Money Well Spent? Dubious Medicine on Medicare

By Mal Vickers

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

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.

Click full size. Chiropractic rebates 2005-2012

Click full size

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.

Standard rebates

Click full size

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.

Click full size, Acupuncture Consultations 2005-2012

Click full size

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

8 Responses to Money Well Spent? Dubious Medicine on Medicare

  1. anon says:

    Mal,
    You may be unaware, but Medicare rebates for chiropractic services (10964) have only been available since 2004/5. Of course its not going to be difficult to see a ‘dramatic’ increase in services when you’re using statistics from the first full year it was introduced. In the last 2 full calendar years however, the growth in the cost of chiropractic services has been roughly 24%, not substantially more than the ‘modest’ 20% for doctor-patient consults that you highlight above.

    • malvickers says:

      Dear ‘anon’
      Thanks for the interesting comment.

      I went back and checked the Medicare data for some other newly introduced consultations. Some do follow a trend similar to chiropractic i.e. podiatry (MBSI 10962) and occupational therapy (MBSI 10958). Others don’t follow the same trend at all i.e. dentistry (MBSI 53700). Others are a smaller increase i.e. exercise physiology (MBSI 10953), a four times increase from 2007 to 2012.

      I don’t think comparing standard consultations over the last eight years, to chiropractic over the last “2 full calendar years” is a fair comparison.

      As I said in the post “I’m unsure of the reasons for this rise.” It’s interesting to speculate.

  2. Rumour has it that the ‘nice little earner’ business model of over servicing clients by chiro’s, means many of them now own medical centres, where medical doctors are employed on the basis that the doctors will refer their patients to the chiro. I would like to know if there is evidence of this occurring.

  3. anon says:

    Mal,
    You said, “I don’t think comparing standard consultations over the last eight years, to chiropractic over the last “2 full calendar years” is a fair comparison.”

    Perhaps you could compare the growth in chiro rebates ($Benefit) in the last couple of years to the other related allied health professions ie: physio, osteo, ex phys. I think you will find that growth in chiropractic medicare rebates over the last couple of years, is roughly in line with these and other allied health professions. I think your article is unnecessarily dramatic and somewhat misleading.

  4. anon says:

    jbd,
    As Mal points out in the article, the stats can be found here
    https://www.medicareaustralia.gov.au/statistics/mbs_item.shtml

    • malvickers says:

      Here we go again, just for Mr anon’s satisfaction.

      Physiotherapy (MBSI 10960) was 158,305 rebates in 2005, 1,110,422 in 2012. Physiotherapy shows a growth of 7.0 which is not as high as chiropractic over the same period at 13.2.

      Osteopathy (MBSI 10966) was 7,136 in 2005, 90,225 in 2012, growth of 12.6 over the same period, high growth and quite comparable, almost as high as chiropractic at 13.2.

      Exercise physiology (MBSI 10953) is not comparable over the same time period because it was introduced in 2006. However, there is a way, I’ll compare exercise physiology and chiropractic from 2007 to 2012. Ex phys was 37,231 rebates in 2007, 121,926 in 2012 a growth of 3.3. Chiro was 48,782 in 2007, 197,797 in 2012, a growth of 4.0.

      Again, I will mention dentistry, small numbers of rebates and going backwards. Acupuncture, large numbers and going backwards.

      Repeating what I said in the post: “I’m unsure of the reasons for this rise. [in chiropractic rebates]”.

      Why mention only acupuncture and chiropractic? Because they are dubious medicines. The scientific evidence suggests that Australian tax payers will get little to no benefit for the $33M spent. And, if you project the slope of the graph forward for chiropractic, we’ll probably spend even more this year and next.

      I could have mentioned all the data that you would like me to have mentioned, however I would probably have drowned my point in a sea of data, one must stop somewhere.

      I’m quite happy to see growth in other consultation types, those not mentioned in the post, because the science behind those is better i.e. Australian tax payers are more likely to see a benefit in improved health.

      I’m being too dramatic? I’ve just seen an article in Australian Doctor that suggests chiropractic referrals for x-rays have cost Medicare $156M over the last five years:

      http://www.australiandoctor.com.au/news/latest-news/chiros-run-up-big-bill-for-x-ray-referrals

      Now, if you’ll excuse me, I have better things to do, I must get my ‘innate intelligence’ adjusted :)

  5. anon says:

    Mal,
    I stand by my comments regarding recent per year growth rates. Chiropractic is roughly in line with other related health professions.

    If you read the comments at the end of the chiropractic article you posted a link to, you will realise that based on the figures quoted, it equates to 18.66 x-ray referrals per year for each chiropractor. Or one roughly every 3 weeks. Hardly excessive.

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