OUTCOMES, ACCESS, AND COST THE CHIROPRACTIC ANSWER: COPAY PARITY - - PowerPoint PPT Presentation

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OUTCOMES, ACCESS, AND COST THE CHIROPRACTIC ANSWER: COPAY PARITY NC C HIRO PRA C TIC A SSO C IA TIO N Dr . Joe Sir a g usa E xe c utive Dir e c tor www.nc c hiro .o rg drjo e @ nc c hiro .o rg 919-832-0611 e xt. 104 WHY SHOULD

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SLIDE 1

NC C HIRO PRA C TIC A SSO C IA TIO N

OUTCOMES, ACCESS, AND COST THE CHIROPRACTIC ANSWER: COPAY PARITY

Dr . Joe Sir a g usa – E xe c utive Dir e c tor

www.nc c hiro .o rg drjo e @ nc c hiro .o rg 919-832-0611 e xt. 104

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SLIDE 2

WHY SHOULD SHP CHIROPRACTIC CO-PAYS BE LOWERED?

  • Chiro pra c tic Ca re is sa fe , no n-d rug , no n-surg e ry

c a re fo r pa tie nts, pro vid e d b y Do c to rs o f Chiro pra c tic who a re lic e nse d b y the sta te o f NC.

  • Chiro pra c tic Ca re is c o st-e ffe c tive c o mpa re d to

sta nd a rd me d ic a l c a re fo r se le c te d c o nd itio ns.

  • Chiro pra c tic c a re , whe n pro pe rly inc e ntivize d b y

lo we r c hiro pra c tic c o -pa ys c a n po te ntia lly sa ve pa tie nts a nd e mplo ye rs mo ne y, inc re a se pa tie nt c ho ic e a nd pro vid e re lie f to me d ic a l prima ry c a re

  • ffic e s.
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SLIDE 3

CHIROPRACTIC OVERVIEW

  • Prima ry po rta l o f e ntry into the he a lth c a re syste m
  • Autho rity to e xa mine , d ia g no sis, tre a t, ma na g e ,

re a sse ss a nd re fe r b y the NC Bo a rd o f Chiro pra c tic E xa mine rs

  • Chiro pra c to rs prima rily tre a t spine re la te d

c o mpla ints suc h a s lo w b a c k a nd ne c k pa in

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SLIDE 4

WHY COPAY PARITY?

  • Pa tie nts d e se rve c ho ic e o f pro vid e r fo r b a c k a nd

ne c k c o nd itio ns.

  • T

he le g isla ture pa sse d a no n-d isc rimina tio n sta tute (90-157.1 F re e Cho ic e b y Pa tie nt Gua ra nte e d ) to e nsure tha t pa tie nts ha d the ir c ho ic e o f pro vid e rs.

  • Curre ntly, c hiro pra c tic c o pa ys a re no t c o nsiste nt

with the spirit a nd inte nt o f tha t la w.

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SLIDE 5

EXAMPLE OF A PLAN WITH PCP $30 COPAY VS. DC (SPECIALIST) $70 COPAY

Ide ntic a l Ba c k Pa tie nt Pr ima r y Ca r e Physic ia n Visit Doc tor

  • f Chir
  • pr

a c tic Visit

T

  • ta l Co st o f Visit

$128 $68 Pa tie nt’ s Co pa y $30 $70 Insure r Pa ys $98 $0 (Pha nto m Be ne fit)

5

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SLIDE 6

RELIEF FOR THE PRIMARY CARE SYSTEM

  • Pa tie nt c ho ic e with c hiro pra c tic c o pa y pa rity will

a llo w pa tie nts to c ho o se a d o c to r o f c hiro pra c tic witho ut pe na lty o f hig he r c o pa ys, a nd will o pe n up c a pa c ity in prima ry c a re o ffic e s.

