shown how adding DCs to multidisciplinary care teams is improving clinical outcomes and patient satisfaction. One of the most comprehensive recent studies of this trend involves nine medical facilities with on-site chiropractic care, including five hospitals and four clinics.13

The study involved 135 stakeholders including DCs, other clinicians, support staff, administrators and patients. Across the facilities, authors note that DCs used an evidence-based approach to patient care, practiced collaboratively within a multidisciplinary team, engaged in interprofessional case management and adopt organizational mission and values.

Researchers found chiropractic care was perceived to have high value among patients, medical providers and the administration. Patient satisfaction scores for chiropractic care were reported as being among the highest of all providers.14 Patients interviewed for the project found it convenient to receive chiropractic care in a facility where they go for their other healthcare needs and were reassured that their providers worked together closely and shared records. As in the cost studies, the facilities participating in this study were found to be less costly while provider productivity was higher.

One of the most common conditions that benefits from a collaborative, multidisciplinary approach is LBP, which affects nearly 30 percent of Americans.15 As such, a study examined how LBP was impacted by medical care with and without chiropractic care. In a randomized controlled trial, 131 older adults with subacute or chronic LBP were divided into three groups using the Collaborative Care for Older Adults with Back Pain (COCOA) testing protocol.16 [The COCOA model is described in greater detail later in this paper]. The patients received 12 weeks of primary medical care, concurrent medical and chiropractic care (dual care), or medical and chiropractic care with enhanced interprofessional collaboration (shared care).

After the study period, participants who received chiropractic care either through dual or shared care reported greater perceived benefits in secondary measures of LBP global improvement, overall health and quality of life compared to the medical care group. Patient perceptions of healthcare quality, such as information, treatment recommendations and provider concern, were also better in those groups.

Researchers noted that participants in the dual and shared groups had more treatment visits to the DC than the medical doctor, which may have provided these clinicians more time to talk with patients about LBP. However, given the considerable costs as highlighted in the Optum study, those added visits are still likely to be less costly than medical subspecialty care while delivering better outcomes and satisfaction.

In a much larger-scale study, 750 active-duty U.S. military personnel at three sites across the country received collaborative care that included chiropractic manipulation integrated with usual medical care. They reported improvement in LBP intensity and disability compared with those who received standard medical care (medication, physical therapy, pain management) alone.17 The study, published in May 2018, is the largest randomized clinical trial in chiropractic research in the U.S. to date, taking place over four years from September 2012 to February 2016.

According to Daniel Lord, DC, Physical Medicine Sr Program Manager, Crossover, “As leaders in neuro-musculoskeletal injury prevention and treatment, doctors of chiropractic are extremely valuable members of a multidisciplinary care team. We provide a large scope of conservative musculoskeletal treatment that facilitates maximal outcomes in the shortest time. Doctors of chiropractic will continue to have opportunities in these settings since more than 80 percent of Americans experience low back pain in their life and management of low back pain and arthritis has reached $200 billion annually.”

TEAMS WITH DCs REPORT BETTER OUTCOMES

THE

RISE

OF

CO

LLA

BO

RATI

VE

HEA

LTH

SET

TIN

GS

04

One of the most significant positive professional qualities DCs bring to these teams, according to another study based on interviews with other clinicians, patients and community members, is “patient-centeredness.”18 DCs were viewed as “respectful, responsive and inclusive of the patient’s values, preferences and needs.” Apart from clinical skills and outcomes, other clinicians emphasized DCs demonstrated a sense of teamwork, resourcefulness and openness to feedback. As researchers point out, these characteristics can and should be cultivated by DCs to positively enhance the patient outcomes and the experience of healthcare, influence clinical decision-making and interprofessional teamwork, and impact healthcare organizations.

Before a DC considers creating a multidisciplinary practice or before a medical practice introduces chiropractic care to their service, they need to conduct an assessment of their goals and an impact analysis for the patients. As doctor and consultant Mark Sanna, DC, points out about creating a multispecialty practice: “A multidisciplinary practice should be created for the benefit of the patient following best practices to maximize outcomes.19 A multidisciplinary practice can offer chiropractic and medical patients a much broader scope of services than those available in either type of practice alone. It will also deliver these services in a more efficient and cost-effective manner.”

To date, DCs are integrated into multidisciplinary care teams across numerous types of care venues. A recent study of these teams showed that 40 percent worked in hospitals, 21 percent in multispecialty offices, 16 percent in ambulatory clinics and 21 percent in other healthcare settings. The median number of DCs per setting was two.20

As far as facilitating collaboration, the same study showed DCs used the same health record as medical staff and worked in the same clinical setting. More than 60 percent reported co-management of patients with medical professionals. Integrated DCs also most often received and made referrals to primary care, physical medicine, pain medicine, orthopedics and physical or occupational therapy.

