Helping Ontarians Access the Chiropractic Care They Need

Working with Insurers, Patients and Employers to Support Ontario’s Recovery and Beyond

Covers of OCA-produced Understanding Extended Health Care guide for chiropractors, Patient's Guide to Extended Health Care Coverage and example infographic titled EHC Insurance 101.
To support a growing understanding of extended health care (EHC) among Ontario chiropractors, our EHC Advisory Council recently produced an Understanding EHC Guide for chiropractors, A Patient’s Guide to EHC Coverage and a series of infographics.

With COVID-19 pandemic restrictions easing, Ontario’s economic recovery is in motion but much of its success will hinge on maintaining a healthy and productive workforce.

As impaired spine, muscle and joint or musculoskeletal (MSK) health has been found responsible for the greatest loss of productive years in the workforce, now more than ever it’s important for employees to access the chiropractic care they need.[1] In turn, chiropractors also play a key role in helping employers provide ergonomically safe work environments, supports and processes to keep their employees healthy and productive, be they onsite or at home.

We can take pride in Ontario’s publicly funded health care system, but it doesn’t cover everything. We know 72 per cent of Ontarians pay for their chiropractic care and treatments privately through extended health care (EHC) insurance plans. [2] They are also called supplementary medical/health coverage plans or employee benefit plans and employers typically provide them as part of a total compensation package, but self-employed people may purchase them individually.

The more effective and comprehensive support EHC plans offer for chiropractic care, the greater opportunity there is for employees to get the expert care they need for their spine, muscle, joint and related nervous system or neuromusculoskeletal (nMSK) conditions. This broad availability also gives employees a choice about who they seek for that care from the growing number of chiropractors listed with EHC insurers.

That said, employees must navigate through the private pay, as well as the publicly funded system to receive the care they need to live their best lives. And this care can be limited by the amount of coverage for effective treatment plans.

Ensuring Employees Access the Care They Need

As the chiropractic profession evolves, research evidence continues to build on its positive benefits in treating nMSK conditions. This knowledge is translated into care plans for each patient’s condition, including treatments and timelines.

To ensure satisfactory patient outcomes, EHC plans should support employees to complete their specific course of treatment.

Most guidelines for nMSK conditions recommend care for four to six weeks. Unfortunately, many EHC plans have inadequate coverage for employees to complete their treatment plans, unless they opt to pay out of pocket.

When this happens, the employee may not complete their care and subsequently experience poor treatment outcomes. This scenario may also cost the employer more in the long term, as well as potentially hinder the employee’s job attendance and retention.

A recent survey of Partnership4BetterHealth, our patient and family advisory council, reinforces this position, as 64 per cent of respondents told us health care benefits factor in their employment-related choices and decisions.[3]

Flexible EHC Plans Foster a Productive and Attractive Workplace

Conversely, when EHC plans align with guidelines so employees can complete their treatment, they’re more able to keep working or return to work, if they’ve been off due to an nMSK issue. In fact, it’s been found that patients receiving chiropractic care have lower disability recurrences and for shorter durations, compared to those receiving care from other health care professionals.[4]

Data also tells us that employees who access chiropractic care tend to incur fewer costs because they’re less likely to be prescribed medications or end up with complex medical procedures.[5]  Similarly, as I outlined in my previous post, interprofessional collaboration between publicly funded medical doctors or nurse practitioners and privately funded chiropractors can help patients effectively manage their MSK pain, while reducing their reliance on opioids.

Given the pent-up demand for publicly funded care due to the pandemic, an efficient program of private care that helps employees get back to work and stay at work serves everyone’s best interests.

Employees are also likely to favour employers with EHC plans that give them the coverage they need to complete their treatment. And according to a 2019 AON survey, compared with past expectations, employees today expect increased flexibility and 56 per cent of respondents expect a high degree of benefit personalization.[6]

With current labour shortages across Canada, employers’ recruitment and retention efforts need to focus on compensation packages that highlight health care and meet needs and expectations across generations.[7]

Helping Patients and Others Through Our Extended Health Care Strategy

To help ensure more Ontarians have access to the effective chiropractic care they need and build internal expertise, we developed an EHC strategy, which complements the Canadian Chiropractic Association’s national EHC strategy.

