J Manipulative Physiol Ther. 2016 (May); 39 (4): 229–239 ~ FULL TEXT
Eric L. Hurwitz, DC, PhD, Maria Vassilaki, MD, MPH, PhD, Dongmei Li, PhD,
Michael J. Schneider, DC, PhD, Joel M. Stevans, DC, Reed B. Phillips, DC, PhD,
Shawn P. Phelan, DC, Eugene A. Lewis, DC, MPH, Richard C. Armstrong, MS, DC
Office of Public Health Studies,
University of Hawai`i at M?noa,
OBJECTIVES: The purpose of the study was to compare patterns of utilization and charges generated by medical doctors (MDs), doctors of chiropractic (DCs), and physical therapists (PTs) for the treatment of headache in North Carolina.
METHODS: Retrospective analysis of claims data from the North Carolina State Health Plan for Teachers and State Employees from 2000 to 2009. Data were extracted from Blue Cross Blue Shield of North Carolina for the North Carolina State Health Plan using International Classification of Diseases, Ninth Revision, diagnostic codes for headache. The claims were separated by individual provider type, combination of provider types, and referral patterns.
RESULTS: The majority of patients and claims were in the MD-only or MD plus referral patterns. Chiropractic patterns represented less than 10% of patients. Care patterns with single-provider types and no referrals incurred the least charges on average for headache. When care did not include referral providers or services, MD with DC care was generally less expensive than MD care with PT. However, when combined with referral care, MD care with PT was generally less expensive. Compared with MD-only care, risk-adjusted charges (available 2006-2009) for patients in the middle risk quintile were significantly less for DC-only care.
CONCLUSIONS: Utilization and expenditures for headache treatment increased from 2000 to 2009 across all provider groups. MD care represented the majority of total allowed charges in this study. MD care and DC care, alone or in combination, were overall the least expensive patterns of headache care. Risk-adjusted charges were significantly less for DC-only care.
KEYWORDS: Chiropractic; Headache; Health Services; Healthcare Costs; Medical Care; Utilization
From the FULL TEXT Article:
Headache is one of the most common complaints that cause patients to seek medical care.  Almost every adult will experience headache in their lifetime, making it the most prevalent neurological symptom, with up to 47% of the global adult population experiencing an active headache.  It is also one of the most common complaints in emergency care,  with the World Health Organization ranking it among the 10 most disabling conditions for men and among the 5 most disabling conditions for women.  Migraine’s health-related impact, for example, has been compared with that experienced by patients with congestive heart failure, hypertension, or diabetes. 
Despite its high prevalence and considerable health-related impact, headache disorders remain underrecognized and undertreated.  In most cases, headache is a benign disorder. However, it can cause significant suffering and disability to patients and their families, leading to decreased quality of life similar to other chronic conditions.  Headache also leads to higher healthcare utilization  and substantial direct and indirect (eg, work absenteeism or reduced efficiency) costs. 
Hu et al  reported that the 1994 annual direct medical costs in the United States were about $1 billion among migraine sufferers, in addition to $13 billion in estimated indirect costs to employers. This estimate was considered conservative, as over-the-counter and preventive medications, as well as non–drug-related interventions, were not evaluated.  A more recent report has been published using the 2004 data from the Thomson-Medstat Commercial Claims and Encounters database. This report estimated the medical claims’ direct cost burden of migraine as being substantially higher, with a national migraine burden of $11 billion for those who sought medical treatment. This $11 billion total cost was divided into these subgroups:
$4.6 billion was attributed to prescription drugs,
$5.2 billion to outpatient costs,
$0.52 billion to emergency room care, and
$0.73 billion to inpatient costs. 
They also reported that the average total costs for pharmacy and medical care were $7,007 yearly for a patient with migraine compared with $4,436 for those without migraine. 
Researchers from Beth Israel Deaconess Medical Center in Boston identified 9,362 visits for headache using data from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey. These data represent an estimated 144 million visits from 1999 through 2010. The researchers found substantial increases in the use of low-value, high-cost services.  Figures for the United Kingdom indicated £956 million (equivalent to $1.60 billion US) due to service costs, probably an underestimation because many patients do not contact their general practitioner for headache.  In the European Union, the total annual cost for headache in adults (18-65 years) has been estimated at €173 billion by the Eurolight project. 