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SLIDE 7

CHIROPRACTIC CO-PAY PARITY

  • Co pa y pa rity wo uld pro hib it he a lth pla ns fro m

re q uiring tha t c o nsume rs pa y a hig he r c o -pa y fo r c hiro pra c tic visits whe n c o mpa re d to a PCP visit fo r a c o mpa ra b le c o nd itio n

  • Co pa y pa rity d o e s NOT

ma nd a te c hiro pra c tic o r PCP c o -pa y a mo unts

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SLIDE 8

SOUTH DAKOTA LANGUAGE HB 1146

  • "No he a lth insure r ma y impo se a ny c o pa yme nt o r

c o insura nc e a mo unt o n a n insure d fo r se rvic e s re nd e re d b y a d o c to r o f c hiro pra c tic lic e nse d pursua nt to c ha pte r 36-5 tha t is g re a te r tha n the c o pa yme nt o r c o insura nc e a mo unt impo se d o n the insure d fo r the se rvic e s o f a prima ry c a re physic ia n

  • r pra c titio ne r fo r the sa me o r a simila r d ia g no se d

c o nd itio n e ve n if a d iffe re nt no me nc la ture is use d to d e sc rib e a c o nd itio n."

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SLIDE 9

NORTH CAROLINA SB 561

  • 5 SE

CT ION 1. G.S. 58-50-30(a 3) re a ds a s re writte n:

  • 6 "(a 3) Whe ne ve r a ny he a lth b e ne fit pla n, sub sc rib e r c o ntra c t, o r po lic y o f insura nc e issue d
  • 7 b y a he a lth ma inte na nc e o rg a niza tio n, ho spita l o r me dic a l se rvic e c o rpo ra tio n, o r insure r
  • 8 g o ve rne d b y Artic le s 1 thro ug h 67 o f this Cha pte r pro vide s c o ve ra g e fo r me dic a lly ne c e ssa ry
  • 9 tre a tme nt, the insure r sha ll no t impo se a ny limita tio n o n tre a tme nt o r le ve ls o f c o ve ra g e if
  • 10 pe rfo rme d b y a duly lic e nse d c hiro pra c to r a c ting within the sc o pe o f the c hiro pra c to r's pra c tic e
  • 11 a s de fine d in G.S. 90-151 unle ss a c o mpa ra b le limita tio n is impo se d o n the me dic a lly ne c e ssa ry
  • 12 tre a tme nt if pe rfo rme d o r a utho rize d b y a ny o the r duly lic e nse d physic ia n. An insure r sha ll no t
  • 13 impo se a s a limita tio n o n tre a tme nt o r le ve l o f c o ve ra g e a c o -pa yme nt a mo unt c ha rg e d to the
  • 14 insure d fo r c hiro pra c tic se rvic e s tha t is hig he r tha n the c o -pa yme nt a mo unt c ha rg e d to the
  • 15 insure d fo r the se rvic e s o f a duly lic e nse d prima ry c a re physic ia n fo r a c o mpa ra b le me dic a lly
  • 16 ne c e ssa ry tre a tme nt o r c o nditio n."
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SLIDE 10

J OEL STEVANS, DC

P O S T D O C TO R A L FELLO W S C H O O L O F H EA LTH & R EH A B ILITA TIO N S C IEN C ES U N IV ER SITY O F P ITTS BUR G H

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SLIDE 11

BACK PAIN - KEY STATISTICS

  • L
  • w b a c k pa in is ub iq uito us
  • 80% will e xpe rie nc e it in the ir life time
  • 40% will e xpe rie nc e it a nnua lly
  • 14% will se e k tre a tme nt a nnua lly
  • $90 b illio n a nnua lly in dire c t me dic a l c o st
  • 2nd le a d ing sympto ma tic re a so n fo r physic ia n visits
  • Mo st c o mmo n re a so n fo r visits to o rtho pe d ic surg e o ns a nd

ne uro surg e o ns

  • 3rd mo st c o mmo n re a so n to und e rg o surg e ry
  • 5th mo st fre q ue nt c a use o f ho spita liza tio n
  • $50 b illio n a nnua lly in a b se nte e , disa b ility, a nd lo st

pro duc tivity

  • Mo st c o mmo n c a use o f lo st wo rk pro d uc tivity
  • 2nd le a d ing c a use o f lo st wo rk time (1st c o mmo n c o ld )
  • Mo st fre q ue nt re a so n fo r d isa bility a mo ng wo rking a d ults