ADDING DCS TO THE TEAM

THE

RISE

OF

CO

LLA

BO

RATI

VE

HEA

LTH

SET

TIN

GS

05

THE COCOA MODELTo further achieve an interdisciplinary team environment, medical doctors and DCs need to become more familiar with each other’s practice to appropriately refer and coordinate care. This is crucial because medical doctors, outside of a few specialties, receive little training in spinal manipulation or other forms of chiropractic care.

The Collaborative Care for Older Adults with Back Pain (COCOA) model has been shown to be an effective method for integrating primary care doctors and DCs. Released in 2013, the COCOA model is a testing protocol created to study the most effective methods for treating LBP.21 As demonstrated in the clinical-trial study above, the COCOA model was tested with patients divided into three groups: receiving medical care only, chiropractic and medical care separately or a shared modality where DCs and medical doctors worked as a team. As early testing showed, the shared structure delivered the most optimal outcomes, according to patients.

Implementing the shared COCOA model includes three unique elements, which other organizations can emulate for integrating DCs into their care teams:

1. Interprofessional education

2. Research record sharing

3. Team case management

In the study, interprofessional education included a six-month educational program with instruction delivered for both medical physicians and DCs on LBP, medical and chiropractic treatments for LBP and imaging studies for LBP. All shared-care clinicians also completed a half-day site visit at the partner clinic to observe one or more doctors during a typical day treating patients to develop interprofessional collaborative relationships.

For record sharing, the COCOA model included a web application communications module to allow secure, convenient availability and access of participant research records, according to the study. Shared care clinicians and clinical support staff also received automated e-mail notifications when research-related documents are uploaded and available for review.

Collaboration between DCs and family medicine doctors was most intensive for case management portion of the COCOA model. In the study, clinicians uploaded their case summaries onto the secure website and discussed patients’ health history and status, goals, anticipated progress and while developing care plan recommendations. The doctors then mutually agreed to a care plan. From there, the DC or family medicine doctor, whichever the patient chooses, presented the plan and recommendations to the patient and relayed the feedback to their care team member.

Throughout, a close, collaborative relationship is maintained between the doctors, as well as their support staff to ensure care plan progress and patient engagement.

Chiropractic Care’s Role in Opioid Substitution

Since D.D. Palmer invented chiropractic care in 1895, the profession has practiced a non-pharmacological approach. This is especially relevant with the United States still in the grip of an opioid epidemic that killed more than 47,600 Americans through overdoses in 2017.26 While most of those overdose deaths were not due to prescription opioids, initiation of heroin often starts with misuse and abuse of painkilling pills, according to research.27 In fact, of those who began abusing heroin between 2008 and 2010, nearly 83 percent reported that their first opioid was a prescription drug.28

Chiropractic care can be a significant tool in multidisciplinary care teams for diverting patients from opioids before a prescription is even written. According to recent guidelines developed by the American College of Physicians, conservative non-drug treatments should be favored over drugs for most back pain. The recommendations are an update and included a review of more than 150 recent studies. The ACP concluded that, “for acute and subacute pain, the guidelines recommend non-drug therapies first, such as applying heat, massage, acupuncture or spinal manipulation, which is often done by a chiropractor.”29

The Canadian Medical Association Journal Guidelines published in May 2017 strongly recommend non-pharmacologic therapy, including chiropractic, before using opioid therapy for chronic non-cancer pain. Guideline Recommendation 10 provides for “…a coordinated multidisciplinary collaboration that includes several health professionals whom physicians can access according to their availability (possibilities include, but are not limited to, a primary care physician, a nurse, a pharmacist, a physical therapist, a chiropractor, a kinesiologist, an occupational therapist, an addiction medicine specialist, a psychiatrist and a psychologist).”30

These evidence-based guidelines are based on the fact that opioids are simply ineffective for pain while chiropractic care delivers better outcomes. In fact, a 2018 study published in The Journal of Alternative and Complementary Medicine concludes that for adults receiving treatment for low back pain, the likelihood of filling a prescription for an opioid was 55 percent lower for those receiving chiropractic care than for adults not receiving chiropractic care.31

With more than 70,000 practitioners nationwide, DCs on multidisciplinary care teams offer commercial and government payers, employers – and most importantly patients – safe pain relief approaches that offer reduced costs, with improved outcomes and without drugs or surgery.

