By Mal Vickers

Before you read any further, try to guess the answer to this question:

In Australia, in 2012, how many chiropractic treatments occurred as a result of a doctor’s referral?

To clarify, I’m not asking for the total number of chiropractic consultations that occur per year, just patients consultations for chiropractic treatment where the patient was referred by a medical doctor – how many? Find the answer in the text below highlighted in red. How close were you?

Medicare Dollars are Taxpayer Dollars

Everyone in Australia pays for Medicare rebates through the tax system. Medicare enables community access to a variety of quality health services but that’s not in question. What I’d really like to look at is how much we pay through the Medicare system for treatments that show little or no efficacy.

This information is not easy to find, however the Medicare website allows anyone to generate statistical reports based on the information Medicare collects. It’s possible to work out the number of consultations of different kinds for which Medicare benefits are paid, and to itemise the costs.

Medicare assigns a Medicare Benefits Schedule Item (MBSI) number to each type of consultation.

A standard doctor-patient consultation is MBSI 23. A chiropractic consultation is MBSI 10964. Acupuncture is a little more complicated, with different MBSI numbers representing different types of consultations. For example, the MBSI  reflects whether or not the practitioner was a GP, or whether  or not the consultation took place in a hospital. Acupuncture consultations are MBSI 173, 193, 195, 197 and 199.

Chiropractic

Let’s look in detail at the statistics that can be generated for chiropractic consultations. Note that in order to claim a Medicare rebate for chiropractic treatment you must have a referral for that treatment from a GP.  The total number of Medicare rebates for chiropractic treatment in the 2005 calendar year was 14,957. In 2008 the number climbed to 76,449. The 2012 calendar year saw Medicare rebates for chiropractic treatment reach 197,797. That’s a an amazing 13-fold increase in rebates from 2005 to 2012.

I’m not sure why there’s been such an increase (more on this later). It’s not that chiropractic is a new technology. There has been no significant change to chiropractic treatment, or new studies revealing that chiropractic is efficacious.

In 2005 the total Medicare rebate for chiropractic was $648,891. In 2012 it was a whopping $10,234,422. The average Medicare rebate for a chiropractic treatment in 2012 was $51.74, which is a small increase on the 2005 average rebate of $43.38.

Standard Consultations

In all fairness, I should compare this trend with that of ordinary doctor-patient consultations. The number of Medicare rebates for MBSI 23, (a standard consultation) was 71,972,522 in 2005 rising to 86,267,019 in 2012. The cost of standard consultation rebates was $2,234,467,859 in 2005 which increased to $3,110,538,034 in 2012. The average rebate for a standard consultation was $36.06 in 2012.

Proportionally, in dollar terms, the cost of chiropractic consultations represents 0.3% of that of standard consultations.

The numbers and total cost of standard doctor-patient consultations (MBSI 23) are much greater than those of chiropractic consultations. Proportionally, however, the growth in standard consultations is a modest 20%. This is dwarfed by the 13-fold growth in chiropractic consultations for the same period.

Acupuncture

Let’s examine  the combined  data for all the MBSI numbers for acupuncture. In 2005 the total number of rebates was 621,897. In 2012 the total had actually fallen slightly to 536,663. However, in 2005 the total cost was $21,924,153 and in 2012 it was $23,204,642. I guess that’s due to a rise in charges and rebates amount for acupuncture procedures.

The statistics of the specific MBSI acupuncture numbers are interesting. For example MBSI 193 is where an acupuncture consultation was conducted by a GP, who is qualified to perform acupuncture, but was not carried out at a hospital. A total of 365,408 of these were done in 2012. On the other hand, the statistics for an MBSI 195 is quite different. An MBSI 195 is an acupunctural consultation, performed by a GP who is qualified to give acupuncture at a hospital. There were just 12 of these conducted in Australia in 2012. I don’t know which hospital in Australia has this doctor, but business appears to be fairly quiet for him or her.

Why the Increase in Chiropractic Rebates?

There has clearly been a significant increase in Medicare rebates for chiropractic over the last eight years. I’m unsure of the reasons for this rise.

There is a scheme in place that might explain the most recent rise in chiropractic rebates.

The Department of Health and Ageing (DoHA) wants to help people who are heavy users of the Medicare system because they have chronic conditions such as diabetes, stroke, depression, heart disease etc. If you have one of these conditions, DoHA would like you to develop a ‘Chronic Disease Management’ (CDM) plan in consultation with your doctor. If you are on a CDM plan you can legitimately claim a Medicare rebate for things like, dentistry, podiatry, occupational therapy, chiropractic and others.

Asthma is one condition that qualifies as a Chronic Disease under the CDM scheme. One would hope that doctors are not referring asthma patients for chiropractic as there is no scientific evidence to support the use of chiropractic to treat asthma. I base this on a large review of the medical literature conducted in the UK in 2010.

In Summary

What do we get for our $10 million spent on chiropractic and our $23 million spent on acupuncture? The scientific evidence suggests we get nothing – well close to nothing. We get the placebo effect of course, which you would also get with evidence-based medical practice. There may be some plausible evidence that chiropractic is effective for a small number of  conditions such as back and neck pain, but that evidence isn’t clear cut. See this systematic review.

Chiropractic and acupuncture are based on the implausible, immeasurable ideas of ‘innate intelligence’, ‘subluxations’, ‘qi’ and ‘meridians’.

I don’t really want to argue as to why chiropractic and acupuncture are unlikely to be beneficial to your health. For those wanting to argue the case, please see Appendix A and then write your comments in the comments section below. Note that this post is not about the efficacy of chiropractic and acupuncture, it’s about the cost to the community.

You can’t get a Medicare rebate for other pseudo-medicines like flower remedies, homeopathy, iridology or dolphin therapy. I’m not sure why chiropractic and acupuncture qualify.

Medicare does have a ‘Practitioner Review Program’. However, reading through the blurb, it looks to be more about getting rid of the ‘bad apple’ doctors rather than checking for efficacy.

I believe that there is a ‘right way’ to go about assigning Medicare rebates for various consultation types; (note I didn’t say ‘treatments’, as that might imply efficacy). Firstly, chiropractic and acupuncture need to establish their efficacy through rigorously conducted clinical trials, to establish much the same level of efficacy that we expect for other medical interventions. Then, if they are found to be significantly beneficial, taxpayer support through a Medicare rebate may be appropriate.

OK…fine…tell me I’m dreaming… it’s only a $33 million dollar dream.

Appendix A

Recommended reading:

Trick or Treatment

Chiropractic

The Skeptic’s Dictionary: Chiropractic

Ernst E.  Chiropractic: a critical evaluation..

The Quackcast episode on chiropractic #10

Acupuncture

The Skeptic’s Dictionary: Acupuncture

Science Based Medicine – More “bait and switch” acupuncture studies

Ernst E. Acupuncture for chronic pain? Almost certainly not!

The Quackcast episodes on acupuncture #7 and #8