Strains, sprains and pains

What do you think would happen if you gave a bunch of “complementary and alternative medicine” practitioners access to a big pot of money — say, up to $10,000 per patient — and let them treat patients virtually without restriction, hampered only by a fee schedule. No utilization review, no refusal based on a treatment being “experimental” — none of the usual foils which trip up CAM practitioners in the health insurance field.

Think they’d run up the bill? Yes, they would.

In fact, that’s exactly the scenario playing out in Florida right now with the state’s no-fault auto insurance.

Good intentions, and the road from there

Some background: The Florida legislature mandated no-fault motor vehicle insurance coverage personal injury protection (or “PIP” coverage, as it is commonly called) for all vehicles in 1971. The laudable goal was to give those injured in auto accidents ready access to money for economic losses, such as medical bills and lost wages, without having to determine who was at fault, a process litigation could delay for several years. Up to $10,000 in coverage is currently required for all vehicles.

For medical bills, this coverage is meant mainly for temporary, and therefore generally minor, injuries. Bodily injury coverage — and the necessity for proving fault — takes over for more permanent injuries. Indeed, for 2007, according to a recent report by the Insurance Research Council (IRC), 70% of injuries reported by no-fault auto insurance claimants were sprains and strains.

By statute, only medical doctors, osteopaths, dentists, and chiropractors can supervise, order, or prescribe medical services for PIP claims. However, physical therapy, massage, and acupuncture can be prescribed by the provider.

Medical costs represent 90% of all claimed economic losses, according to an analysis of 2007 Florida PIP claims, even though coverage is meant for other expenses due to injury as well, such as lost wages. In fact, medical expenses eat up so much of the $10,000 limit that there is often little — or no — money left for lost wages.

Since 1971, vehicle and highway safety have improved dramatically, reducing the severity of crashes and resulting injuries. According to the Florida Highway Patrol, between 2006 and 2010 alone there were 21,000 fewer traffic accidents and only a 1.5 percent increase in the number of drivers.

So, over time, there’s a trend toward fewer, less serious, accidents. As well, the injuries covered by PIP are mainly minor and self-limiting. But in Florida PIP coverage rates are out of control. According to a report issued by Florida’s Chief Financial Officer (CFO) Jeff Atwater the state’s paid PIP losses per auto have increased over 66 % in the last 2.5 years, and PIP premiums will double every 3 years if the trend continues.

Faced with these stats, the CFO (whose office regulates insurance) decided to look into things and gave the Office of Insurance Consumer Advocate the task of doing so. The Consumer Advocate’s report [PDF], issued this month, produced some very interesting data on the question I posed in the first paragraph.

And the results are …

The Consumer Advocate found that, for 2010, the most expensive average provider charge per PIP claim was paid to these top three providers:

  • Massage Therapist: $4,350
  • Acupuncture: $3,674
  • Chiropractor: $3,482

In contrast, the three provider types with the lowest charge per claimant were:

  • Emergency Medicine: $1,613
  • General Practice: $1,826
  • Orthopedic Surgery: $2,810

Yes, you read that right. Over 4,000 bucks for massage therapy but only about $1,600 for the ER doc.

Remember that a full 70% of these claims were — if the 2007 stats held true for 2010 — for strains and sprains. And let me go out on a limb here and guess that the emergency medicine doctors and orthopedic surgeons were treating the more serious types of injuries. Yet, they still came out far below the average per claim charges for massage therapists, acupuncturists, and chiropractors.

And there are other interesting stats in the report.

Forty-three percent of Florida PIP claimants saw a chiropractor in 2007, compared to 25% seeing a General Practitioner and 9% seeing a Physical Therapist. According to an IRC report referenced by the Consumer Advocate:

Chiropractors are the largest percentage of medical providers submitting charges for treating PIP claimants and had the highest average total charge per claimant as compared with other medical providers.

Although, as we can see from the data for 2010, even they have been surpassed in average charge per claimant by massage therapists and acupuncturists.

As well, the IRC report noted:

Treatment by a GP tends to involve many fewer visits than treatment by other types of providers. For PIP claims countrywide closed in 2007, claimants treated by GPs had 4.8 GP visits, on average. In contrast, PIP claimants treated by a chiropractor had 21.7 chiropractor visits, on average.

That’s right, rounded off, 5 visits versus 22 visits, over four times as many. Think of the poor patient: maybe 22 times getting off work or getting a baby sitter. The carbon footprint alone for 22 visits is alarming. And all this for a strain or sprain?

But is it worth it?

All of this raises an obvious question: Even if treatments by massage therapists, acupuncturists and chiropractors are more expensive, are they worth it?

