The chiropractic physician is qualified to intervene in community health problems, with necessary consultations and referral networks.

The chiropractic physician treats lesions which manifest as body pain, systemic symptoms, altered neuromusculoskeletal function, altered flexibility, and disturbed physical performance.

Chiropractic physicians address patient problems from the pediatric to the geriatric populations without gender restriction.

Chiropractic care is not restricted to any organ system, pathology or methodology. It provides non-drug/non-surgical holistic care with due regard to patient safety.

Chiropractic physicians directly encounter patients with acute and chronic illnesses.

Primary care, which is characterized by first contact, continuity and longitudinal responsibility for patients that span all stages of the life cycle, demonstrates that chiropractic physicians are ideal candidates to be sentinels for the welfare of their patients.

The primary care chiropractic physician in Iowa coordinates care, including care provided by other specialists. The chiropractic physician is the ombudsman for patient contacts with other providers; referring patients to appropriate specialists, providing pertinent information to and seeking opinions from specialists and explaining diagnosis and treatment to patients.

Chapter 201 ODS Licensure and regulation rules:( 201.2) Defines "Primary Care" to mean essential, community based health care services that are coordinated, comprehensive, accountable and accessible on a first contact and on an ongoing basis. Primary care includes diagnosis and treatment, prevention, maintenance of chronic problems, and linkages for specialized care.

On the evidence, particularly the most scientifically valid clinical studies, spinal manipulation applied by doctors of chiropractic is more effective than alternative treatments for spine problems (LBP).

Many medical therapies are of questionable validity or are clearly inadequate. There is an overwhelming body of evidence indicating that chiropractic management of spine problems is more cost effective than medical management.

Numerous studies reviewed range from very persuasive to convincing in support of this conclusion. The lack of any convincing argument or evidence to the contrary must be noted and is significant in forming conclusions and recommendations.

The evidence includes studies showing lower chiropractic costs for the same diagnosis and episodic need for care.

To date the model for medical and osteopathic gatekeeping has not been defined or explained. Indeed, the pattern of referrals to primary care chiropractic health care providers demonstrates that the referrals are usually based upon excessive case load by the MD/DO primary care physician. Cases are "dumped" to the DC which decrease the financial impact on the "gate", so-called "cherry-picking" by the primary care MD/DO.

Specialists, nationally board certified and recognized by the US Government agencies regulating tertiary levels of education, do exist within chiropractic health care.

The causes of greater economic efficiency and equity are much more likely to be served by effecting a shift toward less expensive forms of delivery and away from medically-dominated, technology-oriented high cost medicine.

The boundaries between health care professionals have and will continue to change because of changes in educational systems, medical technologies, information systems, insurance coverage and the organization of health care services.

Keeping service boundaries intact is an illusory and unwise goal and is counterproductive to the objectives of improving the efficiency of Iowa's health care system.

Turf is money. It is important to understand that battles over professional turf will shape to a considerable extent the nature and design of the new health care system. It also determines the efficiency of the system.

Suffice it to say, there is great scope for professions other than medical doctors to assume greater responsibilities in delivering services and caring for patients in institutional and especially in non-institutional settings.

Scientific data has accumulated to support the efficacy and cost-effectiveness of manipulative neuromusculoskeletal health care.

Between 1900 and 1993, 17,000 articles concerning chiropractic health care have been published in 700 biomedical journals. Currently 190 textbooks are in print concerning chiropractic, and OCLC identifies more than 1500 textbooks.,

From 1940 to 1993, 58 controlled trials have been completed, concerning chiropractic health care. Indeed the delivery of manipulative care by doctors of chiropractic has been widely scrutinized.

A retrospective worker’s compensation study was conducted in Australia. The study compared chiropractic and medical management of 1996 cases of work-related mechanical low back pain. The number of compensation days taken by claimants was found to be significantly lower; an average of 6.26 days for chiropractic patients and 25.56 days for medical patients.