11

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SLIDE 12

KEY CONCERN IN HEALTH BENEFIT PLANS

  • OptumHe a lth, a Unite d He a lthc a re c o mpa ny,

re po rts:

  • Ortho pe dic pro b le ms a re the mo st c o stly c o nditio n

c a te g o ry

  • Spine pro b le ms a c c o unt fo r 46% o f the se c o sts
  • Blue Shie ld o f CA re po rts b a c k pro b le ms a re third

hig he st b y a llo we d c o sts

  • UPMC He a lth Pla n re po rts tha t o nly c a nc e r a nd

c a rd io va sc ula r c o nd itio ns c o st mo re tha n b a c k pa in

12

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SLIDE 13

BACK PAIN – COST DRIVERS

$0 $1 $2 $3 $4 $5

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Phar mac y E xpe nditur e s (Billions)

20 40 60 80

1998 1999 2000 2001 20022003 2004 2005 2006 2007 2008 Spine F usion Sur ge r y Rate s pe r 100,000

L umba r Ce rvic al T ho rac ic

5 10 15 20 25

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Pr e vale nc e (Millions)

1000 2000 3000 4000 5000

2000 2001 2002 2003 2004 2005 2006 2007 2008 Spine Inje c tion Rate s pe r 100,000

E p id ural F a c e t Sac ro iliac

13

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SLIDE 14

EVIDENCE BASED LBP GUIDELINES

Ac ute & Sub Ac ute Chr

  • nic

Prima ry Spine Ca re Pa tie nt E duc a tio n No nna rc o tic Ana lg e sic NSAIDS Spina l Ma nipula tio n Pa tie nt E duc a tio n No nna rc o tic Ana lg e sic NSAIDS Sho rt-te rm Opio ids Spina l Ma nipula tio n Ba c k e xe rc ise s Spe c ia lty Spine Ca re Spine Inje c tio ns Surg e ry Be ha vio ra lthe ra py Multidisc iplina ry Re ha b ilita tio n Spine Inje c tio ns Surg e ry

14

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SLIDE 15

AMBULATORY EXPENDITURES BY PROVIDER TYPE

15

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SLIDE 16

AMBULATORY EXPENDITURES PCP VS SPECIALIST

16

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SLIDE 17

EPISODE COSTS FOR NON-SURGICAL BACK PAIN

OptumHe a lth (adjuste d)

$0 $200 $400 $600 $800 $1,000 $1,200 $1,400

DC PCP Spe c ia list

17

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SLIDE 18

SPREADING THE WORK LOAD

40% 34% 26%

Distribution of Porta l of E ntry Provide r for Ba c k Proble ms

(1.5 million e pisode s)

Chiro p ra c to r Prima ry Ca re Physic ia n Me dic a l Spe c ia list

18

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SLIDE 19

ALIGNING EVIDENCE & POLICY

  • UPMC Insura nc e Se rvic e s Divisio n po lic y fo r Surg ic a l

Ma na g e me nt o f L

  • w Ba c k Pa in
  • “Spina l surg e ry will b e c o nsid e re d me d ic a lly

ne c e ssa ry…whe n me mb e rs ha ve fa ile d c o nse rva tive ma na g e me nt…”

  • Co nse rva tive Ma na g e me nt inc lud e s the fo llo wing :

1. No n-Pha rma c o lo g ic T he ra py 2. Pha rma c o lo g ic T he ra py 3. E a rly re fe rra l to c hiro pra c to r o r physic a l the ra pist

19

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SLIDE 20

WHY IS COST SHARING IMPORTANT?