First, let’s examine that $4,000+ worth of massage therapy. Under state law, “massage” means

the manipulation of the soft tissues of the human body with the hand, foot, arm, or elbow, whether or not such manipulation is aided by hydrotherapy, including colonic irrigation, or thermal therapy; any electrical or mechanical device; or the application to the human body of a chemical or herbal preparation.

(I know, I know, colonic irrigation! Massage is routinely associated with quackery, unfortunately.)

While the use of “any electrical or mechanical device” might seem scarily broad and open to abuse in pumping up the bill, it appears that the massage therapists billing for treatment of PIP claimants were actually performing, well, massage. In 2010, massage and deep tissue massage were among the top ten billed procedures in PIP claims. Measured in 15 minute increments, called “units,” there were a whopping 1,836,308 units of deep tissue massage billed, and an even more whopping 4,051,016 units of what is generically referred to as “massage” billed. That’s almost 6 million units total, which equals one 15 minute massage for about every third person in the whole state of Florida. (1)

I’m no biostatistician, but I did look on PubMed to see what the evidence might be for massage. One Cochrane Review found that “massage might be beneficial for patients with subacute and chronic non-specific low-back pain, especially when combined with exercises and education.” In the cited studies, massage (of several different types), lasted between 10 minutes and one hour, for between one and 10 sessions.g

SBM assistant editor Paul Ingraham, a former massage therapist, has written in detail about another paper, with the revealing and title, “Massage Therapy Kinda, Sorta Works for Back Pain: It works, but not very well.” Damned with faint praise? That’s what Paul said.

A 2007 Cochrane Review found that “No recommendations for practice can be made at this time because the effectiveness of massage for neck pain remains uncertain.” I couldn’t find any good evidence on cost-effectiveness compared with other treatments.

In his very evidence-centric low back pain book, Paul Ingraham concedes the cost-effectiveness problem with a personal anecdote:

Thus, hunting for trigger points [a common form of “advanced” massage] invariably involves expensive fumbling around. When I was a Registered Massage Therapist, I was painfully aware that $1.67 was flying out of my patient’s pocket every single minute as I hunted around for their trigger points — I ought to be damned good to justify that kind of expense, and the sad truth is that I wasn’t always, and I was supposedly unusually expert at it (the author of an entire books about back pain and trigger points).

Thus, my lightly evidence-based conclusion is that, while massage might be beneficial for some types of low back pain (if this is the problem presented by the sprain or strain at hand), at $4,350 a pop it doesn’t appear that you’re getting your money’s worth.

Massage is often included as CAM by CAM proponents. I am not so sure that is a correct characterization. But for the purposes of this post, I’ll cede the point because it illustrates something proponents don’t particularly like to acknowledge: that what they call “CAM” can have some very real adverse effects on the public, even if they are not of the physical sort, a point I’ll return to later.

Let’s move on to the far more studied acupuncture and chiropractic, which won second and third place, respectively, in the category we’ll call “Most Expensive Provider of Treatment for Mostly Inconsequential Injuries.”

Sorting out the details on acupuncture is complicated by the broad scope of practice given acupuncturists under Florida law:

Acupuncture shall include, but not be limited to, the insertion of acupuncture needles and the application of moxibustion to specific areas of the human body and the use of electroacupuncture, Qi Gong, oriental massage, herbal therapy, dietary guidelines, and other adjunctive therapies, as defined by board rule.

“As defined by board rule” is a boon to acupuncturists, because the acupuncture board has helped itself to a whole bunch of nonsense, including cupping, “thermal methods,” magnets, reflexology, laser biostimulation (whatever that is), recommendation of supplements and homeopathic preparations (which acupuncturists can also sell to the patient) and herbology.

Thus, we cannot know from the Consumer Advocate’s report how much of a billed procedure was acupuncture or “thermal methods” or cupping. But from the fact that, as the law now stands, acupuncture would have to be prescribed by a covered provider (M.D., osteopath, chiropractor or dentist) or performed by the covered provider himself, I think we can safely assume that most of what was done was acupuncture, although we don’t know what kind.

Acupuncture of all stripes has been the subject of numerous posts here at SBM, and we know that it doesn’t work for anythingPeriod. This was recently confirmed by yet another study. Thus the $3,674 per claim paid to acupuncturists is a huge waste of money.

The problem will get worse if a bill proposed for the 2012 legislative session becomes law. It would amend the no-fault auto insurance statute to include licensed acupuncturists as covered providers. This would mean that the acupuncturist is in total control of the diagnosis and treatment, no referral required. Magnets, anyone?