Given this considerable public health burden, there is a need for detailed study of the economic consequences of all varieties of headache  and the types of services used, including medical care, chiropractic care, and physical therapy. Although migraine-related costs have been examined more extensively, data on nonmigrainous headaches suggest that costs for this condition also have significant economic consequences. 
Headache patients are often seen by medical doctors (MDs), doctors of chiropractic (DCs), physical therapists (PTs), and other medical specialists to whom they are referred. Among headache patients seeking alternative and complementary therapies, chiropractic care is one of the most often selected. [13, 14] In North Carolina, PTs must treat under the direction of either an MD or a DC; therefore, the MD and/or DC act as the portal of entry provider.  Currently, the portal of entry provider combinations (patterns) involved in care (utilization) and the role of specialist referrals as cost drivers are unclear in the literature. There is an increased health insurance industry interest in containing costs by encouraging patients with musculoskeletal pain to pursue care through the primary care “medical home” portal.
This raises an important question: Does reducing patient self-selection of providers reduce the cost of care for these conditions, or does it increase cost?
The aim of this study was to assess the utilization and cost of care patterns for headache among patients in the North Carolina State Health Plan (NCSHP) for Teachers and State Employees from 2000 to 2009. We compared the cost of care of these patterns of care: patients who used MDs and DCs alone; MD and DC care in combination with each other; MD or DC care in combination with PT and/or with additional referred provider care.
Although the prevalence of headache disorders such as migraine has not changed since the 1990s, rates of physician consultation have increased.  Even though consultation rates have increased, approximately half of those with headache do not use medication or are not under the care of a physician. [17, 18] In any given year, it is estimated that only 48% of migraineurs will see a doctor, usually those having the most severe cases of headache (compared with nonconsulters).  Despite the fact that a substantial portion of those with headache do not seek treatment, our analysis is consistent with previous research  that has shown large increases in utilization and expenditures throughout the 2000-2009 decade for the management of headache.
The present study found that utilization by patients with headache increased most dramatically for care involving MDs, PTs, and referral providers or services. The majority of patients and claims were in the MD-only or MD plus referral patterns, representing 65% of claims in 2009. Chiropractic care showed the least gain in the number of patients and claims over the decade. These findings are similar to those of Adams et al.  In their critical review on complementary and alternative medicine (CAM) use for migraine and headache, they reported that DC care was among the most commonly used CAM therapies. However, they also found that CAM therapies were primarily used concurrently or following a general practitioner visit, with fewer patients reporting the use of CAM therapies (including chiropractic care) before their MD visit.
Previous reports of costs in patients with migraine suggest that primary care and specialty physician office visits account for about 60% of all costs.  Pharmaceutical charges account for a large proportion of the total charges associated with medical care. In our study, pharmaceutical charges accounted for more than a third of total allowed charges for all care patterns combined. This compares well with the migraine cost findings in Hu et al,  who reported that expenses related to prescription medication accounted for nearly 30% of the total direct costs, whereas Latinovic et al  reported that antimigraine medication was prescribed in 33.9% of the headache consultations.
In 2009, our unadjusted analysis showed that MD-care patterns with or without referral to PT or other providers (but without DC care) were on average 15% less expensive than DC care. Although charges per claim were less for DC-associated services, patients in DC-care patterns had many more claims on average than patients in MD-care patterns. This may simply be a reflection of the nature of DC treatment, which typically involves a series of manual therapy visits over time leading to multiple claims for their professional services.
In care patterns where additional referral care was provided, the combination of MD-DC-referral care was somewhat more expensive ($483 per patient) than the combination of MD-PT-referral care. On average, referrals associated with MD-only care were much more expensive ($1,856 per patient) than referrals associated with DC-only care. Investigators in the United Kingdom have reported that mean service costs were higher for those patients receiving referrals compared with those attending only their general practitioner.  However, higher costs were also associated with the intensity of pain.  We did not have clinical information available in our claims database, although, beginning in 2006, the NCSHP database did carry a risk score. The risk score allowed us to control for some patient characteristics (ie, age, sex, primary diagnosis, comorbidities, and use of prescription drugs) that influence both utilization and charges.
