NWHSU Alum David Elton Helps Establish Chiropractic Care as the First Intervention for Back Pain
Between 1906 and 1975, tens of thousands of chiropractors were thrown in jail for simply practicing natural medicine. (1) Today, chiropractic care not only is recognized by the U.S. Department of Health and Human services and licensed in all 50 states, but also the majority of insurance providers, including Medicaid, pay for at least a portion of chiropractic services for their patients.
Now the largest insurance payer in the U.S., UnitedHealthcare (UHG) has rolled out a new benefit for people with low back pain that makes it more affordable to access chiropractic care and physical therapy. Introduced in July of 2019, the new benefit design eliminates copays and deductibles for the first three chiropractic or physical therapy visits.
This increase in access to chiropractic and physical therapy services has the potential to reduce spinal imaging by 22 percent, spinal surgeries by 21 percent, opioid use by 19 percent, and lower the total cost of care for eligible plan participants and employers, according to a press release issued by UHG.
Historic change for chiropractic care
This sea change for chiropractors came about thanks to the hard work and dedication of individuals who, over decades, delivered high quality patient care, networked, lobbied, persuaded and won over healthcare professionals and legislators in every state.
Northwestern Health Sciences University (NWHSU) alum David Elton, D.C. ‘86, continues this long tradition of determined advocacy, working to advance the profile of the chiropractic profession at the largest commercial healthcare payer in the United States—UHG. Elton has worked at UHG since 2001 and currently serves as the Chief Strategy Officer for the UHG Ventures Orthology business, a growing, multidisciplinary practice currently operating in Minnesota and New York.
“The UHG mission is to make the healthcare system work better for everyone, one person at a time. From the beginning my experience within UHG has been one of curiosity among my colleagues and support for helping patients access care from chiropractors and physical therapists” Elton says.
Proving the effectiveness of chiropractic and acupuncture with data
After graduating from Northwestern Health Sciences University in 1986, Elton worked in private practice before joining the American Chiropractic Network (ACN) in 1995. In 2001, ACN was acquired by UHG’s Optum business unit. Shortly after the acquisition, Elton and his colleagues began networking within UHG to obtain access to data that might provide insights into the effectiveness and value proposition of chiropractic care.
“For decades chiropractors, and their patients, recognized the value of chiropractic care, yet high quality studies demonstrating those benefits were hard to find,” Elton says. “Research has been too focused on randomized clinical trials exploring the effectiveness of spinal manipulative treatment, or SMT. By their design, these trials can remove much of what makes chiropractic care so effective, resulting in seemingly small effects for spinal manipulations, which can lead stakeholders believe they are not effective.”
In 2005, Elton and his colleagues at Optum acquired access to a very large volume of data, and developed an analytic approach that enabled them to summarize and compare different treatment pathways seen for musculoskeletal conditions categorized the specialty of the first provider. As they expected, the data illustrated the importance of the first referral.
“The data available to us was national in scope, included all services, settings and provider specialties, and covered many years,” Elton says. “The initial outputs seemed to support our hypothesis, that early chiropractic care had a number of benefits, including a much lower rate of opioid use for back pain patients who initially sought treatment from a chiropractor. From 2005 to 2014, we focused on developing practical actions and were making consistent progress in helping stakeholders better understand how chiropractors could improve the quality and affordability of back pain treatments.”
The Opioid Crisis adds urgency
After Elton focused on translating insights derived from the total episode of care analytics into practical and high-impact action, in 2015 he switched gears and pursued publishing the data to help better inform the industry.
“From 2005 to 2014 our time and resources were focused on taking action to help make the healthcare system work better for people with back pain and we consciously did not slow down to submit the data for publication. By 2015, it became important to attempt to publish the data.”
While healthcare leaders were focused on the growing opioid epidemic, Elton approached Optum Labs with a proposal for in-depth research into the various care pathways patients take for lower back pain. A member of the UHG Opioid Task Force and Pain Management Work Group, Elton worked with both UHG and Optum Labs to research solutions to the opioid epidemic.
