Lessen the Pain of Health Care Costs

Americans spend $300 billion annually on pain treatment. Much of this is on treatment for back and neck pain, which two-thirds of us have sought at some point. Fortunately, we have more and better options than ever, and the American College of Physiciansconsiders chiropractic treatment and physical therapy to be effective. Unfortunately, medical licensing laws, as currently written in many states, may not be helping the situation.

In recently published research by the Mercatus Center at George Mason University, we examine how medical occupational licensing laws – including those that specify the tasks medical professionals are allowed to perform, or require patients to visit physicians before they can seek other treatments – are affecting the health care market.

We find that broadening chiropractors’ scope of practice to allow them to perform routine medical tasks is associated with an 8.6 percent increase in their earnings. Why is it that chiropractors making more money is a good thing for patients? Our research suggests that patients are more comfortable with chiropractor services as a result of the legislative change. In addition, a visit to the chiropractor costs about 35 percent less than a visit to the physician.

Why, then, do Americans typically choose to see their family physician instead? It may be personal preference, or a lack of awareness of alternative health care providers. Or perhaps it is because physicians wield the authority to foreclose access to competitors as a result of their position on medical licensing boards and thus protect their market share.


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Why does this matter? Physicians are more likely to prescribe invasive treatments (e.g., surgery and medication) than chiropractors and physical therapists. It is not always clearthat these more invasive (and much more expensive) treatments are necessary, and the risks of the procedures may sometimes outweigh the intended benefits.

Prior to the mid-1990s, chiropractors were not permitted to discuss over-the-counter medications with patients. They were also not allowed to perform phlebotomy (blood drawing). The lack of authority to perform these routine medical services may have prevented chiropractors from earning the trust of patients. Having to go to another provider for these routine medical tests may not inspire patient confidence.

Meanwhile, patients have historically had to see a physician before being allowed to see a physical therapist. Before 1980, just three states (California, Maryland and Nebraska) granted patients so-called direct access to physical therapists without physician referral. This gave physicians the opportunity to prevent patients from considering alternative care options.

In the 1980s and 1990s, several states made important changes to chiropractor scope of practice and physical therapist access to patients. For example, seven states began to allow chiropractors to perform phlebotomy in the mid-1990s. Today, all states allow patients direct access to physical therapists, but many do so with limitations.


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While we do find evidence that broader chiropractor scope of practice has had a measurable effect on the market, we find little evidence that direct access to physical therapists has affected the marketplace in the same way. Perhaps with the passage of time, more patients will consider seeking treatment for back and neck pain from a physical therapist. There are also different degrees of direct access (for example, limiting the number of visits to physical therapists without physician referral) that might influence a patient’s ability to see one.

Surgery and medication are sometimes the best, or perhaps the only viable, treatment for patients with neck and back pain. In other cases, however, less invasive and less expensive treatments as prescribed by chiropractors or physical therapists are the better option. But physicians, as a result of their positions on state medical licensing boards, can sometimes exert monopoly power that leads to less consumer choice.

Patients should benefit from a full menu of choices when seeking treatment for their ailments. Further widening of the scope of practice of chiropractors and granting physical therapists unrestricted direct access to patients may help Americans receive more effective treatment at lower costs.

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