THE

RISE

OF

CO

LLA

BO

RATI

VE

HEA

LTH

SET

TIN

GS

06

DCs are a necessary and invaluable addition to a multidisciplinary care team. Not only are more healthcare organizations realizing this fact, but so are employers. On-site clinics for large employers now include multiple healthcare and wellness services delivered by multidisciplinary teams, including DCs across the nation.22 The reason? Employers and employees prefer it.

For example, a 2018 Gallup-Palmer College of Chiropractic report shows that 79 percent of U.S. adults would prefer to address their neck or back pain using methods other than prescription medication first.23 The same survey results show 90 percent of adults who saw a DC most often for significant neck or back pain in the last 12 months say their DC often listens (93 percent), provides convenient, quick access to care (93 percent), demonstrates care/compassion (91 percent) and explains things well (88 percent).

According to the University of Southern Florida’s (USF) Chair of the College of Medicine Neurosurgery Harry Van Loveren, MD, states, “USF Department of Neurosurgery employs chiropractors for evaluation, treatment and research as one of its tools to aid patients with spine-related conditions. We work in a comprehensive, compassionate and safe manner with avoidance of opioids and limited use of surgery. We work together for the well-being of our patients.”

Susan Welsh, DC, DACBSP, USF College of Medicine Neurosurgery, states, “Our department of Neurosurgery and Brain Repair includes chiropractic care and research to emphasize that doctors of chiropractic are front runners for neuro-musculoskeletal and spine care in our fully integrative patient-centered clinics. We have over 750 providers in the Morsani College of Medicine at USF and chiropractic is included as a first-line of treatment.”

Patients are demanding chiropractic care and published research is demonstrating that integrating DCs in multidisciplinary care teams will help them achieve their goals. As a result, not only will healthcare costs decrease, but pain management and mobility outcomes will improve and patient satisfaction and quality of life will increase. For any type of doctor, those are goals worth pursuing.

“The literature focusing on integration and collaboration specifically has been overwhelmingly positive for doctors of chiropractic in the last five years or so,” said Jeff S. Williams, DC, host and producer, “The Chiropractic Forward Podcast.” “More and more medical practitioners are developing the understanding that the addition of chiropractic helps patients progress by improving pain management and physical functioning.24 Not only that but doctors of chiropractic, in greater numbers than ever, are currently working in diverse medical settings in various capacities. At least 60 percent of these chiropractors are involved in co-management of patients with their medical colleagues. In many of these facilities, the chiropractor is the sole provider of spinal manipulation.25 At this point in time, there is little doubt that chiropractic standardization, integration and collaboration are the future of our profession.”

THE FUTURE OF MULTIDISCIPLINARY TEAM-BASED CARE

www.f4cp.org

THE

RISE

OF

CO

LLA

BO

RATI

VE

HEA

LTH

SET

TIN

GS

07

1. “Team-Based Care: Optimizing Primary Care for Patients and Providers.” Institute for Healthcare Improvement. http://www.ihi.org/communities/blogs/team-based-care-optimizing-primary-care-for-patients-and-providers-

2. “What is the U.S. Opioid Epidemic?” U.S. Department of Health and Human Services. https://www.hhs.gov/opioids/about-the-epidemic/index.html

3. Bulletin of the World Health Organization 2019;97:423-433. doi: http://dx.doi.org/10.2471/BLT.18.226050

4. “Can Health Care Teams Improve Primary Care Practice?” JAMA. https://jamanetwork.com/journals/jama/article-abstract/198334

5. “How does health spending in the U.S. compare to other countries?” Peterson-Kaiser Health System Tracker. https://www.healthsystemtracker.org/chart-collection/health-spending-u-s-compare-countries/#item-start.

6. National Health Expenditure Projections, 2018–27: Economic And Demographic Trends Drive Spending And Enrollment Growth. Health Affairs. https://www.healthaffairs.org/doi/10.1377/hlthaff.2018.05499

7. National Academies of Sciences, Engineering, and Medicine 2019. The Role of Nonpharmacological Approaches to Pain Management: Proceedings of a Workshop. Washington, DC: The National Academies Press. https://doi.org/10.17226/25406.

8. Et al. “Cost-effectiveness of guideline-endorsed treatments for low back pain: a systematic review.” European Spine Journal. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3176706/

9. “Appropriateness of Spinal Manipulation for Low-Back Pain: Project Overview and Literature Review. Rand Corp.