Recognizing insurers must be accountable to the employers who purchase their plans, a key part of our strategy is to help our chiropractic members work effectively within this system. By helping our members engage effectively with EHC plans and guide their patients to do the same, we aim to support insurers to meet their mandates.

Building Internal Expertise and Providing Practical Resources

Our members know how important EHC coverage is to their patients. In fact, through our 2019 Environics study we learned that four in five chiropractic patients have private health care coverage, the vast majority being EHC.[8]

Members also tell us how they’re sometimes challenged by the complexity of the conditions or limitations that vary across EHC insurers.

Addressing this complexity and building EHC literacy was the genesis of our Extended Health Care Advisory Council. This council aims to develop EHC expertise within our association to best support our members, their patients and collaborate with insurers, while advancing our strategy.

This support includes helping our members to understand and follow leading practices in billing, receipts management and other priorities for EHC insurers, such as virtual care, orthotics and assistive devices.

We also recognize that it’s essential to help our members understand and follow each insurer’s processes as required. Otherwise, the insurer may request an audit and in extreme cases, cease to cover care the chiropractor delivers – leaving their patients to stop their treatment or pay out of pocket.

Based on our organization and others’ requests over the past couple of years, we are seeing more openness to transparency and improved clarity in processes within the insurance sector. We welcome this approach because a practitioner can only be as successful as their understanding of what’s expected of them.

According to the Canadian Life and Health Insurance Association (CLHIA)’s latest data, there are 72 insurers providing EHC coverage in Ontario alone.[9],[10] As patients may have coverage with any one of these, that’s a lot of insurers’ policies for busy chiropractors to keep track of.

To support a growing understanding among Ontario chiropractors, our EHC Advisory Council has recently produced:

  • An Understanding Extended Health Care Guide as a leading practices OCA member resource with practical tools to help patients get the most out of their chiropractic care and chiropractors to fully understand the EHC system.
  • A Patient’s Guide to Extended Health Care to help patients understand their EHC coverage for chiropractic care.

These comprehensive resources help our members, and their teams to effectively structure their clinic’s administrative processes. They also give them accurate tools to inform their patients about the insurance process and answer their questions.

To complement these resources, we produced this podcast on EHC trends and what they mean to Ontario chiropractors.

And we’re in the process of developing an EHC audit tool to help chiropractors provide the information insurers need to be accountable to employers and their EHC investments.

Opportunities to Enhance Patient Care and Outcomes

We also know that EHC insurers have incredible amounts of data that they use to analyze trends and look for opportunities but it’s not readily available.

If that data was shared with health care leaders, it could help private pay and the publicly funded system planners to collaborate on what’s in the best interest of patients and our overall health ecosystem. For example, this data could help inform areas of research that we should be pursuing within chiropractors’ nMSK expertise. We are working towards this ideal among other goals.

In the meantime, our aim is to continue to grow these relationships and become a trusted advisor among EHC insurers and major employers in Ontario.

Future of EHC and What’s Next

Since launching our strategy, we’ve been learning a lot from working with EHC insurers about what employers and patients are looking for.

We need to keep listening to patients about what they want from EHC plans because after all, we all contribute to this private pay system – from the employers who purchase them to the practitioners who deliver care. And as our Partnership4BetterHealth community grows, we want to continue to hear from our patients about their expectations, and what’s working or needs to improve.

Given our pandemic experience and the changes it’s prompting, I think we also have some important questions to address about future working conditions and employee needs that will impact EHC insurance. For example: Will employees continue to work from home? If so, how will the role of employers change vis-à-vis the occupational health and safety of their teams? What supports will employers need to safeguard their employees’ nMSK health and meet occupational health and safety mandates in this new world of work?

As Ontario’s recovery moves forward, we’ll need to be flexible, as we help to shape future strategies that respond to employees’ expectations and how employers, as well insurers, adapt to support Ontario’s workforce.

