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New California Law Limits
Workers' Compensation Visits to Chiropractors

Stephen Barrett, M.D.

Chiropractors are notorious for "keeping their patients coming back." Many advise everyone to have their spine checked for "subluxations" and "adjusted" throughout life. Many chiropractors advise people whose symptoms have stopped to keep coming back for "preventative maintenance. Some chiropractors are networked with attorneys (and even medical doctors) to provide unnecessary tests and treatment to injured works and auto accident victims. Partly as a result, in many states, workers' compensation programs has become so expensive that employers have asked their state legislature to limit the amount of chiropractic coverage.

In 1992, Florida Trend magazine published a cover story on "why chiropractors get blamed for fueling the cost of workers' compensation." The author concluded that, "Workers' compensation is fraught with abuse, but no other players in the system rile business more than the chiropractors." A spokesman for the American Insurance Association even said that, "Sometimes I think of workers' comp as the chiropractic full-employment act." Some health-insurance companies called for limits on chiropractic treatment, and some wanted chiropractors out of the WC system altogether. The main complaints were about exaggerated diagnoses, overtreatment, and aggressive marketing aimed at patient retention from cradle to grave. The author also noted:

Less scrupulous attorneys turn to chiropractors, hoping they will give injured workers the highest impairment rating and extend treatment for as long as possible. The chiropractors who play the game are then rewarded with a steady stream of clients provided by their unspoken lawyer/partners.

The payback for a lawyer comes in the medical expenses: The larger the expenses, the more the lawyer can expect, with legal fees paid by the insurer. . . . If a carrier disputes a claim . . . the lawyer can rack up hefty costs for time-consuming depositions and pre-trial appearances. Meanwhile, the chiropractor continues to provide treatment [1].

Two studies have focused attention on the problem in California. The first one, published by the Workers Compensation Research Institute of Cambridge, Massachusetts, analyzed 28,539 workers' compensation cases involving back strains and sprains in California and four other states and concluded:

• Chiropractic care could achieve the same outcome at lower costs if the number of visits were limited (see Figure A).
• Chiropractor-directed physical medicine care costs 30% more than physician-directed care and achieved the same outcomes as measured by duration of temporary disability.
• The higher number of visits that chiropractors use per case is the major driver behind the higher physical medicine payments.
• In Florida, chiropractic care achieved the same outcome at lower cost than physician-directed physical medicine care in Florida where reimbursement rules place strict limits on the number of chiropractic visits per case that will be reimbursed by workers' compensation payors. The fact that treatment and billing practices by Florida chiropractors result in lower medical costs while achieving a similar duration of disability as physician-directed care may provide lessons that other states can draw from.
• Physical medicine services are most often used for back injuries, representing 41% of all injuries that receive such services. This is not surprising because back injuries -- mostly strains and sprains -- represent one-quarter of all workers' compensation injuries, so they are disproportionately more likely to receive physical medicine services.
• In most cases, physicians manage care and arrange for physical medicine, either within or outside their organizations. Chiropractors are involved in about 13% of the cases, two-thirds of which are under the exclusive care of chiropractors.
• The average payment per workers' compensation claim was 30% higher in chiropractor-treated cases in California, Connecticut and Texas to achieve the same duration of disability as they are in physician-directed care. That's because chiropractor-treated claims involve more than double the number of visits, although the payment per visit is 19% to 24% lower.
• On average, chiropractors use 137% to 158% more visits that provide physical medicine services and 74% to 90% more visits for which office visits are billed. By contrast, in Florida, chiropractor-treated claims are 10% less expensive than similar physician-treated claims to achieve the same duration of disability. Medical costs per claim are 14% lower to achieve the same outcome.
• Florida chiropractors appear to treat and bill differently from chiropractors in other states. For example, Florida chiropractors treat with an average of eight visits per claim for claims with more than seven days of lost time from the job. Chiropractors in the other study states treat these cases with an average of 14 to 35 visits per claim. And Florida chiropractors are less likely to bill for office visit codes, and when they do, they bill for fewer visits.
• Part of the reason for the different results is that Florida law mandates absolute limits on the number of chiropractic visits per case -- the lesser of 18 visits or eight weeks of treatment.
• Cases treated exclusively by chiropractors have much longer durations of physical medicine services. Nearly one-quarter have durations of 15 weeks or more. Only 35% have durations of 4 weeks or less.
• The shortest durations of physical medicine treatment involve cases in which physicians manage treatment. In these cases, physical medicine services are either provided internally, externally by physical therapists or through hospital providers. Between one-half and three-quarters receive two weeks or less of services and more than three-quarters receive four weeks or less. About 5% have durations of physical medicine services of 15 weeks or more.
• Cases treated by both chiropractors and physicians, either sequentially or concurrently, have the longest durations of treatment with 43% having durations of 15 weeks or more [2,3].

