Journal of Occupational Rehabilitation

, Volume 20, Issue 1, pp 90–103 | Cite as

Adjusting Rehabilitation Costs and Benefits for Health Capital: The Case of Low Back Occupational Injuries

  • Richard J. ButlerEmail author
  • William G. Johnson


Introduction Case-mix adjustments for treatment/rehabilitation costs and benefits of non-traumatic injuries, such as occupational back pain, are much more difficult than adjustments for traumatic injuries. We present a new method for adjusting for severity differences in the costs and benefits of treating occupational low back injuries. Methods Using initial post-injury differences in the health capital of prospective sample of 1,831 occupational related back pain patients, we combine survey data with workers’ compensation claim files and medical billing information to adjust the costs and benefits of treatment using multivariate techniques. Results We find that large differences in the net benefits of treatment between the three lowest cost provider groups virtually disappear once adjustments are made for worker’s health capital (injury severity) at entry into treatment. Conclusions Once adjustments are made for initial health capital immediately after injury, the net benefits of treating occupational low back pain are virtually identical for physician only care, physician plus physical therapy care, and chiropractic care. Net benefits of care are lower for combined physician/chiropractic care, and lowest for all other forms of care (principally, treatment by orthopedic surgeons). Our method is readily adapted for comparisons among individual health care/occupational rehabilitation professionals or among group practices and other health care organizations.


Health capital Cost/benefit analysis Low back pain Provider type Survival curve analysis 



This research has been approved by the IRB of Arizona State University and East Carolina University. There are no financial conflicts involved in this research.


