Steven Kehres, D.C.

Pran Magna graduated from the University of Toronto with a PhD in economics in 1970. Since 1977 he has been a Full Professor at the Telfer School of Management at the University of Ottawa, where he teaches ethics, health economics, and globalization. He is also the director of the Masters Program in Health Administration.

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In 1993, the Ministry of Health, Government of Ontario, CANADA, commissioned Dr. Pran Manga and colleagues to evaluate the effectiveness and cost-effectiveness of chiropractic management of low-back pain. This project was undertaken because:

• “The Government of Ontario is placing increasing emphasis on allocating public funds for services that are relatively more cost effective and appropriate.”
• “The Government of Ontario is also keenly interested in reducing the incidence of work-related disability and injury and to improve the rehabilitation of disabled and injured workers.”
• “The Ontario Worker’s Compensation Institute notes that low back pain is ubiquitous.”

The result of these efforts is a 104-page publication titled (1):

The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low-Back Pain

The last 15 pages of the book are a bibliography that contains approximately 400 citations. In the beginning of the book, Dr. Manga writes and signs a letter to:

The Honourable Ruth Grier, Minister of Health, Ministry of Health, Government of Ontario, Toronto, Ontario, CAN. Pertaining to his booking regarding chiropractic and low back pain, his letter states:

“We are very pleased to enclose our final report on the ‘The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low-Back Pain’. It is rather voluminous testimony to the extensive and growing literature and clinical research in this area.”

“In these times of severe fiscal constraints, we commend the Ministry of Health for funding much needed research in this increasingly important area, and we encourage further research pertinent to the consumer and provide surveys we recommend in the report. The potential for major gains in effectiveness and cost-savings is very significant. Our recommended reforms are all consistent with and promote the health care objectives of the Government of Ontario.”

The EXECUTIVE SUMMARY of Dr. Manga’s book includes these points:

[I added the bold emphasis]

INTRODUCTION

The serious fiscal crisis of all governments in Canada is compelling them to contain and reduce health care costs. It has brought a new and unprecedented emphasis on evidence-based allocation of resources, with an overriding objective of improving the cost-effectiveness of health care services.

The area of low-back pain (LBP) offers governments and the private sector an excellent opportunity to attain the twin goals of greater cost-effectiveness and a major reduction in health care costs. Today LBP has become one of the most costly causes of illness and disability in Canada - a phenomenon which does not appear to be generally appreciated or understood in medical and government circles in Canada. Studies on the prevalence and incidence of LBP suggest that it is ubiquitous, probably the leading cause of disability and morbidity in middle-aged persons, and by far the most expensive source of workers' compensation costs in Ontario - as indeed in most other jurisdictions.

Much of the treatment of LBP appears to be inefficient. Evidence from Canada, the USA, the UK and elsewhere shows that there are conflicting methods of treatment, many with little - if any scientific evidence of effectiveness, and very high costs of treatment. Despite this, levels of disability from LBP are increasing.

In the Province of Ontario, LBP is managed mostly by physicians and chiropractors, with physiotherapists also playing a significant role. While medical services are fully insured under Medicare, chiropractic care services are only partially covered. LBP patients incur the highest out-of-pocket expenses for chiropractic services. Virtually, no out-of-pocket expenses are incurred for medical treatment, with the exception of drugs, and out-of-pocket expenses incurred for physiotherapy services fall somewhere in between the two.

Medical physicians, chiropractors, physiotherapists and an assortment of other professionals together offer about thirty-six therapeutic modalities for the treatment of LBP. In this study we focused principally on the effectiveness and cost effectiveness of chiropractic and medical management of LBP.