What are your thoughts about our current EHC system and how Ontarians access the chiropractic care they need? How can our members best support insurers and employers? I welcome your feedback.

In my next post, I’ll discuss our evolving evidence-based framework for chiropractic care and how patient preference plays a key role.

[1] Briggs, A., et al. (2018). Reducing the global burden of musculoskeletal conditions. Bulletin of the World Health Organization.

[2] Environics Research – Study commissioned by the Ontario Chiropractic Association. (2019). Attitudes of Ontarians Toward Chiropractors.

[3] Partnership4BetterHealth. OCA Patient and Family Advisory Community (council).

[4] Allen, H., Wright, M., Craigh, T., Mardekian, J., Cheung, R., Sanchez, R., Bunn, W. & Rogers, W. (2014). Tracking low back problems in a major self-insured workforce: toward improvement in the patient’s journey. Journal of Occupational and Environmental Medicine. 56(6), 604-620.

[5] Allen et al. (2014). Tracking low back problems in a major self-insured workforce.

[6] AON Hewitt Inc. (2019). Employee Benefits: Rethinking objectives in the age of flexibility and choice.

[7] Express Employment Professionals. (2021). Help Wanted – Labour Market in Crisis.

[8] Environics Research – Study commissioned by the Ontario Chiropractic Association. (2019). Attitudes of Ontarians Toward Chiropractors.

[9] Canadian Life and Health Insurance Association (CLHIA). (2021). Canadian Health and Life Insurance Facts: 2021 Edition.

[10]This number excludes property and casualty insurers that are currently actively providing health coverage.

Addressing the Opioid Crisis with Interprofessional Collaboration

Word cloud of keywords related to spine. muscle and joint pain and the opioid crisis, including: Spine, Muscle & Joint Pain, MSK Pain, Low Back Pain, Manual Therapy, Addiction, Pain Management, Mental Health, Prescriptions, Co-ordinate Care, Collaboration, Interprofessional, Families, Economic Impact

Among its consequences, the COVID-19 pandemic is an unplanned experiment in what it means to have reduced access to care. Sadly, while it’s occurring, Ontarians’ need for care is rising. This increased need is not directly related to COVID-19 but because of it.

Pandemic’s impact on patients

Ontario Medical Association president Dr. Adam Kassam recently advised that due to restrictions during COVID-19’s three deadly waves, “more than one health care service was not performed for every Ontario resident this year.”[1]

This hugely diminished access to care affected primary care, emergency departments, as well as regulated health care professionals, such as chiropractors, registered massage therapists and physiotherapists, who could have provided relief.

As mentioned in my last post, the pandemic’s demands on essential workers and added stress was high, increasing their risk of injury and need for care. Those in labour-intensive roles also had to keep working in less-than-ideal conditions and in moving to makeshift home offices, knowledge workers faced new challenges. These pandemic-driven demands, stress and challenges exacerbated back pain and other spine, muscle, joint and related nervous system or neuromusculoskeletal (nMSK) conditions.

And as musculoskeletal (MSK) conditions and related pain account for the largest share of global disability burden,[2] there’s no doubt reduced access to care impacted many Ontarians with these issues.

In fact, our members have told us of patients who turned to or increased their use of pain management medications to compensate.

Opioid-related deaths increased by more than 75 per cent

Tragically, the fallout of reduced access to health care and other services is notably evident in the number of monthly, opioid-related deaths in Ontario, which rose by 79.2 per cent between February and December 2020.[3]

Some of these fatalities are pandemic related. Others are indicative of the ongoing crisis. For example, almost one third of opioid-related deaths among employed individuals comprised those in the labour-intensive construction industry both before and after the pandemic started.

More than 50 per cent of opioid users have reported back pain

What may come as a surprise to some is that back pain has been reported in more than half of regular opioid users.[4] It’s also one of the most common diagnoses emergency and family physicians cite for prescribing opioids.[5]

And even though many patients are prescribed opioids for pain, a 2016 systematic review and meta-analysis found that opioid medications provide modest, short-term pain relief for people with chronic back pain but evidence of long-term efficacy is lacking.[6] Fortunately, there’s alternatives.

