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reference
Lind BK, Lafferty WE, Tyree PT, Diehr PK. Comparing health care expenditures among insured users and nonusers of complementary and alternative medicine in Washington state: a cost minimization analysis.J Altern Complement Med. 2010;16(4):411-417.
design
Analysis of 2000-2003 insurance claims data from Washington state requiring coverage of complementary and alternative medicine (CAM). Patients who used CAM were matched to those who did not based on age group, sex, index disease state, total disease burden, and previous year expenditures.
Results
"Both unadjusted tests and linear regression models showed that CAM users had lower average expenditures than non-users. (Unadjusted: $3.79 β7 vs $4,153, P = 0.0001; β from linear regression - $367 for CAM users.) CAM users had higher outpatient expenditures, offset by lower Expenses for inpatient treatment and imaging were offset. The largest difference was seen among patients with the highest disease burden, where CAM users paid an average of $1,420 less than non-users, P<0.0001, more than offsetting the slightly higher average expenditure of $158 among CAM users with lower disease burden.”
Effects on practice
This paper is the latest in a series by this team evaluating insurance claims databases created following a 1996 insurance coverage mandate for CAM providers in Washington State. The rule change required health insurance companies operating in the state to provide access to all federally qualified health care providers. Previous work by the group found that overall claims were little affected by coverage from CAM providers due to lower claims levels compared to traditional medical claims. These studies also found that CAM users tended to have higher morbidity than non-users.
There are few cost studies in CAM research. Cost minimization, the approach of this work, analyzes which of the two care approaches is associated with lower overall expenditures, assuming comparable health outcomes between the two approaches. “CAM users” were those who claimed eligibility for a visit to one of the following CAM providers: acupuncturists, chiropractors, massage therapists, and naturopathic physicians. Average claims costs over one year in this analysis were approximately 9% lower for CAM users than nonusers, demonstrating lower inpatient and incidental costs (e.g., imaging, laboratory) but higher outpatient visit costs.
The cost consequences, while favorable for the use of CAM providers, are related to, and are not verifiably attributable to, the CAM provider visits set forth in the claims. The lower costs among CAM users may be caused by other health and lifestyle factors associated with visiting CAM physicians (e.g., activation of a new patient in the face of a chronic problem, forgoing conventional medical interventions due to treatment failure).
Although insurance coverage was made available by CAM providers, coverage generally did not match that of traditional providers and was limited between different insurance companies by limits on the number of CAM visits, a specific provider's network, or an overall cost cap for CAM.
[PULLEDQUOTE]Not all CAM care costs are included in the data set; For example, nutritional supplements, which may be a necessary part of CAM treatment, are typically not covered, even if they are during doctor visits. The analysis was conducted on three serious medical conditions - back pain, fibromyalgia and menopausal symptoms - the causes of which are all unclear. These are also conditions that often do not respond to conventional treatment, so the results may not be generalizable to all conditions. These disorders fall into the emerging research area of medically unexplained physical syndromes (MUPS), where the lowest hanging fruit for CAM research targets can be found.
Prospective intervention studies are needed to answer the question of causality. However, assigning patients into user and non-user comparison groups based on their total medical claims in the year prior to initiation of CAM claims, this study suggests a generalizable finding in future economic analyses. Patients without 1 year of claims prior to initiation of CAM claims were not included in the analysis.
Different provider types were not differentiated in the analysis because there was too little information for a provider type for a valid interpretation of the data by discipline (personal communication with the first author). The study therefore offers consumers little guidance when choosing a provider, but rather confidence that doing something alternative could be a good choice. The cost of damage in just one year was assessed; Savings from CAM use may accompany prevention and therefore subsequent savings could not be addressed. The study did not include patients covered by Medicaid, Medicare, or government programs—populations that may be more vulnerable to improvements under CAM care because they have not had access to it in the past.
Despite its limitations, this creative use of existing data provides some evidence that the costs of CAM providers do not exceed conventional care and that the use of CAM providers can certainly be cost-saving. As more such data have become available with the increasing inclusion and longevity of CAM providers in insurance coverage over the past decade, replication of this study in other regions and conditions is increasingly possible and should be undertaken.