FINDINGS

1. Based on the evidence, particularly the most scientifically valid clinical studies, spinal manipulation applied by chiropractors is shown to be more effective than alternative treatments for LBP. Many medical therapies are of questionable validity or are clearly inadequate.
2. There is no clinical or case-control study that demonstrates or even implies that chiropractic spinal manipulation is unsafe in the treatment of low-back pain. Some medical treatments are equally safe, but others are unsafe and generate iatrogenic complications for LBP patients. Our reading of the literature suggests that chiropractic manipulation is safer than medical management of low-back pain.
3. While it is prudent to call for even further clinical evidence of the effectiveness and efficacy of chiropractic management of LBP, what the literature revealed to us is the much greater need for clinical evidence of the validity of medical management of LBP. Indeed, several existing medical therapies of LBP are generally contraindicated on the basis of the existing clinical trials. There is also some evidence in the literature to suggest that spinal manipulations are less safe and less effective when performed by non-chiropractic professionals.
4. There is an overwhelming body of evidence indicating that chiropractic management of low-back pain is more cost-effective than medical management. We reviewed numerous studies that range from very persuasive to convincing in support of this conclusion. The lack of any convincing argument or evidence to the contrary must be noted and is significant to us in forming our conclusions and recommendations. The evidence includes studies showing lower chiropractic costs for the same diagnosis and episodic need for care.
5. There would be highly significant cost savings if more management of LBP was transferred from medical physicians to chiropractors. Evidence from Canada and other countries suggests potential savings of many hundreds of millions annually. The literature clearly and consistently shows that the major savings from chiropractic management comes from fewer and lower costs of auxiliary services, much fewer hospitalizations, and a highly significant reduction in chronic problems, as well as in levels and duration of disability. Workers' compensation studies report that injured workers with the same specific diagnosis of LBP returned to work much sooner when treated by chiropractic physicians than by medical physicians. This leads to very significant reductions in direct and indirect costs.
6. There is good empirical evidence that patients are very satisfied with chiropractic management of LBP and considerably less satisfied with physician management. Patient satisfaction is an important health outcome indicator and adds further weight to the clinical and health economic results favoring chiropractic management of LBP.
7. Despite official medical disapproval and economic disincentive to patients (higher private out-of-pocket cost), the use of chiropractic has grown steadily over the years. Chiropractors are now accepted as a legitimate healing profession by the public and an increasing number of medical physicians.

RECOMMENDATIONS

1. Current policy discourages the utilization of chiropractic services for the management of LBP. There should be a shift in policy to encourage and prefer chiropractic services for most patients with LBP.
2. Chiropractic services should be fully insured under the Ontario Health Insurance Plan, removing the economic disincentive for patients and referring health providers. This one step will bring a shift from medical to chiropractic management that can be expected to lead to very significant savings in health care expenditure, and even larger savings if a more comprehensive view of the economic costs of low-back pain is taken.
3. Chiropractic services should be fully integrated into the health care system. Because of the high incidence and cost of LBP, hospitals, managed health care groups (community health centers, comprehensive health organizations, and health service organizations) and long-term care facilities should employ chiropractors on a full-time and/or part-time basis. Additionally such organizations should be encouraged to refer patients to chiropractors.
4. Chiropractors should be employed by tertiary hospitals in Ontario. Hospitals already employ chiropractic in the United States with good effect. Similar recommendations have been made recently by government inquiries in Australia and Sweden, and following government funded research in the U.K. and other countries. Unnecessary or failed surgery is not only costly but also represents low quality care. The opportunity for consultation, second opinion and wider treatment options are significant advantages we foresee from this initiative which has been employed with success in a clinical research setting at the University Hospital, Saskatoon.
5. Hospital privileges should be extended to all chiropractors for the purposes of treatment of their own patients who have been hospitalized for other reasons, and for access to diagnostic facilities relevant to their scope of practice and patients' needs.
6. Chiropractors should have access to all pertinent patient records and tests from hospitals, physicians, and other health care professionals upon the consent of their patients. Access should be given upon the request of chiropractors or their patients.
7. Since low-back pain is of such significant concern to workers' compensation, chiropractors should be engaged at a senior level by Workers' Compensation Boards to assess policy, procedures and treatment of workers with back injuries. This should be on an interdisciplinary basis with other professional, technical and managerial staff so that there is early development of more constructive relationships between chiropractors, physicians, physiotherapists and Board staff and consultants. A very good case can be made for making chiropractors the gatekeepers for management of low-back pain in the Workers' Compensation System in Ontario.
8. The government should make the requisite research funds and resources available for further clinical evaluation of chiropractic management of LBP, and for further socioeconomic and policy research concerning the management of LBP generally.