We conducted a subgroup analysis using patients in the middle quintile of risk to determine the utilization and charges for the typical patient. We chose this approach because the distribution of patient risk scores was heterogeneous across MD and DC patterns of care. The subgroup analysis favored DC patterns of care, showing that DC-only and MD-DC care patterns were less costly on average than MD-only and MD-PT care. However, charges for DC with referral care and MD with referral care were statistically similar in most years.
In the United States, the use of high-cost, low-value ambulatory medical services for headache increased dramatically from 1999 to 2010.  For example, referrals to other physicians almost doubled from 6.9% to 13.2%, and use of advanced imaging more than doubled from 6.7% of visits in 1999-2000 to 13.9% in 2009-2010.  Therefore, creating policies to encourage the use of lower-cost services, such as chiropractic care, may be a mechanism to mitigate the escalating costs associated with headache management.
One potential policy lever to achieve this aim would be to reduce patient copayments for these lower-cost services. This is necessary because previous studies have shown DC care to be very sensitive to patient out-of-pocket payments. [20, 21] The RAND Health Insurance Experiment found that use of chiropractic care was reduced by 50% when patient cost-share was 25% or more of the visit cost.  Therefore, we suggest that it might be possible that the current trend toward higher patient cost-sharing may have unintended consequences in that it discourages the use of lower-cost chiropractic services and may inadvertently steer patients into more expensive patterns of care. This hypothesis would require confirmation in future prospective research studies.
The North Carolina legislature reversed a mandate in 2007 that required insurers to maintain copayment equity between primary medical care and chiropractic care. As a result of the legislative change, the NCSHP implemented a new policy treating DC care as a specialty service. This new policy increased the copayments for DC visits by 20% to 100%, thereby creating a substantial barrier to the use of DC services. Interestingly, there were noticeable changes in the total costs for managing the headache population around this time.
Over the decade, there was a clear upward trend in total allowed charges for all care patterns over time. The combined charges for headache in 2000 were $15.2 million, which had escalated to $44.5 million by 2005. However, there was a noticeable break in this trend the following year when total allowed charges dropped to $40.7 million. That flattening of the trend may reflect changes in the NCSHP benefit plan options that were introduced in October of 2006. The downward trend then reversed following the copayment policy change which became effective on October 1, 2007.
Following the copayment increase for DC services, the total allowed charges resumed an upward trend in 2008 to $43.6 million and eventually to $46.4 million in 2009 (Fig 1). The temporal association between the hike in DC copays and the escalating costs may be important because the change in chiropractic copayments may have shifted the utilization patterns and may partially account for the dramatic increase in costs for the North Carolina NCSHP population. Exploring this association of the policy decision and its economic consequences is necessary but was beyond the scope of this current analysis and will be the focus of our future work.
Investigators have suggested that patients with chronic headache should receive interdisciplinary care.22 This becomes especially important as more information on headaches and their association with future sequelae become available. Recent reports suggest that migraine might be a progressive disease with cardiovascular, cerebrovascular, and longer-term neurologic effects and that repeated headache episodes may result in permanent central nervous system changes.  This can have important implications on quality of life and productivity, as well as total healthcare costs. For example, the economic impact of migraine includes both direct healthcare costs and indirect costs due to lost workplace productivity or absenteeism. [18, 23]
For migraine, several studies have presented annual direct and indirect cost estimates ranging from $127 to $7,089 and from $709 to $4,453, respectively, per patient with migraine.  It is also noteworthy that among survey-ascertained patients with migraine, those who already had a formal migraine diagnosis (ie, using claims data for ICD-9) seemed to incur higher 12-month medical care costs compared with those ascertained by survey only ($4,597 vs $2,520 respectively).  Previous reports indicate that adults with headache are more likely to have physical and mental comorbidities, [11, 25] and estimates of migraine often include costs of these comorbid conditions.  As such, it is important to report estimates and variations in patterns of utilization and charges for the care of headache. These estimates can be used to assess and plan accordingly for future healthcare
There are methodologic challenges inherent in the analysis of health insurance databases. For this study, these challenges arise in the form of inability to control for tiering, possible inaccuracy of diagnostic, management and treatment codes, as well as the lack of availability of risk factors for a portion of the analysis. All of these factors could have influenced our analysis of comparability across provider groups and may have created the potential for provider underrepresentation.