In the Australian study the average cost of compensation for chiropractic management was $392 and for medical management $1569 or four times greater than chiropractic management.

The 1991 RAND study confirmed the appropriateness of spinal manipulation for some low back pain patients.(RAND 1991)

In 1988, chiropractic care was found to be more cost-effective than the standard medical care in the management of work-related back injuries. The results of this study indicated that chiropractic patients suffered shorter periods of disability and their cost of care was lower, compared to patients of medical doctors who were likely to be hospitalized. (Florida Study, 1988)

Also in 1991 a study found that patients of chiropractic returned to work sooner after an injury, reporting an average of 2 lost work days versus 20 under standard medical care. The study also revealed that chiropractic care was 10 times less expensive than standard medical care in compensation payout. (Utah Workmen's Compensation Fund/LACC/Greenwalt Fellowship Fund, 1991)

A 1991 study examined cost comparisons between medical and chiropractic providers for back-related injuries with identical diagnostic codes. It concluded that compensation costs for work time lost were and astonishing $68.38 for patients who received chiropractic care, compared to $668.39 for patients who received standard, non-surgical medical treatment.

The number of work days lost under medical care in the Phillips study was nearly ten (10) times higher than those receiving chiropractic care.

A major study examined 10,562 closed cases of patients with back related injuries who were covered by Florida’s worker’s compensation law to compare chiropractic case management with standard medical case management. The results indicated that the duration of temporary total disability was 51.3% shorter for chiropractic patients, the cost of service was 58.8% lower and 52.2% of medical claimants were hospitalized versus 20.3% of chiropractic patients.

A nationwide demographic study of users of chiropractic services was conducted by the renowned Gallup Organization. They found that nine of ten chiropractic users felt their treatment was effective. Eight of ten chiropractic users were satisfied with the treatment they received and they felt that most of their expectations were met.

Chiropractic patients are described as being three times more satisfied with their care than patients of family practice physicians.

A survey presented to the Governor and General Assembly of Virginia examined mandated insurance claims. Their findings indicated that doctors of chiropractic offered the lowest median cost per visit for therapeutic exercise, massage, ultrasound in comparison to physicians, physical therapists, podiatrists.

The research organization Louis Harris and Associates of New York conducted a study of 1253 Americans to determine the public’s general experience with back problems. The survey revealed that 70% of the general public feels that chiropractic care should be a basic benefit of their health care plan. Direct access to a chiropractor without having to see another doctor first was supported by 62% of the general public.

Chiropractic patients who submit back injury claims return to work faster than family/general practice, orthopedic or physical medicine patients, according to a pilot study prepared by Willis Corroon Corporation for the State of New Hampshire.

According to the New Hampshire study, patients who received chiropractic care lost an average of just 16 working days; family/general practice patients lost an average of 37 days; orthopedic patients lost 90 days and physical medicine patients lost 140 days. Thirteen patients who initially sought family/general practice care and then changed to a specialist lost a staggering 193 work days.

3-year British comparison of chiropractic care and standard medical care of low back patients found chiropractic treatment more effective than hospital outpatient management for patients with chronic or severe back pain.

A 1991 Dutch project comparing manipulative therapy (chiropractic) and physiotherapy (physical therapy) for the treatment of persistent back and neck complaints found that after 12 months, the chiropractic treatment group showed better improvement in the primary complaints as well a in the physical function, with fewer visits.(Koes'/ Dutch Ministry of Welfare)

A study funded by the Ontario Ministry of Health and conducted by Pran Manga, PhD, was done to determine, among other things, the efficacy of chiropractic management of low back pain(LBP). Dr. Manga found that "on the evidence, particularly the most scientifically valid clinical studies, spinal manipulation applied by chiropractors is shown to be more effective than alternative treatments for LBP." Based on his findings, Dr. Manga recommended that the Ontario Ministry of health fully integrate chiropractic into its health care system.