9. Chiropractic education in Ontario should be in the multidisciplinary atmosphere of a university with appropriate public funding. Chiropractic is the only regulated health profession in Ontario without public funding for education at present, and it works against the best interests of the health care system for chiropractors to be educated in relative isolation from other health science students.
10. Finally, the government should take all reasonable steps to actively encourage cooperation between providers, particularly the chiropractic, medical and physical therapy professions. Lack of cooperation has been a major factor in the current inefficient management of LBP. Better cooperation is important if the government is to capture the large potential savings in question and, it should be noted, is desired by an increasing number of individuals within each of the professions.

This report by Dr. Manga and colleagues assesses the most appropriate use of available health care resources for the management of low back pain. The report overwhelmingly supported the efficacy, safety, scientific validity and cost-effectiveness of chiropractic for low back pain.

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In 1998, Dr. Manga and colleague Doug Angus updated their original Manga Report with (2):

Enhanced Chiropractic Coverage Under OHIP as a Means of Reducing Health Care Costs: Attaining Better Health Outcomes and Achieving Equitable Access to Health Services

This document consists of 70 pages and 59 references. Their Executive Summary includes these Key Points:

1. The deterrent effect of existing copayments or user fees for chiropractic care is now very high, and represents a major barrier to access for most Ontarians. Patients are steered away from chiropractic care to medical management which is free under OHIP.
2. The OCA proposes improved access to chiropractic services through enhanced coverage under OHIP.
3. Currently 4 out of 5 chiropractic patients have had their disorders for over 6 months and many have already had extensive medical diagnosis and treatment.
4. Expenditure to improve access to chiropractic services, and the changed utilization patterns it produces, will lead to very substantial net savings in direct and indirect costs. Direct savings to Ontario’s health care system may be as much as $770 million, will very likely be $548 million, and will be at least $380 million. The corresponding savings in indirect costs - made up of the short and long term costs of disability - are $3.775 billion, $1.849 billion and $1.255 billion.
5. Approximately 95% of chiropractic practice in Ontario involves the management of patients with neuromusculoskeletal disorders and injuries.Musculoskeletal disorders and injuries are the second and third most costly categories of health problems in economic burden of illness studies.Musculoskeletal disorders are also among the most important reasons for activity limitations and short-term disability. They rank first in prevalence in chronic health problems and first as a cause of long-term disability.Musculoskeletal disorders rank first as a reason for consultation with a health professional in Ontario, and rank second as a reason for the use of prescription and non-prescription drugs.

   There is considerable empirical support for the cost-effectiveness and the safety of chiropractic management of musculoskeletal disorders. This means that chiropractic care can bring about improved health outcomes at a lower cost.

6. The Ministry of Health of Ontario should employ chiropractors on a salaried basis in hospitals, community health centers, and long-term care institutions.
7. More workers with neuromusculoskeletal disorders covered by the Workers Safety and Insurance Board should be channeled to chiropractic care.
8. Medical doctors and chiropractors are both substitutes for and complementary to each other in the management of neuromusculoskeletal conditions and injuries. Interprofessional relations between the two have improved over the years, and are evidenced by official pronouncements and greater inter-referral of patients between the two professions.

This 1998 Mange Report concludes that NMS disorders and injuries are very prevalent and costly, causing a disproportionate amount of chronic illness and disability. Chiropractic and medical management of many NMS disorders and injuries are substitutes and yet complimentary. Chiropractic care is significantly more cost-effective than medical care within a common scope of practice. Chiropractic is safe and preferred by patients. Chiropractic is superior in both efficiency (producing health care services at the lowest costs) and effectiveness (getting the best health outcomes per dollar spent).