Another limitation of the study was capturing data only from those patients who sought care and being restricted to the information available in the claims database. For example, we did not have access to any clinical data, outcomes, or additional factors such as patient or disease characteristics that could have affected choice of provider or number of claims.  However, the objective of our study was to estimate and compare overall charges and utilization across patterns of care for primary headache diagnoses, not to estimate effectiveness of headache treatment by pattern of care, undeniably an important aim but not our focus here. Another limitation is that secondary, tertiary, and quaternary codes were not used to identify headache cases, but doing so would have led to an overestimation of headache charges in our cohort.
This is a large study with claims generated by approximately 660 000 persons (state employees, dependents, and retirees) that accrued 910 778 claims for headache in multiple and combined healthcare pathways over the 2000-2009 decade in North Carolina.
The series of articles it has generated on the treatment of low back pain,  neck pain,  and headache provides an opportunity to healthcare policy makers and legislators for a unique economic examination. It was also an opportunity to view costs using a lateral vs vertical analysis.
When accumulating provider costs are viewed vertically (as if in “silos”), increasing utilization of one particular provider or another can be seen as a simple net cost increase in that particular silo (“vertical view”). However, when costs are viewed across the silos, as this study has done, an increase in the utilization of one provider group might result in a net cost decrease in the total costs across silos (“lateral view”)..
Overall utilization and average charges for the treatment of headache increased considerably from 2000 to 2005 and then decreased in each subsequent year. Policy changes that took place between 2005 and 2007 may have affected utilization rates of certain providers and their associated charges. MD care accounted for the majority of total allowed charges throughout the decade. In general, patterns of care involving multiple providers and referral care incurred the largest charges, whereas patterns of care involving single or nonreferral providers incurred the least charges. MD-only, DC-only, and MD-DC care were the least expensive patterns of headache care; however, risk-adjusted charges (available 2006-2009) were significantly lower for DC-only care compared with MD-only care.
This study found that MD care accounted for the majority of total
allowed charges throughout the decade 2000-2009.
Patterns of care involving multiple providers and referral care
incurred the largest charges, whereas patterns of care involving
single or nonreferral providers incurred the least charges.
Not accounting for patients’ differences in risk, MD care with
no referral care was the least expensive pattern of headache care.
Compared with MD-only care, risk-adjusted charges
(available 2006-2009) for patients in the middle quintile
of risk are significantly lower for DC-only care.
Stovner, L, Hagen, K, Jensen, R et al.
The global burden of headache: a documentation of headache prevalence
and disability worldwide.
Cephalalgia. 2007; 27: 193–210
Jensen, R and Stovner, LJ.
Epidemiology and comorbidity of headache.
Lancet Neurol. 2008; 7: 354–361
Gilbert, JW, Johnson, KM, Larkin, GL, and Moore, CL.
Atraumatic headache in US emergency departments:
recent trends in CT/MRI utilisation and factors associated with severe intracranial pathology.
Emerg Med J. 2012; 29: 576–581
Hazard, E, Munakata, J, Bigal, ME, Rupnow, MF, and Lipton, RB.
The burden of migraine in the United States:
current and emerging perspectives on disease management and economic analysis.
Value Health. 2009; 12: 55–64
Lyngberg, AC, Rasmussen, BK, Jorgensen, T, and Jensen, R.
Secular changes in healthcare utilization and work absence
for migraine and tension-type headache: a population based study.
Eur J Epidemiol. 2005; 20: 1007–1014
Hu, XH, Markson, LE, Lipton, RB, Stewart, WF, and Berger, ML.
Burden of migraine in the United States:
disability and economic costs.
Arch Intern Med. 1999; 159: 813–818
Hawkins, K, Wang, S, and Rupnow, M.
Direct cost burden among insured US employees with migraine.
