Alberta Expert Advisory Panel
Report on Chiropractic

December 2002

The mission of Alberta's Expert Advisory Panel is to ensure that the province's publicly funded health services remain comprehensive, sustainable, and good value. The panel's most important considerations are effectiveness and cost-effectiveness. The chiropractic section of its first progress report (shown below) expressed concern about rising costs and recommended that chiropractic services be limited to treatment for pain related the muscles and joints of the spine and pelvis.

Chiropractic Care

Current situation

Chiropractic services are not covered under the Canada Health Act. Currently, the Alberta Health Care Insurance Plan provides coverage for chiropractic services up to a maximum of $200 per person per year. 418,000 clients were served in 2000-01 and close to three million services were provided. 85% of the clients are 19 years of age and older. Since 1997, chiropractic services have grown by 5.7% per year. In 2000-01, the Alberta Health Care Insurance Plan paid $36.5 million for chiropractic services. Chiropractors are allowed to charge patients a co-payment over and above the rate paid by the Alberta Health Care Insurance Plan.

Research Group Findings

Chiropractic services do not fail the technical screen.

  • Evidence suggests that the risks of cervical manipulation are small and within an acceptable range.
  • Based on limited evidence, chiropractic care appears to be as effective as other treatments for acute and chronic back pain. Patients also report high levels of satisfaction with chiropractic treatments. There is insufficient evidence to judge whether treatments for other conditions are effective.
  • Most chiropractic services are not well integrated with other health services.
  • There is insufficient evidence to draw conclusions about cost effectiveness.

Chiropractic services may not pass the social and economic screen.

  • The existing significant co-payment does not appear to have limited access. However, without public funding, access may be an issue for premium-subsidy clients.
  • Catastrophic coverage is not an issue.
  • Chiropractic services do not affect independence, however, the evidence suggests that chiropractic care does provide short-term relief from back pain. Minority ethical views are not an issue.
  • There is considerable overlap in services with physical therapy and some overlap with physician services.
  • Chiropractic services may be covered by employer or individual supplementary health insurance plans.
  • Chiropractic care is not covered by the Canada Health Act and it is not funded in the majority of Canadian jurisdictions.
  • In terms of consistency with health reform, the Research Group notes that there are no issues related to chiropractic services.

Chiropractic services may not pass the fiscal screen.

  • Although costs are not increasing as fast as some other allied health services, costs are increasing by 5.6% a year and are not sustainable given provincial revenue growth.

Assessment by the Expert Advisory Panel

The Panel reviewed the findings of the Research Group and, based on the evidence available and the burden of proof for currently funded services, concluded that chiropractic services did not fail the first screen. In terms of the second screen, opinion was divided and the majority of Panel members did not support continued public funding for all chiropractic services.

The Panel was concerned primarily with continuing access to treatment for back pain. Both chiropractic services and physical therapy can be used to treat back pain. Research reviewed by the Research Group indicates that there is no evidence to suggest that one type of treatment is preferable than the other. Both can be effective for specific individuals and under certain conditions. Consequently, the Panel’s view is that funding for chiropractic treatments and physical therapy treatments for back pain should be handled in a consistent way. If public funding is not provided for either chiropractic care or community physical therapy, there would be a significant gap in access to treatment for back pain. The Panel therefore concluded that continued public funding was important to ensure access to treatment in the community.

The Panel also considered whether or not public funding for the treatment of back pain (provided by either chiropractors or physical therapists) should be restricted to adults only. Because 85% of the clients are 18 years of age and older, limiting the services to adults would ensure that funding is targeted to those who use the services the most. However, there are cases where adolescents, in particular, may have back pain as a result of sports injuries, falls, or other causes. Therefore, an argument was made that they should have access to publicly funded treatment for back pain on the same conditions as adults. On the other hand, back pain is not common in young children and can be a result of serious medical conditions. Chiropractors who see children with health-related back pain would typically refer them to physicians. While there is no evidence to suggest that the treatment of back pain in young children by either chiropractors or physical therapists is unsafe, an argument was made that, because of the potentially serious health conditions involved, public funding should not be provided for treatment of back pain in children by either chiropractors or physiotherapists. Children could continue to access these services, but no public funding would be available.

Recommendations

Public funding for chiropractic services should be limited to treatment for pain related to the muscles and joints of the spine and pelvis.

A co-payment should be allowed and an annual cap should be set on the funding to be provided per person per year. A single, annual shared cap should apply to both chiropractic and community physical therapy treatments for pain related to the muscles and joints of the spine and pelvis.

Funding should not be continued for chiropractic services provided outside the province or outside Canada.

The Panel supports public funding for these treatments for adults but was unable to reach a consensus on whether or not public funding should be provided for treatment of back pain in children by either chiropractors or physiotherapists.

Advice to Minister

  • The Panel did not review each of the services provided within the category of chiropractic services. Individual services could be reviewed in future for possible public funding provided that they meet the requirements of the three screen process.
  • The Panel could not come to a consensus on the question of whether public funding for treatments of back pain should be limited to adults. There is insufficient evidence for the Panel to assess the effectiveness of these treatments and, given the timelines involved, the Panel was not in a position to do any further research on the question. This relates directly to an overall concern by the Panel that there frequently is insufficient evidence on a number of treatments and services to assess their effectiveness in treating certain health problems. The Panel suggests that further research should be done on the effectiveness of these treatments in children. The Panel would be prepared to reconsider the issue when additional research evidence is available.
  • In the case of community physical therapy, there is evidence to suggest that services are more effective if they are integrated with other types of care. While comparable evidence is not available for chiropractic care, given the similarity in services, the Panel believes a good case can be made for improving the integration of chiropractic care with other types of health services and treatments.
  • The Panel also notes that there are inconsistencies across the province in terms of chiropractors’ access to x-ray services. In the major centres, chiropractors can refer patients to x-ray services in clinics and, in some cases, in hospitals. In smaller centres, x-ray services are only available in hospitals and a referral from a physician is required. The Panel suggests that regional health authorities should consider entering into agreements with chiropractors to allow access to x-ray services without a physician referral.
  • In order to contain increasing costs, the Panel suggests that the government may want to consider alternative ways of capping the amount of funding provided for these services including an overall cap on the amount allocated to these treatments or adjustments to the annual cap on services per individual.

This page was posted on June 16, 2008.

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