The second study, published a few months later by the California Workers Compensation Institute (CWCI), analyzed data from 134,312 cases in which a chiropractor was identified as a service provider on work injury claims from accident years 1993 to 2000. The Institute reported:

• More than one out of every six California workers' compensation treatment dollars paid to classified medical providers paid for chiropractic care, even though proportion of claims in the system involving chiropractic services declined from 8.0% in 1993 to 6.1% in 2000.
• The average amount paid for chiropractic care on these claims climbed more than 75% ($1,100) as the average number of visits per claim rose 48%, the average number of procedures per claim more than doubled, and the average number of unique procedures performed by chiropractors during the course of each claim increased 27%.
• Snapshots of the average payments, average number of visits, and average number of procedures per claim at 12 and 24 months after injury showed that the increased utilization of chiropractic services started early in the life of the claim, indicating that chiropractic providers became more aggressive in the way they treat injured workers. The result has been a significant increase in chiropractic costs in California workers' compensation, with more dollars now spent on chiropractic services than on any other classified medical specialty.
• The California Chiropractic Association reports that between 1995 and 2000, the number of licensed chiropractors in California grew from 9,879 to 12,600, a 27.5% increase. At the same time, however, workers' compensation claim frequency declined and the number of injured workers in California fell from 825,000 to 787,000, a 4.6 % drop. Thus, the ratio of chiropractors to injured workers increased by one-third from 1.2 per 100 in 1995 to 1.6 per 100 in 2000. The combined effect of an increase in the number of chiropractic providers servicing fewer injured workers with higher levels of chiropractic services per claim increased both the average cost per claim and the overall cost of chiropractic care in California workers' compensation [4].

In 2003 , the California legislature held a hearing on a bill (SB 354) that called for limiting chiropractic care without special authorization to 15 visits per claim. This provision was subsequently removed by an amendment, but a representative of the California Chiropractic Association made an interesting comment about the hearing:

Unfortunately, many of our arguments fell on deaf ears when an advertisement touting a chiropractic seminar to "double or triple" workers' compensation income from the "high profit" market, with testimonials bragging of increases of income of "over $30,000," was passed around by Sen. Speier. The effect of the ad was immediate and devastating [5].

California Senate Bill 228, which took effect on January 1, 2004, states that for injuries occurring on or after that date, an employee shall be entitled to no more than 24 chiropractic and 24 physical therapy visits per industrial injury. The law, part of a 6-bill package intended to curb runaway costs, was passed in the wake of two reports which concluded that the costs of treating back strains and sprains for injured workers with physical medicine services, such as manipulations, exercise, hot and cold packs and massage were greater when the care was directed by chiropractors than when it was managed by physicians.

In 2005, the California Worker's Compensation Institute (CWCI) concluded that SB228 had sharply reduced the cost of chiropractic and physical therapy. SB 228 states that employees shall be entitled to no more than 24 chiropractic and 24 physical therapy visits per industrial injury. The CWCI study found that since January 2004, the average number of chiropractic visits per case has been about 50%% lower and payments per chiropractic claim have been nearly nearly 60% lower than they were in 2002. For physical therapists, the average number of visits per claim dropped about 44% and the total cost per claim dropped about 48%. At the time implementation began, payments for physical therapy and chiropractic manipulation together comprised 37% of all California workers' compensation outpatient costs [6].

References

1. Coletti RJ. The manipulators. Florida Trend 35(2):32-36, 1992.
2. Patterns and Costs of Physical Medicine: Comparison of Chiropractic and Physician-Directed Care. Cambridge, MA: Workers Compensation Research Institute, Dec 2002.
3. Chiropractor-directed costs more than when physical medicine care is managed by physicians, says WCRI study: Chiropractic care could achieve lower costs by limiting visits. WCRI media release, Jan 23, 2003.
4. Changes in Utilization of Chiropractic Care in California Workers' Compensation, 1993-2000. California Workers Compensation Institute, March 21, 2003.
5. Whalen WM. California DCs face Workers' Compensation dilemma: SB 354 would require MD authorization after 15 visits. Dynamic Chiropractic 21(12):23, 2003.
6. [Swedlow S. The Utilization & Cost of Physical Therapy and Chiropractic Manipulation in California Workers’ Comp Following Implementation of Mandatory UR and 24-Visit Caps. California Worker's Compensation Institute, 2005]