Headache. 2008; 48: 553–563
Mafi, JN, Edwards, ST, Pedersen, NP, Davis, RB, McCarthy, EP, and Landon, BE.
Trends in the ambulatory management of headache:
analysis of NAMCS and NHAMCS data 1999-2010.
J Gen Intern Med. 2015; 30: 548–555
McCrone, P, Seed, PT, Dowson, AJ et al.
Service use and costs for people with headache: a UK primary care study.
J Headache Pain. 2011; 12: 617–623
Linde, M, Gustavsson, A, Stovner, LJ et al.
The cost of headache disorders in Europe: the Eurolight project.
Eur J Neurol. 2012; 19: 703–711
Gaul, C, Finken, J, Biermann, J et al.
Treatment costs and indirect costs of cluster headache:
a health economics analysis.
Cephalalgia. 2011; 31: 1664–1672
Stovner, LJ and Hagen, K.
Prevalence, burden, and cost of headache disorders.
Curr Opin Neurol. 2006; 19: 281–285
Eisenberg, DM, Davis, RB, Ettner, SL et al.
Trends in Alternative Medicine Use in the United States, from 1990 to 1997:
Results of a Follow-up National Survey
JAMA 1998 (Nov 11); 280 (18): 1569–1575
Adams, J, Barbery, G, and Lui, CW.
Complementary and alternative medicine use for headache and migraine:
a critical review of the literature.
Headache. 2013; 53: 459–473
Physical Therapy Act.
North Carolina General Statute 90-270.24.
SAS Institute. SAS (release 9.2).
Statistical Software, Cary, NC; 2012
Lipton, RB, Scher, AI, Kolodner, K,
Liberman, J, Steiner, TJ, and Stewart, WF.
Migraine in the United States—epidemiology and patterns of healthcare use.
Neurology. 2002; 58: 885–894
Blumenfeld, AM, Varon, SF, Wilcox, TK et al.
Disability, HRQoL and resource use among chronic and episodic migraineurs:
results from the International Burden of Migraine Study (IBMS).
Cephalalgia. 2011; 31: 301–315
Latinovic, R, Gulliford, M, and Ridsdale, L.
Headache and migraine in primary care: consultation, prescription, and
referral rates in a large population.
J Neurol Neurosurg Psychiatry. 2006; 77: 385–387
Shekelle, PG, Rogers, WH, and Newhouse, JP.
The effect of cost sharing on the use of chiropractic services.
Med Care. 1996; 34: 863–872
Stevans, JM and Zodet, MW.
Clinical, demographic, and geographic determinants of variation in
chiropractic episodes of care for adults using the 2005-2008 Medical Expenditure Panel Survey.
J Manipulative Physiol Ther. 2012; 35: 589–599
Nicol, Andrea L, Hammond, Nancy, and Doran, Shamsha Velani.
Interdisciplinary management of headache disorders.
Tech Reg Anesth Pain Manage. 2013; 17: 174–187
Munakata, J, Hazard, E, Serrano, D et al.
Economic burden of transformed migraine:
results from the American Migraine Prevalence and Prevention (AMPP) Study.
Headache. 2009; 49: 498–508
Elston Lafata, J, Moon, C, Leotta, C,
Kolodner, K, Poisson, L, and Lipton, RB.
The medical care utilization and costs associated with migraine headache.
J Gen Intern Med. 2004; 19: 1005–1012
Kalaydjian, A and Merikangas, K.
Physical and mental comorbidity of headache in a nationally representative
sample of US adults.
Psychosom Med. 2008; 70: 773–780
Scher, AI, Bigal, ME, and Lipton, RB.
Comorbidity of migraine.
Curr Opin Neurol. 2005; 18: 305–310
Hurwitz, EL, Li, D, Schneider, MJ et al.
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
J Manipulative Physiol Ther. 2016 (May); 39 (4): 252–262
Hurwitz, EL, Li, D, Schneider, MJ et al.
Variations in Patterns of Utilization and Charges for the Care of Neck Pain
in North Carolina, 2000 to 2009: A Statewide Claims' Data Analysis
J Manipulative Physiol Ther. 2016 (May); 39 (4): 240–251
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