Manual therapy: a medication-free alternative for low back pain

Over the past 10 years, research has demonstrated that treatments chiropractors provide, such as spinal manipulation and therapeutic exercise programs, can relieve low back, neck, shoulder or other MSK pain. Also, the type of care chiropractors provide is now globally recognized as an evidence-based first and second-line approach for low back pain.[7]

In fact, the 2017 Canadian Guideline for Opioid Therapy and Chronic Non-Cancer Pain recommends therapies without medication, such as spinal or joint manipulation and therapeutic exercise, for treating back and neck pain, as well as knee osteoarthritis, fibromyalgia and severe headaches/migraines. Similarly, Health Quality Ontario suggests that making better use of non-medical treatments to manage acute and chronic pain will reduce the number of people who end up using opioids for the long-term.

This means Ontario’s health care system now has a recognized option for treating low back and other spine, muscle and joint pain, aside from opioids. But this option hasn’t been utilized to its full capacity. This shortfall is due in part to the complexity in the public and private pay components it requires to help all patients, including those most vulnerable.

Success of Ontario’s Primary Care Low Back Pain program

For an extended period, Ontario has monitored utilization of the health system with a goal to appropriately move care from acute care settings and emergency departments into the community. So, successive governments focused on strengthening primary care and interprofessional teams as a way of bringing leading practice and efficient health care models to Ontario.

With the knowledge that MSK conditions could be managed in the community, our association advocated with the provincial government to include chiropractic care in the primary care models it was developing at the time.

These efforts led to it funding seven Primary Care Low Back Pain (PCLBP) pilot sites across the province in 2015. Under this model, interprofessional primary care teams were formed to deliver efficient, co-ordinated and integrated care to vulnerable patients with low back pain via MSK experts, such as chiropractors.

Successful outcomes followed and 83 per cent of patients surveyed after receiving MSK care at one PCLBP pilot site said they now rely less on medication, including opioids, to help manage their low back pain.[8] And the PCLBP program continues today.

However, evolution of the community-based model of care has generally seen primary care models focus on disciplines funded by the public health care system – limiting chiropractors’ potential to bring relief to more patients.

OCA’s Opioid and Pain Reduction Collaborative

With the growing awareness of the opioid crisis, there is a desire for all levels of health care professionals, as well as governments to decrease the burden it creates and research what’s causing it. That research reveals significant links to MSK pain and that, for example, these conditions presenting in emergency departments contribute to patients’ initial access to opioids.

So our Board of Directors had the foresight to prioritize the opportunity for chiropractors to help solve the opioid crisis.

Subsequently, we partnered with the Centre for Effective Practice (CEP) to create the evidence-based Opioid and Pain Reduction Collaborative (‘Collaborative’). It’s designed to help chiropractors, or other manual therapists, co-ordinate a plan of care with patients and their prescribing health care professionals toward the end goal of them successfully reducing their opioid use.

Our solution includes the CEP-developed Manual Therapy as an Evidence-Based Referral for Musculoskeletal Pain clinical tool. It’s designed to inform physicians and nurse practitioners with the best available evidence.

Another key part of this solution is a script to help chiropractors start a conversation with a patient about reducing their opioid dependency. Most importantly, this script enables chiropractors to do so while staying within their professional scope of practice. We also offer fillable forms to help chiropractors share care plans with prescribing health care professionals.

Why interprofessional collaboration is imperative

But chiropractors can’t do this on their own. Interprofessional collaboration is imperative because MSK disability that’s related to opioid dependency involves much more than the pain of sitting or standing for long periods of time. It affects all aspects of a patient’s life, including their work, social interactions, family life, mental health and finances.

Spine, muscle and joint experts, such as chiropractors, can target the cause of the MSK pain and connect to affected areas of the patient’s life. Patients, primary care providers, as well as often social workers and other health care professionals, are also essential for the depth and expertise they bring to the complexity of a patient’s situation.