The US Government has also taken a giant step in support of spinal manipulation. In December 1994 the Agency for Health Care Policy and Research (AHCPR), an arm of the Department of Health and Human Services, published and announced its new clinical practice guidelines for the treatment of acute low back problems in adults. The guideline was developed by a multi disciplinary team that reviewed relevant scientific research on LBP treatments.

The AHCPR Guideline found that for patients with acute low back pain without radiculopathy [disease of the spinal nerve roots], the scientific evidence suggests spinal manipulation is effective in reducing and perhaps speeding recovery within the first month of symptoms. The panel goes onto recommend spinal manipulation as a first line of treatment for low back problems.

Shortly after the launching of the US Guideline, the British National Health Service announced its new guideline on back pain, developed by the Clinical Standards Advisory Group (CSAG).

Like the US panel, the British panel found there is now evidence that manipulation is an effective method of providing symptomatic relief for some patients. The British panel recommends an early conservative intervention for back pain to prevent chronic pain conditions or other potential complications.

As recently as 12/12/94, the United States Department of Defense implemented plans for integration of Doctors of Chiropractic in the military health services (MHS) for the various branches of the armed forces.

The Doctors of Chiropractic are functioning in primary care capacities for active duty personnel, retired personnel and dependents. The Doctors of Chiropractic have been placed in roles and duties analogous to MD/DO Medical Corps personnel and are delivering primary care management, with adjustment of the neuromusculoskeletal system as a critical modality.

Early data collection has supported the claim of cost effectiveness of manipulative care and the need for such care in the management of human ailments to maintain armed personnel in a state of "battle readiness".

The Doctors of Chiropractic are now serving at ten (10) military treatment facilities, caring for a minimum of 60,000 active duty personnel per site.

Chapter 201 for ODS licensure and regulation that each ODS shall provide information to the department (of Insurance) on measures of quality, access, member satisfaction, membership and utilization, finance and management. With regard to access, the department shall establish indicators of access to care with in an ODS.

At least one of the indicators shall be the ratio of primary care providers to enrollees by category of provider. The regulatory agency exists now and has rules to implement such oversight. The needs for more regulation are negated as are additional cost burdens.

In Iowa, there are 855 Doctors of Chiropractic, 7,846 Doctors of medicine, and 1,049 Doctors of Osteopathy.

There are 49 Iowa communities that do not have a medical doctor or an osteopathic doctor, but do have a chiropractic physician.

According to a recent census approximately 448,800 Iowans state-wide receive chiropractic health care.

It has been demonstrated that 4.0%-7.5% of the population of the United States will use chiropractic physical medicine within a three to five year period.

The chiropractic patient population numbered 10-18.75 million persons in 1992, and will include twice that number over the next few years (20-37.5 millions).

For Iowa, the figure of 448,800 chiropractic patients represents 16% of the population, more than double the national experience.

In many instances these citizens are using the doctor of chiropractic as a portal of entry into health care.

While most of the health problems presented can be diagnosed by either a chiropractic physician or a medical physician, under most, if not all third party payer systems, services by the medical physician are fully insured while chiropractic physician services are only partially covered.

This is especially severe under Medicare guidelines.

Patients using chiropractic health care incur the highest out-of-pocket expenses for those services. Virtually no out-of-pocket expenses are incurred for medical treatment, with the exception of drugs.

The disparity in out-of-pocket costs serves as an artificial barrier to conservative and cost-effective primary health care.

The Iowa public is acutely aware of the disincentives to needed health care, i.e., co-pays and out-of-pocket expenses.

In the context of a primary portal of entry for health care, the chiropractic physician assesses the various physiological and biomechanical aspects of the patient's health problem.

In many instances modern chiropractic health care includes supplementing manipulation with a variety of physiotherapeutic modalities, exercises and nutritional counseling.

As stated earlier, in 49 Iowa communities, the Doctor of Chiropractic is the only source of primary health care. Two-hundred and forty Iowa communities only have one physician of any type.