And finally, bringing up the rear of the top three, is chiropractic. In Florida, we adhere to the traditional, D. D. Palmer definition of chiropractic:

the science, philosophy, and art of the adjustment, manipulation, and treatment of the human body in which vertebral subluxations and other malpositioned articulations and structures that are interfering with the normal generation, transmission, and expression of nerve impulse between the brain, organs, and tissue cells of the body, thereby causing disease, are adjusted, manipulated, or treated, thus restoring the normal flow of nerve impulse which produces normal function and consequent health by chiropractic physicians using specific chiropractic adjustment or manipulation techniques taught in chiropractic colleges accredited by the Council on Chiropractic Education.

As we know, the vertebral subluxation doesn’t exist. But tell that to the Florida Legislature.

Given the ubiquity of chiropractic belief in the subluxation, and the fact that, according to chiropractors, these putative subluxations can be caused by accidents, it seems reasonable to conclude that at least some of the $3,482 per PIP claim charged by chiropractors is going to the detection and correction of the non-existent subluxation (or one of its many iterations, such as manipulable lesion or joint dysfunction) which is, after all, the very definition of chiropractic practice in Florida.

But even when chiropractors branch out and include other treatments, the results are unimpressive. A recent Cochrane Review looked at, for low back pain, “a combination of therapies such as SMT or adjustment, massage, thermotherapies, electrotherapies, the use of mechanical devices, exercise programs, nutritional advice, orthotics, lifestyle modification, and patient education” rendered by chiropractors. (2) The conclusion:

Combined chiropractic interventions slightly improved pain and disability in the short-term and pain in the medium-term for acute and subacute LBP. However, there is currently no evidence that supports or refutes that these interventions provide a clinically meaningful difference for pain or disability in people with LBP when compared to other interventions.

It is interesting to note that several of the therapies employed by chiropractors and included in the Cochrane Review are among the top ten PIP procedures billed for 2010. In addition to “Chiropractic Manipulation, 3-4 regions,” which came in number 10, at 1,023,671 procedures, we have the following, along with the number of these procedures performed last year on PIP claimants by all providers:

  •  Electrical Stimulation (15 min.): 1,172,400
  •  Electrical Stimulation (time not specified): 2,219,955
  •  Hot Pack/Cold Pack: 2,315,997
  •  Ultrasound Modality (15 min.): 2,324,928

 What’s the harm?

The harm caused by CAM providers and their therapies is generally reported in terms of side effects of those therapies. Here, we have evidence of a larger economic harm to the general public. Three CAM providers — as defined by CAM proponents — are the most expensive providers of PIP-insured claims. Of these, the main therapy of two — acupuncture and chiropractic — are scientifically implausible and have (as one might guess) no evidence of effectiveness. The third, massage, is the most expensive, with limited evidence of effectiveness and no evidence that it is more cost effective than other treatments.

And all this for mostly sprains and strains.

Obviously, there are other drivers of these huge premium increases in the PIP system. One is out and out fraud. Another is increased litigation, and here it is fair to note that claimants under chiropractic care were more likely to have an attorney. For 2007, the association between the type of provider and having an attorney were:

  • Chiropractor: 62%
  •  Orthopedist: 24%
  • Physical Therapist: 15%

And here’s the harm.

According to the Consumer Advocate’s report, some Florida families are paying $3,500 annually in PIP premiums for $10,000 in PIP coverage. That’s right: more than a third of the total coverage amount in premiums.

Another example from the report: A retired couple in Tampa with one car insured by State Farm paid $471 in PIP premiums this year. The average family with teen drivers and two cars in Tampa paid almost $2,000 to State Farm for the same coverage. If this family earned the $40,000 median income for Hillsborough County (Tampa), they would be paying an astounding five percent of that income for $10,000 in PIP coverage.

We don’t know from the Consumer Advocate’s report how much of this can be attributed to diagnosis and treatment of conditions that don’t exist by covered providers. Nor can we know how much can be attributed to expensive treatment by massage therapists where less expensive but equally effective treatment might take its place.But we do know this. When given the opportunity to treat mostly minor, self-limiting injuries with methods of dubious, or no, effectiveness, and given expansive insurance coverage, CAM providers come out on top in terms of expense. And I’ll bet that’s a statistic you’ll never see CAM proponents quote.


1. According to the 2000 census, the population of Florida is 15,982,378.

2. To the uninitiated, the referenced “adjustment” means, in chiropractic lingo, adjustment of the aforementioned vertebral subluxation which, as noted, can’t do the patient any good because spinal subluxations don’t exist.


Posted in: Acupuncture, Chiropractic, Legal, Politics and Regulation

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