  1. 1.
    Waddell G, Burton AK. Occupational health guidelines for the management of low back pain at work: evidence review. Occup Med. 2001;51:124–35.CrossRefGoogle Scholar
  2. 2.
    Michie S, Williams S. Reducing work related psychological ill health and sickness absence: a systematic literature review. Occup Environ Med. 2003;60:3–9.CrossRefPubMedGoogle Scholar
  3. 3.
    Butler RJ, Johnson WG, Baldwin ML. Managing work disability: why first return to works is not a measure of success. Ind Labor Relat Rev. 1995;48(3):452–69.CrossRefGoogle Scholar
  4. 4.
    Baldwin ML, Richard J. Butler upper extremity disorders in the workplace: costs and outcomes beyond the first return to work. J Occup Rehabil. 2006;16(3):296–316.CrossRefGoogle Scholar
  5. 5.
    Nordin M, Hiebert R, Pietrek M, Alexander M, Crane M, Lewis S. Association of comorbidity and outcome in episodes of nonspecific low back pain in occupational populations. J Occup Environ Med. 2002;44(7):677–84.CrossRefPubMedGoogle Scholar
  6. 6.
    Loisel P, Poitras S, Lemaire J, Durand P, Southiere A, Abenhaim L. Is work status of low back pain patients best described by an automated device or by a questionnaire? Spine. 1998;23(14):1588–94.CrossRefPubMedGoogle Scholar
  7. 7.
    Johnson WG, Baldwin ML, Marcus S. The impact of workers’ compensation networks on medical costs and disability benefits. Cambridge: Workers’ Compensation Research Institute; 1999.Google Scholar
  8. 8.
    Hurwitz EL, Morgenstern H. The effects of comorbidity and other factors on medical versus chiropractic care for back problems. Spine. 1997;22:2254–64.CrossRefPubMedGoogle Scholar
  9. 9.
    Grossman M. The demand for health: a theoretical and empirical investigation. Columbia: Columbia University for NBER; 1972.Google Scholar
  10. 10.
    Hurwitz EL, Morgenstern H, Kominski GF, Yu F, Chiang LM. A randomized trial of chiropractic and medical care for patients with low back pain: eighteen-month follow-up outcomes from the UCLA low back pain study. Spine. 2006;31(6):611–21. Discussion 622.CrossRefPubMedGoogle Scholar
  11. 11.
    Baldwin ML, Cote P, Frank JW, Johnson WG. Cost-effectiveness studies of medical and chiropractic care for occupational low back pain. A critical review of the literature. Spine J. 2001;1:138–47.CrossRefPubMedGoogle Scholar
  12. 12.
    Carey TS, Garrett J, Jackman A, McLaughlin C, Fryer J, Smucker DR. The outcomes and costs of care for acute low back pain among patients seen by primary care practitioners, chiropractors, and orthopedic surgeons. The North Carolina back pain project. N Engl J Med. 1995;333(14):913–7.CrossRefPubMedGoogle Scholar
  13. 13.
    Skargren EI, Oberg BE, Carlsson PG, Gade M. Cost and effectiveness analysis of chiropractic and physiotherapy treatment for low back and neck pain: six-month follow-up. Spine. 1997;22:2167–77.CrossRefPubMedGoogle Scholar
  14. 14.
    Skargren EI, Carlsson PG, Oberg BE. One-year follow-up comparison of the cost and effectiveness of chiropractic and physiotherapy as primary management for back pain: subgroup analysis, recurrence, and additional health care utilization. Spine. 1998;23:1875–84.CrossRefPubMedGoogle Scholar
  15. 15.
    Cherkin DC, Deyo RA, Battle M, Street J, Barlow W. A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain. N Engl J Med. 1998;339:1021–9.CrossRefPubMedGoogle Scholar
  16. 16.
    Meade TW, Dyer S, Browne W, Townsend J, Frank AO. Low back pain of mechanical origin: randomized comparison of chiropractic and hospital outpatient treatment. BMJ. 1990;300:1431–7.CrossRefPubMedGoogle Scholar
  17. 17.
    Ebrall PS. Mechanical low-back pain: a comparison of medical and chiropractic management within the Victorian workplace scheme. Chiroprac J Aus. 1992;22:47–53.Google Scholar
  18. 18.
    Johnson WG, Baldwin ML, Butler RJ. The costs and outcomes of chiropractic and physician care for back pain. J Risk Insur. 1999;66:185–206.CrossRefGoogle Scholar
  19. 19.
    Carey TS, Garrett J, Jackman A, McLaughlin C, Fryer J, Smucker DR. The outcomes and costs of care for acute low back pain among patients seen by primary care practitioners, chiropractors, and orthopedic surgeons. N Engl J Med. 1995;333:913–7.CrossRefPubMedGoogle Scholar
  20. 20.
    Hurwitz EL. The relative impact of chiropractic vs. medical management of low back pain on health status in a multispecialty group practice. J Manipulat Physiol Ther. 1994;17:74–82.Google Scholar
  21. 21.
    Gold MR, editor. Cost-effectiveness in health and medicine. New York: Oxford University Press; 1996.Google Scholar
  22. 22.
    Kaplan EL, Meier P. Nonparametric estimation from incomplete observations. J Am Stat Assoc. 1958;53:457–81.CrossRefGoogle Scholar
  23. 23.
    Kolata G. With costs rising, treating back pain often seems futile. The New York Times, February 9, 2004. Late Edition.Google Scholar
  24. 24.
    Bigos SJ. United States Agency for Health Care Policy and Research. Acute low back problems in adults. USA: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; 1994.Google Scholar
  25. 25.
    Roland M, Morris R. A study of the natural history of back pain. Part I: development of a reliable and sensitive measure of disability in low-back pain. Spine. 1983;8:141–4.CrossRefPubMedGoogle Scholar
  26. 26.
    Deyo RA, Centor RM. Assessing the responsiveness of functional scales to clinical change: an analogy to diagnostic test performance. J Chron Diseases. 1986;39(11):897–906.CrossRefGoogle Scholar
  27. 27.
    Stratford PW, Binkley J, Solomon P, Finch E, Gill C, Moreland J. Defining the minimum level of detectable change for the Roland–Morris questionnaire. Phys Ther. 1996;76:359–65. discussion 366-368.PubMedGoogle Scholar
  28. 28.
    Stratford PW, Binkley J, Solomon P, Gill C, Finch E. Assessing change over time in patients with low back pain. Phys Ther. 1994;74(6):528–33.PubMedGoogle Scholar
  29. 29.
    Jensen MP, Karoly P, Braver S. The measurement of clinical pain intensity: a comparison of six methods. Pain. 1986;27:117–26.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2009

Authors and Affiliations

  1. 1.Department of EconomicsBrigham Young UniversityProvoUSA
  2. 2.Department of Biomedical InformaticsArizona State UniversityTempeUSA

Personalised recommendations