Evidence is now surfacing that the strict "gated" plans are devolving to the former, tightly controlled panels, with unlimited access by patients enrolled in those plans. Costs are controlled via capitation systems. "Gating" and capitation are redundant schemes.

Based upon the "Iowa experience" in chiropractic health care, pre-reform markets demonstrated utilization of chiropractic health care services to be 16% of the total Iowa population.

In 1994 there were 135000 subscribers under an Iowa based large multi-product, single company system. Nine chiropractic providers were used across 9 gatekeeper products. For 1994 there was a total of 148 referrals from gatekeepers to chiropractic providers in the 9 gated plans, for all 135000 patients. In Iowa 448,000 to 600,000 citizens utilize chiropractic health care in any 12 month period. This represents a approximately 16% chiropractic health care utilization or encounter frequency statewide The expectation for gated referrals should have been 21,600 in the course of a year or 2,400 per chiropractic provider for the gamut of plans offered by the single company. The actual experience percentage of subscriber base that was referred in 1994 is .0011%, instead of 16%. This alone largely identifies the gross misrepresentation of accessibility of subscribers to services paid for and covered in contractual health care indemnification agreements.

In 1993, at the time of gatekeeper implementation, the Group Health Association of American reported in an industry-wide survey, with a 72% response rate, that gated chiropractic healthccare encounters ranged from 0.01 to 1.21 encounters or refrerrals per thousand per year.

Total insurance payments have been found to be substantially greater for medically initiated episodes, especially for episodes of care lasting longer than 1 day. For the latter category, total payments were nearly twice as great for the medically initiated cases and their outpatient payments were nearly 50% higher.

Inclusion of chiropractic health care coverage provides a more socially optimal package of insurance coverage than would emerge from the private decisions of individual insurers, employers and households.

Using three statistical methods, the claims made, actuarial and hedonic price approaches there is little evidence that chiropractic health care services increase gross outpayment by more than 1%. The actual net cost effect appears to be lower than 1%, perhaps approaching O% or even cost reducing.

The low cost impact of chiropractic health care is due not to its low rate of use, but to its apparently offsetting impacts on costs in the face of high rates of utilization.

By every test of cost and effectiveness, the general weight of evidence demonstrates chiropractic health care to provide important therapeutic benefits at economic costs. Additionally, these benefits are achieved with apparently minimal, even negligible impacts of the costs of health insurance.

Health reform in Iowa appears to be designed to limit the supply of health care providers and restrict competition to MD/DO physicians from DC physicians.

The primary result is an increase in physician fees and income that drives up health care costs. In some instances, managed care sytems (panels, PPO, HMO, and Gated) have generated 13%+ premium increases to subscribers since late 1994, at a time when the models were touted to demonstrate premium savings.

It is widely known that about seventy percent or more of the existing medical technology and procedures have not been subjected to adequate cost-effectiveness analysis. at least 30% of hospital admissions are thought to be inappropriate.

Some studies are motivated by the burgeoning evidence of sizable variations in medical practice, inappropriate provision of care, and doubtful effectiveness of treatment or service.

There is no question that many of these studies are motivated by concerns about the very sizable cost and the economic waste of inappropriate care.

Other concerns are the quality of care and the desire by patients and the public generally for more informed decisions about health care treatment.

The role of medicine in this work will be significant, but it must not be dominant: after all it is due to the absence of scientific rigor in medicine that we are so ignorant about appropriateness and cost-effectiveness today.

It is also interesting to note that the majority of standard treatments provided by all health providers for all disorders, whether these disorders are minor or life-threatening, have not been validated by formal scientific methodology.

Only about 15% of medical interventions are supported by valid evidence and many have not been assessed at all.

Health care reform in Iowa presents unique problems that are not adequately addressed in any broad national plan. Iowa has a large elder population, the majority of which is living and working in rural environments. It also has an unusually large base of self-employed citizens in the agricultural industries.

