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House Committee on Veterans' Affairs
Subcommittee on Health

Hearing on Chiropractic Services
in the Department of Veterans Affairs
October 3, 2000

Testimony of RADM Michael L. Cowan, MC, USN
Deputy Executive Director and Chief Operating Officer
Tricare Management Activity
Office of The Assistant Secretary of Defense For Health Affairs

Mr. Chairman, I am Rear Admiral Michael Cowan, Deputy Executive Director and Chief Operating Officer, TRICARE Management Activity, Office of the Assistant Secretary of Defense (Health Affairs) and I am pleased to be invited here today to share with you and the members of the Subcommittee, the Department of Defense's experience with its Chiropractic Services Demonstration.

As you may know Mr. Chairman, health care services in the Department of Defense are provided to approximately 3.5 million active duty personnel and their dependents and 2 million retirees and their dependents through TRICARE, the Department's managed care program. Before the Chiropractic Demonstration Project, chiropractic care was not offered at any of the health care facilities within the Military Health System (MHS). Individuals seeking chiropractic treatment visited a civilian chiropractor and paid for their care out-of-pocket. Neither the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) nor other DoD funding covered chiropractic care.

The Chiropractic Demonstration was mandated by the National Defense Authorization Act for Fiscal Year 1995. The Act directed the Secretary of Defense to evaluate the feasibility and advisability of offering chiropractic health care at military treatment facilities (MTFs). The Act specifically required the Department to provide chiropractic health care services at no fewer than 10 military treatment facilities. It also required the Department to establish an Oversight Advisory Committee to provide guidance in program development and implementation. Finally, we were required to submit plans for evaluating the program and produce a final report at the end of the demonstration period

Under that requirement, DoD established chiropractic demonstration programs at ten military clinics: Fort Benning, GA; Fort Carson, CO; Fort Jackson, SC; Fort Sill, OK; Jacksonville Naval Base, FL; Camp Lejeune, NC; Camp Pendleton, CA; Scott AFB, IL; Travis AFB, CA; and Offutt AFB, NE. Also, three comparison (or control) sites Pensacola Naval Air Station, Pensacola, FL; Fort Stewart, GA; and Andrews AFB, MD collected data on patients being treated by traditional providers.

Subsequently, the National Defense Authorization Act for Fiscal Year 1998 directed the Secretary of Defense to expand the Chiropractic Health Care Demonstration Program into at least three new treatment facilities: Walter Reed Army Medical Center, Bethesda National Naval Medical Center, and one other facility to be chosen by the Air Force. The Air Force selected Wilford Hall Medical Center as the third expansion facility. So, there were a total of thirteen demonstration sites along with three control sites. Seven sites were under primary care management principles. Six sites used a patient choice model. The three control sites used traditional treatment.

Data was collected at all of the sites in the chiropractic demonstration. Each Patient Choice and Comparison demonstration site had a site coordinator. The coordinators were originally hired on a part-time basis to assist with data collection and submission, but the positions were upgraded to full-time in order to provide additional resources to the data collection efforts. At the Patient Choice and Comparison sites, the data was collected using patient satisfaction survey forms at the initial visit and at a four-week follow-up survey. At the Primary Care sites, the data was collected using patient satisfaction surveys as well as encounter data retrieved from the Ambulatory Data System.

I mentioned earlier that an Oversight Advisory Committee was created. The committee membership included the Chief Operating Officer of the TRICARE Management Activity, six chiropractors, three Service members, one member from GAO and one from the Military Coalition. Throughout the demonstration, the Oversight Advisory Committee provided assistance to the DoD in the development of program guidelines, policies, and procedures. The committee provided regular input and feedback to the DoD on issues such as program methodology, site selection, data collection, program operations and review of congressional interim and final reports. Two of the Chiropractic representatives were also included as members of the program evaluation team, which was responsible for data analysis and drafting of the final report. The Oversight Advisory Committee influenced several key decisions that formed the framework for implementing and evaluating the demonstration. Those decisions were to:

The Chiropractic Demonstration Program ended on 30 September 1999, the evaluation was completed and the final report was sent to the Congress in March 2000. The demonstration program report included evaluations as to feasibility and advisability. In the area of feasibility, analysis of the data concluded that it was feasible to establish chiropractic services within the DoD. MTFs participating in the CHCDP succeeded in setting up chiropractic clinics with adequate space, equipment, and qualified personnel. At each of the selected sites, chiropractic health care services were not constrained by contracting issues, physical space, or ability to procure appropriate equipment. Start-up costs ranged from $20,571 to $90,350 at each site and included expenses for facility modifications and equipment loans, leases, and purchases, with an average cost of $67,835. In addition, the data support the fact that doctors of chiropractic were judged more favorably after their integration into the MHS, but the majority of traditional clinicians' perceptions did not change dramatically.