10. “Spinal manipulation epidemiology: Systematic review of cost effectiveness studies.” Journal of Electromyography and Kinesiology. https://www.sciencedirect.com/science/article/pii/S1050641112000429?via%3Dihub

11. “Variations in Patterns of Utilization and Charges for the Care of Low Back Pain in North Carolina, 2000 to 2009: A Statewide Claims’ Data Analysis.” Journal of Manipulative & Physiological Therapeutics. https://www.jmptonline.org/article/S0161-4754(16)00053-1/fulltext

12. “Chiropractic Integration into Private Sector Medical Facilities: A Multisite Qualitative Case Study.” The Journal of Alternative and Complementary Medicine. http://doi.org/10.1089/acm.2018.0218

13. “Integrating chiropractic into multidisciplinary settings adds value.” Chiropractic Economics. https://www.chiroeco.com/integrating-chiropractic-into-multidisciplinary-setting-adds-value/

14. “Severe headache or migraine, low back pain, and neck pain among adults aged 18 and over, by selected characteristics: United States, selected years 1997–2013.” Centers for Disease Control and Prevention. https://www.cdc.gov/nchs/data/hus/2014/046.pdf

15. “Patient-centered professional practice models for managing low back pain in older adults: a pilot randomized controlled trial.” BMC Geriatrics. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5640949/

16. “Effect of Usual Medical Care Plus Chiropractic Care vs Usual Medical Care Alone on Pain and Disability Among US Service Members With Low Back Pain: A Comparative Effectiveness Clinical Trial.” JAMA Network Open. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2680417

17. “Be good, communicate, and collaborate: a qualitative analysis of stakeholder perspectives on adding a chiropractor to the multidisciplinary rehabilitation team” Chiropractic & Manual Therapies. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6014012/

18. “The multidisciplinary model.” Chiropractic Economics. https://www.chiroeco.com/the-multidisciplinary-model/

19. “Integration of Doctors of Chiropractic Into Private Sector Health Care Facilities in the United States: A Descriptive Survey.” Journal of Manipulative & Physiological Therapeutics. https://www.jmptonline.org/article/S0161-4754(17)30154-9/fulltext

20. “Disciplinarities: intra, cross, multi, inter, trans.” Alexander Refsum Jensenius. Blog. http://www.arj.no/2012/03/12/disciplinarities-2/

21. Collaborative Care for Older Adults with low back pain by family medicine physicians and doctors of chiropractic (COCOA): study protocol for a randomized controlled trial” Trials. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3557195/

22. F4cp.com. (2018). F4CP|Educating the public. [online] Available at: http://www.f4cp.com/files/press- releases/2017/12.13.17_NAWHC_chiropractic_research.php

23. “Stakeholder expectations from the integration of chiropractic care into a rehabilitation setting: a qualitative study.” BMC Comp Altern Med. https://bmccomplementalternmed.biomedcentral.com/articles/10.1186/s12906-018-2386-3

24. “Integration of Doctors of Chiropractic Into Private Sector Health Care Facilities in the United States: A Descriptive Survey.” Journal of Manipulative & Physiological Therapeutics. https://www.jmptonline.org/article/S0161-4754(17)30154-9/fulltext

25. “The 2018 Gallup-Palmer College of Chiropractic Annual Report.” https://www.palmer.edu/alumni/research-publications/gallup-report/managing-neck-and-back-pain-in-america/

26. “Overdose Death Rates.” National Institute on Drug Abuse. https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates

27. “Prescription opioid use is a risk factor for heroin use.” National Institute on Drug Abuse. https://www.drugabuse.gov/publications/research-reports/relationship-between-prescription-drug-heroin-abuse/prescription-opioid-use-risk-factor-heroin-use

28. “Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain relievers – United States, 2002–2004 and 2008–2010.” Drug and Alcohol Dependence. https://www.sciencedirect.com/science/article/pii/S0376871613000197?via%3Dihub

29. “No Drugs for Back Pain, New Guidelines Say.” Wall Street Journal. https://www.wsj.com/articles/no-drugs-for-back-pain-new-guidelines-say-1487024168

30. “Guideline for opioid therapy and chronic noncancer pain.” CMAJ : Canadian Medical Association Journal. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5422149/

31. “Association Between Utilization of Chiropractic Services for Treatment of Low-Back Pain and Use of Prescription Opioids.” The Journal of Alternative and Complementary Medicine. http://doi.org/10.1089/acm.2017.0131

FOOTNOTES

This paper represents the views of the author, not America’s Health Insurance Plans (AHIP). The publication, distribution or posting of this paper by AHIP does not constitute a guaranty of any product or service by AHIP.