Four out of five patients of chiropractors have had their problems for more than six months and have typically had medical and/or physiotherapy care before their visit to the chiropractor. The evidence is that chiropractic services should be frontline services for many NMS disorders rather than the default system of care when all else fails, as it seems to be for many patients.

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In 2000, Dr. Manga published an article in the Journal of Manipulative and Physiological Therapeutics, titled (3):

Economic case for the integration of chiropractic services into the health care system

In this article Dr. Magna states:

“The role and position of chiropractic care in the health care system must be transformed from being alternative and separate to alternative and mainstream. This transformation requires that chiropractic services become integrated in the many health care delivery organizations that collectively constitute the health care system. There is solid and impressive economic and related justification for the desired integration.”

“Chiropractic care is a cost-effective alternative to the management of neuromusculoskeletal conditions by other professions. It is also safer and increasingly accepted by the public, as reflected in the growing use and high patient retention rates. There is much and repeated evidence that patients prefer chiropractic care over other forms of care for the more common musculoskeletal conditions.”

“The public interest will be well served by this transformation.”

“Musculoskeletal disorders and injuries are the second and third most costly categories of health problems in economic burden-of-illness studies. They rank first as a cause in the prevalence of chronic health problems and long-term disability and rank at the top for activity limitations and short-term disability. They rank first as a reason for consultation with a health professional and second as a reason for the use of prescription and nonprescription drugs.”

“These conditions are more prevalent among the poor, lower- middle income groups, and the elderly, yet those are precisely the groups that make the least use of chiropractic care for reasons of inadequate insurance coverage.”

“The integration of chiropractic care into the health care system should serve to reduce health care costs, improve accessibility to needed care, and improve health outcomes.”

••••

In 2007, Dr. Manga was a co-author of a study also published in the Journal of Manipulative and Physiological Therapeutics, titled (4):

Chiropractic care of musculoskeletal disorders in a unique population within Canadian community health centers

In this study Dr. Magna and colleagues followed and assessed 259 patients with musculoskeletal complaints before and after a 12-week treatment period. Outcomes were assessed with:

• Short Form-12 as a general health measure
• The VAS pain scale
• The Roland-Morris Questionnaire Disability Index
• The Neck Disability Index

This study was part of a project assessing the integration of chiropractic care into publicly funded Canadian community health centers. It investigated the effectiveness of chiropractic care in reducing pain and disability as well as improving general health status in a population of urban, low-income, and multiethnic patients with musculoskeletal complaints. The study findings and conclusions include:

“Clinically important and statistically significant positive changes were observed for all outcomes [with chiropractic care].”

“No adverse events were reported.”

“Patients of low socioeconomic status face barriers to accessing chiropractic services. This study suggests that chiropractic care reduces pain and disability as well as improves general health status in patients with musculoskeletal conditions.”

To restate, this study found that a 12-week treatment with chiropractic in patients with musculoskeletal complaints resulted in statistically significant improvements in pain, in neck and back disability, and in general health status.

••••

In 2008, Dr. Manga was a co-author of another study published in the journal Explore (NY), [which is PubMed Indexed] titled (5):

Developing integrative primary healthcare delivery:
Adding a chiropractor to the team

In this study Dr. Magna and colleagues sought to investigate the effect of integrating chiropractic on the attitudes of providers of healthcare teams. Two multidisciplinary healthcare teams at two community health centers in Ottawa, Ontario, CAN, participated in the study. The study lasted for 18 months.

The health centers consisted of physicians, nurse practitioners, and degree-trained nurses. A chiropractor was introduced into each of the two healthcare teams.

