Lind BK, Lafferty WE, Tyree PT, Diehr PK. Comparison of 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.
Analysis of insurance claims data for 2000–2003 from Washington State, which mandates coverage of complementary and alternative medicine (CAM). Patients using CAM were matched to those who were not, based on age group, gender, index medical condition, overall disease burden, and prior-year expenditures.
“Both unadjusted tests and linear regression models indicated that CAM users had lower average expenditures than nonusers. (Unadjusted: $3,79β7 versus $4,153, P=.0001; β from linear regression -$367 for CAM users.) CAM users had higher outpatient expenditures that which were offset by lower inpatient and imaging expenditures. The largest difference was seen in the patients with the heaviest disease burdens among whom CAM users averaged $1,420 less than nonusers, P<0.0001, which more than offset slightly higher average expenditures of $158 among CAM users with lower disease burdens.”
This paper is the latest in a series from this team to evaluate insurance claims databases resulting after a 1996 insurance inclusion mandate for CAM providers in Washington state. The change in regulation required that health insurance companies operating within the state to provide access to every state-qualified class of healthcare providers. Earlier papers from the group found that overall claims were little affected by coverage of CAM providers due to smaller claim size compared to conventional medical claims. Those studies also found that CAM users tended to have higher morbidity than non-users.
Cost studies are few in CAM research. Cost minimization, the approach of this paper, analyzes which of 2 approaches to care is associated with lower overall expenditures, assuming comparable health outcomes between the two approaches. “CAM users” were those who had made claims for visiting any of the following CAM providers: acupuncturists, chiropractors, massage therapists, and naturopathic physicians. Average claims costs in this analysis were about 9% lower over 1 year among CAM users than non-users, showing lower inpatient and ancillary costs (e.g., imaging, laboratory) but higher outpatient visit costs.
The cost outcomes, while favorable to CAM provider use, are associated with and not demonstrably caused by CAM provider visits reflected in the claims. The smaller costs among CAM users may be generated by other health and lifestyle factors associated with going to CAM practitioners (e.g., newly acquired patient activation in the face of a chronic problem, surrendering conventional medical interventions due to therapeutic failures).
Though coverage of CAM providers was made available, coverage was generally not equal to coverage of conventional providers, being restricted among different insurance companies by limits to the number of CAM visits, to a specified network of a providers, or to an overall CAM costs cap.
Not all CAM care costs are included in the data set; for example, dietary supplements, which may be a necessary part of CAM treatment, are typically not covered even if provider visits are. The analysis was done in three impactful conditions—back pain, fibromyalgia, and menopausal symptoms—which all have somewhat uncertain etiologies. They are also conditions that are often refractory to conventional treatment, so findings again may not be generalized to all conditions. These conditions fall into the emerging research area of medically unexplained physical syndromes (MUPS), in which the lowest hanging fruit for CAM research targets may be found.
To answer the question of causation requires prospective intervention studies; however, matching patients in the comparison groups of users versus non-users on the basis of their total medical claims in the year prior to initiating CAM claims makes this study suggestive of a generalizable finding in future economic analyses. Patients without a year of claims prior to initiating CAM claims were not included in analysis.
Different providers types were not distinguished in the analysis on the basis that there were too few claims for any 1 provider type for valid interpretation of the data by discipline (personal communication with first author). The study thus provides little guidance to consumers in choosing a provider, but more confidence that doing something alternative may be a good choice. Claims costs in only 1 year were evaluated; savings from CAM use may come with prevention, and thus subsequent savings could not be addressed. The study did not include Medicaid, Medicare, or state program–covered patients—populations that may be more susceptible to improvement under CAM care due to historical lack of access to it.
Despite its limitations, this creative use of existing data provides some evidence that costs of CAM providers are not redundant to conventional care and that CAM provider use may well be cost-saving. As more such data has become available with increasing inclusion and longevity of CAM providers in insurance coverage over the last decade, replication of this study in other regions and conditions is increasingly possible and should be performed.