Data also showed that traditional providers judged using spinal manipulation to treat indications with no neurological findings as appropriate. They responded more favorably over time to spinal manipulation as a technique to treat this set of conditions. In contrast, less than a majority of traditional providers at the MTFs were likely to view the use of spinal manipulation to treat indications related to acute or chronic cervical or thoracic pain with radiating pain or numbness, or indications of muscle contraction weakness, as appropriate.

The integration of doctors of chiropractic into the Military Health System is seen as feasible, but further attention must be given to scope of practice issues among providers and whether spinal manipulation as a technique is appropriate for certain medical conditions.

Results from the empirical models indicated that patients who saw doctors of chiropractic were significantly more likely to show self-reported improvement in health over the four-week survey period than patients who saw traditional providers. Patients were also more likely to give their provider excellent marks (a perfect score) if they were seen by a chiropractor.

With respect to advisability, a statistical profile of care methodology was used to determine the per patient cost for treating low back pain. The quantitative results achieved through this methodology were integral factors in determining the advisability of adopting chiropractic care within the MHS.

The introduction of a system-wide chiropractic benefit would increase the cost of outpatient care. The extent of this cost increase would depend on the type of benefit offered (restricted or open to all beneficiaries) and how well the Military Health System could capture potential cost savings in physical therapy and inpatient services.

The estimated gross cost of providing a chiropractic benefit similar to that offered in the demonstration program model would be approximately $55 million, while the estimated gross cost of providing a chiropractic benefit without restriction to non-active duty beneficiaries would be at least $70 million. Overall, the addition of any chiropractic benefit within the MHS would have a direct increase on operational costs.

The demonstration program has shown that, as a result of chiropractic care, there appears to be a reduction in the number of physical therapy visits among patients with low back pain. The estimated value of an extrapolated reduction in physical therapy services is approximately $19 million. To realize these savings, however, physical therapy staff at facilities would have to be reduced to account for lessened demand, thereby restricting access to physical therapy for other patients presenting with non-back related conditions. The study also showed that chiropractic care may be associated with a reduction in the rate of inpatient admissions among patients with at least one chiropractic visit. The estimated value of reduced admissions for back-related inpatient diagnoses is approximately $6.7 million. Again, to realize the extent of these savings, back-related inpatient admissions within the MHS would have to be reduced, thereby allowing savings to be passed back to the MHS and personnel authorizations for health care staff to treat patients with back-related conditions would have to be reduced.

The total value of these potential economic benefits is $26 million. This amount is not sufficient to fully offset the projected increase in outpatient costs as a result of initiating chiropractic care services.

Another potential resource impact, although difficult to value, is derived from the improved return to duty rates of active duty members after receiving chiropractic care. Self-reported survey measures of reductions in lost and restricted duty days (time that Service members are not fully present for duty), extrapolated to the DoD population, indicate a potential to gain 199,000 labor days per year. This represents about a 0.04 percent increase on an annual basis in duty status among all service members. Currently, there is no mechanism within the DoD to realize cost savings resulting from improved return to duty rates. However, improvements in training availability, deployment readiness, and reporting requirements, would be anticipated as a result of higher present for duty ratings.

The conclusion of our evaluation was that chiropractic services could be implemented within the DoD and is feasible. Analysis of data collected from patients and providers indicates that chiropractic care was well received by the patient population. As a result, chiropractic service appears to have complemented and augmented traditional medical care. Further, the CHCDP analysis did not find any negative patient perceptions that would contraindicate the feasibility of offering chiropractic care to DoD beneficiaries throughout the MHS. The study results indicated that clinics were established and fully operational within 60 to 90 days. Policies and procedures were established and later modified during the demonstration as new issues were identified. Start-up costs ranged from approximately $20,000 to $90,000 depending on the availability of adequate clinic space and construction modification requirements. No insurmountable issues delayed or prevented the establishment of chiropractic services at the 13 demonstration sites.

Also provider attitudes toward doctors of chiropractic changed positively over time. Perceptions and attitudes about the acceptance of doctors of chiropractic and the appropriateness of spinal manipulation to treat certain clinical conditions were judged to be favorable by traditional providers.

However, the demonstration program imposed several patient access limitations. If these patient access limitations were removed, the unconstrained demand of implementing chiropractic care within the MHS could cost at least $70 million annually. Full implementation of chiropractic care services for the DoD beneficiary population at this time would most likely require reducing or eliminating existing medical programs that are already competing for limited Defense Health Program dollars.

The conclusion, based on the demonstration, was that incorporation of chiropractic care into the DoD health care delivery model was not advisable. Factors contributing to this conclusion were that:

The status of the Department's Chiropractic program is that while the original Chiropractic Demonstration Program ended on 30 September 1999, chiropractic services continue to be provided at the current MTFs pending completion of the Fiscal Year 2001 National Defense Authorization Act. Mr. Chairman, that completes my statement, I will be happy to answer any questions.

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This page was posted on October 18, 2000.