The citizens of Iowa consider the delivery of adequate levels of health care to be of great importance., Above all else these statewide characteristics require special consideration in the drafting of an Iowa health reform plan.

There are at least three reasons for inclusion. First, many thousands of Iowans currently use chiropractic services. Second, chiropractic is high quality, low cost care that saves millions of health care dollars. And third, Doctors of Chiropractic provide important primary health care services which are key to health promotion and disease prevention.

The total health care expenditure for Iowa in 1991, (combined state and private dollars) was $4.631 billions. Nationally, chiropractic health care costs $2.4 billion (1988) annually. This represents .01% of the estimated $473.320 billion national health care budget.

Patients seeking chiropractic care received an average between 5 and 18 visits per episode. Chiropractic care is most frequently used by persons who are white, middle-aged, employed and high-school educated.

As will be recalled, chiropractic health care was a mode of care originally included in the Governor’s Health Reform bill, offered in the 1994 Legislative Session. Chirpopractic health care was stricken from the Bill while in deliberations in the Iowa Senate.

The patients of Iowa have been seeking inclusion of chiropractic health care services since that time. The Governor’s Health reform bill was produced form the delibrations of the Iowa Health Reform Council

However, to restrict direct access for subscribers to chiropractic health care is anti-competative and serves as a restraint of trade

A Case History:

Cost Savings Through Prevention

In 1989, the survival of Saco Defense, INC., a federal defense contractor, was threatened by Pentagon cut-backs and by growing worker’s compensation costs that had reached critical proportions. Thanks to a remarkable plan based on prevention that was established with the help of a consulting Doctor of Chiropractic, Saco Defense was able to reduce injuries, increase teamwork and bring those figures down to an all-time low.

"We were facing a projected worker’s compensation premium of $2 million when I joined Saco Defense in 1989," said Greg Black, Vice President of Human Resources. "With the help of Dr. Robert Lynch’s input, we reduced the cost of worker’s compensation to $40,000 in 1993, by creating a series of continuous improvement programs that were designed to decrease work related injuries and lost time."

The results of the plan were extraordinary. In 1990 there were 44 lost time injuries, in 1994 there were two. In 1990 there were 913 work days lost, in 1994 there were three. In just four years there was an 82% improvement in the number of lost time injuries, a 73.3% reduction in worker’s comp costs per hours worked, and a 70% decrease in OSHA recorded injuries.

A review of SACO’s injury records and personal interviews revealed that soft tissue injuries were creating hard dollar problems. In 1989, a staggering 1050 lost work days were attributed to soft tissue injuries. Armed with and extensive knowledge of physiology and ergonomics from his chiropractic experience, Dr. Lynch set out to create a program to reduce injury through prevention.

A trip to the factory floor brought about changes in workstations and immediate corrections in the way a task was performed, but Mr. Black and Dr. Lynch recognized that creating a working team was as important as designing ergonomically correct workstations. To do this, everyone, from the floor manger to union officials had to recognize the importance of a strong team committed to solving the problem. Each and every one eagerly took part in the program.

Employees were empowered by becoming part of ergonomic teams in which individual employees were trained to reviewed different job sites for ergonomic evaluation. All employees also took part in an educational program on common conditions like lower back and disc injuries, carpal tunnel and tendonitis. And twice a day, supervisors lead employees in warm-ups and exercises to help reduce injuries.

A combination of new, ergonomically correct workstations, workplace safety programs, and flexibility conditioning has resulted in major cost savings for Saco Defense. These basic concepts can and should be widely adopted to reduce injuries and ultimately improve the bottom line.

Iowans and their employers seek opportunities to reduce health care costs. Based upon ponderal evidence, Direct Access to chiropractic health care in managed care Plans ensures such opportunity. Denial of such access disenfranchises both from quality, low cost health care.

Footnotes available on request.