  • Co st sha ring de c re a se s ne c e ssa ry &

unne c e ssa ry se rvic e s

  • Inc re a sing c o st-sha ring fo r so me , b ut no t a ll,

se rvic e s c o uld c a use pe o ple to sub stitute mo re e xpe nsive fo rms o f c a re

  • Re spo nse s to c o st-sha ring ma y diffe r b y inc o me

e ve n a mo ng g ro ups tha t a re no t lo w-inc o me

  • Pe o ple in po o r he a lth o r with c hro nic c o nditio ns

ma y b e mo re se nsitive to c o st-sha ring tha n he a lthy pe o ple

20

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SLIDE 21

COST SHARING RESTRICTS CHIROPRACTIC ACCESS

  • Ra nd o mize d c o ntro lle d tria l to e va lua te e ffe c ts o f

c o st sha ring o n he a lth c a re q ua lity & c o sts

  • F

a milie s a ssig ne d d iffe re nt b e ne fit d e sig ns & le ve ls

  • f c o st sha ring (e .g ., 25%, 50% c o insura nc e )
  • T

he o d d s o f a c c e ssing c hiro pra c tic pro vid e rs we re 71% lo we r a t 25% c o insura nc e c o mpa re d to fre e c a re

  • Co nc lusio n: c hiro pra c tic c a re is ve ry se nsitive to

c o st sha ring …mo re tha n o ve ra ll a nd o the r

  • utpa tie nt e xpe nse s

21

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SLIDE 22

BENEFIT SILOS VERSUS THE TRIPLE AIM

  • If the g o a l is to a rb itra rily suppre ss utiliza tio n within

the c hiro pra c tic “b e ne fit silo ” hig h c o pa ys a re a n e ffe c tive ta c tic

  • If the g o a l is a c hie ving the T

riple Aim - impro ve d a c c e ss, q ua lity & po pula tio n he a lth a t lo we r pe r c a pita c o sts:

  • Hig h c hiro pra c tic c o pa ys a re de trime nta l to a c hie ving

the se g o a ls

  • Chiro pra c to rs ha ve the a utho rity to a c t a s po rta l o f e ntry

he a lth c a re pro vide rs

  • Chiro pra c to rs pro vide e vide nc e b a se d prima ry c a re fo r

spine pa tie nts

22

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SLIDE 23

SHAWN PHELAN, DC, FICC

P R IN C IP A L IN V ES TIG A TO R : R ETR O S P EC TIV E A N A LY S IS O F IN S UR A N C E C LO S ED C LA IM S

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SLIDE 24

TOTAL SHP CHARGES: 2000-2009 FOR LOW BACK PAIN (MILLIONS)

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 36 60 70 80 97 103 107 106 119 130

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SLIDE 25

AVERAGE TOTAL PER PATIENT SHP CHARGES: 2009 UNCOMPLICATED LOW BACK PAIN

DC MD 1,363 2,212

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SLIDE 26

GENE LEWIS, DC, MPH

A PRA C TITIO NER’ S PERSPEC TIV E

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SLIDE 27

EXAMPLE OF A PLAN WITH PCP $30 COPAY VS. DC (SPECIALIST) $70 COPAY

Ide ntic a l Ba c k Pa tie nt Pr ima r y Ca r e Physic ia n Visit Doc tor

  • f Chir
  • pr

a c tic Visit

T

  • ta l Co st o f Visit

$128 $68 Pa tie nt’ s Co pa y $30 $70 Insure r Pa ys $98 $0 (Pha nto m Be ne fit)

27

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SLIDE 28

COPAY PARITY PROJ ECTION

  • Co pa y pa rity ha s b e e n pro je c te d b y T

he Se g a l Co mpa ny to inc re a se c hiro pra c tic b e ne fit c o sts.

  • HOWE

VE R this inc re a se c a n b e o ffse t b y:

  • L

e ss o pio id use

  • F

e we r MRI s

  • Re duc e d e me rg e nc y ro o m visits
  • De c re a se d no n-surg ic a l ho spita liza tio ns o r spine surg e rie s

… Whe n pa tie nts ha ve re a l c hoic e of provide r with c hiropra c tic c opa y pa rity.

28