A quantitative questionnaire assessed providers' opinions, experiences with collaboration, and perceptions of chiropractic care. Focus groups were used to encourage providers to communicate their experiences and perceptions of the integration and of chiropractic. The authors state:

“Twelve providers were followed for the full 18 months of integration. The providers expressed increased willingness to trust the chiropractors in shared care. Questions regarding the legitimacy and effectiveness of chiropractic became increasingly positive by study end.”

“This project has demonstrated the successful integration of chiropractors into primary healthcare teams.”

This is one of the first and most unique assessments of the integration of traditional medical practice with chiropractic in an effort to create a workable and superior healthcare team. The positive outcome should be a model for continuing these efforts with the patient’s best welfare in mind.

••••

As closing note, on October 29, 1993, the newspaper USA TODAY published a follow-up to the original Manga Report, stating:

A study, “done by a team of Canadian health economists commissioned and funded by the Ontario Ministry of Health – is based on an extensive review of international medical literature, as well as interviews with researchers, practitioners and patients.”

“The best clinical studies show that spinal manipulation by chiropractors is more effective, safer and more cost-effective than other treatments for low-back pain.”

“Chiropractors could save [Ontario, CAN, Health Ministry] hundreds of millions of dollars a year.”

“Many medical therapies [for low back pain] are of questionable validity or are inadequate, and some are unsafe and even cause complications.”

There is “good empirical evidence patients are very satisfied” with chiropractors and “considerably less satisfied with physician management” of low back pain.

“Many [patients] pay out-of-pocket for chiropractor bills not covered by insurance; they wouldn’t if it didn’t help.”

Manga states “I did not talk to a single chiropractor or person working for them, and they [chiropractors] did not know the study was being done.”

The Manga Report “seems so positive one can’t help but wonder: does he have some personal interest in giving chiropractors a boost? ‘My interest is serving the public interest,’ Magna responds. ‘It’s not personal, and not family-related. If anything, I have many (medical) doctor in my family.’”

Magna “simply believes his findings. ‘The evidence is overpowering.’”

Magna states “I think [medical] doctors do know chiropractors are better and more effective for back pain.”

CONCLUDING REMARKS

The Manga Reports and journal articles are incredibly supportive of the perspective shared by the doctor sending you this letter. A thorough review of international literature shows that chiropractic is significantly superior to other approaches in the treatment of low back pain.

Chiropractic care for the relief of low back pain is effective, cost effective, extremely safe, has extremely high levels of patient satisfaction, and could save hundreds of millions of dollars in Canada and undoubtedly billions of dollars in the United States. Primary research shows that chiropractic care for low back pain provides not only symptom relief but also reduces disability.

Primary research also shows that integrating chiropractic into established medical practices remains impressive and well accepted by other health care providers.

References:

1. Pran Manga, PhD; Doug Angus, MA; Costa Papadopoulos, MPH; William Swan, BA; The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low-Back Pain; Ontario Ministry of Health; Kenilworth Publishing; 1993.
2. Pran Manga, PhD; Doug Angus, MA; Enhanced Chiropractic Coverage Under OHIP as a Means of Reducing Health Care Costs: Attaining Better Health Outcomes and Achieving Equitable Access to Health Services; Ontario Ministry of Health; 1993.
3. Manga P; Economic case for the integration of chiropractic services into the health care system; Journal of Manipulative and Physiological Therapeutics; February 2000; Vol. 23; No. 2; pp. 118-122.
4. Garner MJ, Aker P, Balon J, Birmingham M, Moher D, Keenan D, Manga P; Chiropractic care of musculoskeletal disorders in a unique population within Canadian community health centers; Journal of Manipulative and Physiological Therapeutics; March-April 2007; Vol. 7; No. 3; pp. 165-170.
5. Garner MJ, Birmingham M, Aker P, Moher D, Balon J, Keenan D, Manga P; Developing integrative primary healthcare delivery: Adding a chiropractor to the team; Explore (NY), Jan-Feb 2008; Vol. 4; No. 1; pp. 18-24.