“Early conservative care for back pain does have the potential to help patients avoid opioids,” Elton says. “The data we produced from 2005 to 2014 stood out as potentially important for the UHG Opioid Task Force, but we were concerned that publishing our own data was associated with a risk of perceived bias. That’s why we reached out to Optum Labs, so that we could have independent experts from leading academic institutions lead the research effort.”
Studying the benefits of early conservative care
From 2017-2019, Elton and his Optum Labs colleagues worked with researchers from Boston University to analyze data. The team published three papers, including: “Observational retrospective study of the association of initial healthcare provider for new-onset low back pain with early and long-term opioid use” and “Health Insurance Design and Conservative Therapy for Low Back Pain.”
The data revealed a potential path for reducing the number of people addicted to opioids: When a chiropractor, physical therapist or acupuncturist is the first provider seen by a patient with back pain, the likelihood of early or long-term opioid use is significantly reduced.
Another important finding was high copays and deductibles can be a barrier to patients choosing to the providers that significantly reduce the likelihood to receive an opioid prescription.
“In large claims-based studies like this, you don’t often see these types of very clear results,” Elton says.
Some readers have questioned the validity of the results, considering that the people who elected to go to a chiropractor, physical therapist or acupuncturist are the sort of people who would not have taken opioids in the first place.
“In a study like this, it’s challenging to control for this type of patient preference,” Elton says. “This concern is partially addressed by the way the study reveals both early and long term avoidance benefits of early conservative care for back pain. In addition, we also have data that wasn’t published in the study that shows that patients who had previously filled an opioid prescription for another condition were also less inclined to start opioids for back pain if they went to conservative care first.”
The research also demonstrated several additional—also currently unpublished—beneficial attributes of episodes where a chiropractor was the first provider seen for back pain.
Policy benefits change years in the making
On a parallel path to the Optum Labs research, Elton and the UHG Opioid Task Force kicked off actuarial analyses to confirm the financial benefits of early conservative care for back pain, conducting cost benefit analysis (CBA) for potential design changes to the benefits they offer to patients.
“Research and publication without translation into action is just another paper in a journal sitting on a shelf.” Elton says. “At UHG we have a bias to action, the opioid epidemic created an urgency to do what we could to help, and a commitment to investing the resources necessary to make a difference.”
This independent actuarial analysis was key to getting stakeholders on board to formally change the benefits offered to patients. “Approximately fifty percent of low value care is associated with back pain; and fifty-two percent of opioid morphine milligram equivalents are prescribed is for back pain,” Elton says. “Use of imaging and surgery for back pain are highly variable. All this adds up to the treatment of back pain being very costly, and the actuarial analysis revealed all of these costs go down when a chiropractor is the first provider seen for back pain.”
In 2017, Elton and his UHG colleagues began working to create the benefit plan designs, develop the necessary claims processing technology, and execute the related patient and employer communication plan.
Making sure the new benefits work for patients
With the new benefit plan design changes now being introduced across the country, Elton and UHC are shifting their focus to measuring what is working to help more patients with back pain access conservative treatment. An ambitious measurement plan is in place to look for the volume of back pain cases that shift to a more conservative pathway, and what happens when patients have better access to these types of care.
From now through 2022, the team will continue to modify strategies and tactics to better align treatment of back pain with guidelines that increasingly emphasize early conservative treatment, improving access for patients to care that helps them get better without costly treatments and potentially addictive medications.
“When a change like this happens, there is a tendency to recognize people in roles like mine, or people whose name is on a published paper,” Elton says. “Those that truly deserve to be recognized are the thousands of our colleagues in practice caring for patients, one person at a time, over an entire career. Their efforts created the data that informed the changes we are making.”
“And current NWHSU students need to know that they are acquiring the knowledge and skills to make a difference, and they’re entering a growing market where their expertise is increasingly valued and in demand.”