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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 CHIROPRACTIC CARE IN THE DEPARTMENT
OF VETERANS’ AFFAIRS Before
the SUBCOMMITTEE
ON HEALTH COMMITTEE
ON VETERANS’ AFFAIRS U.S.
HOUSE OF REPRESENTATIVES October 3, 2000
Mr. Chairman, I am RADM 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: Restrict
the patient population for the demonstration to individuals with
spine-related, neuromusculoskeletal conditions, staffing of
each of the chiropractic clinics with no more than two doctors
of chiropractic and two chiropractic assistants Focus
on acute episodes of care for comparison to account for the transient
nature of the military population Select
comparison sites to assess changes that would have taken place without
the advent of the demonstration project Select
measurable performance outcomes 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: ·
Chiropractic care is more expensive on a statistical profile of
care basis and more expensive even if cost savings associated with
substitution of chiropractic care for other traditional care can be
realized. This is true even though the cost analysis portrayed
chiropractic care, when compared with traditional medical care for
back pain, as less expensive on a per visit basis. ·
Utilizing a staffing
model similar to the demonstration, which used restrictive
guidelines limiting patient access to the demonstration program, i.e.,
active duty patients received priority for appointments at some
locations, will result in a cost estimate of approximately $55 million
annually to implement chiropractic care within the DoD direct care
system. ·
Any potential economic benefit of improved outcomes (estimated
at $26 million) would not translate directly back to the MHS in the
form of budgetary savings. This includes reduced inpatient admissions
and reduced physical therapy visits for low back pain. ·
Any potential resource savings from a projected increase in
availability of active duty members receiving care would not accrue
directly to the defense medical budget.
No mechanism currently exists to pass these changes in economic
value back to the military health system in the form of budgetary
savings. 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. Back to Witness List |