And to achieve the best outcomes, all care team members who the patient wants connected to their care plan should be aware of what’s happening at each stage.

So, as the patient’s mobility improves, it’s important for their care team to understand what the chiropractor’s next steps are in their plan of care. This understanding helps ensure the physician or nurse practitioner reduce their medication at an aligned pace or closely monitors the patient’s medication, if they are taking on a greater amount of exercise.

This close connection among the care team is needed to ensure the patient’s overall goals, such as reducing dependence on opioids, strengthening their mobility or improving their ability to stay at work, are met.

I believe patients also recognize the value of collaboration, as our research has found many are frustrated with the lack of communication and coordination among health professionals who care for them.[9] 

Key challenge: communicating across public and private care disciplines

One of the challenges we face is communicating across disciplines and at the right points in time. As we move into post-pandemic recovery, we know the publicly funded system will be under tremendous pressure to catch up and with enhanced interprofessional communication, chiropractors can help.

So, for example, when a physician refers a patient to a chiropractor or a chiropractor reaches out them to discuss a patient’s plan of care, it’s important for them to agree on:

  • What the early weeks of care look will look like
  • When they’ll circle back with each other

This is a watershed moment for all of us to come together to change the outcomes for Ontarians who depend on opioids to relieve their MSK pain.

Health care community’s response to OCA’s Collaborative

This urgency coincides with a growing interest among family health team providers to know what’s going on with their patients’ care – whether it’s from a chiropractor or another health care professional outside the publicly funded system.

There’s a recognition that an increasing number of patients choose to see chiropractors or health care professionals who are not within the public pay system.

We’ve heard about an increasing number of family physicians and nurse practitioners asking about chiropractic care and providing information about the kind of care practitioners can deliver outside the bundled care systems. And again, with a focus on interprofessional care, they want to be engaged in these conversations.

Not surprisingly, the CEP clinical tool has been accessed more than 2,500 times since the Collaborative launched in June 2020 and some of our members have cited favourable feedback from physicians they’ve shared it with.

How the Collaborative will help Ontarians and Ontario

This collaborative approach empowers public and private health care professionals to achieve better patient outcomes for many Ontarians.

Once we reach a critical level of adoption, we expect to see more Ontarians moving, healthy and able to be a committed part of our workforce.

If we can provide the best MSK care at the right place, which is often outside hospitals, we’ll also help enable our health system to efficiently address the pandemic’s backlog of patient needs. Then our publicly funded system can devote its resources to priorities, such as cardiac and cancer care, that can’t be delivered elsewhere.

Finally, I think there’s an opportunity to further explore the co-ordination of care between the public and private pay system for evidence-based, well-established pathways of care. And low back pain would be one of those.

We know more than 70 per cent of Ontarians have extended health care benefit coverage through their workplace and the impact MSK conditions indirectly have on employers.[10] I think there’s an opportunity to leverage these benefits for the greater good, in terms of how they’re covered.

How can you help?

We launched the evidence-based Collaborative’s tools to our members in 2020 and are providing additional supports, such as this podcast series, to advance their implementation.

You can help by encouraging prescribing physicians and nurse practitioners to use this CEP tool and apply this approach to collaboratively help solve this opioid crisis.

I welcome your thoughts and feedback.

(Please note, this blog will be taking a break in August so you can enjoy your summer but it will be back in September with a focus on extended health care insights.)

[1] Kassam, A. (2021, July 4). Doctors’ focus on ‘missing patients’ is just first step in leading the pandemic recovery. Toronto Star.

[2] Vos, T., Lim S.S., Abbafati C., et al. (2020). Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the global burden of disease study 2019. The Lancet, 396:1204–22.

[3] Gomes, T., Murray, R., Kolla, G., Leece, P., Bansal, S., Besharah, J., Cahill, T., Campbell, T., Fritz, A., Munro, C., Toner, L., Watford, J. for Ontario Drug Policy Research Network. (2021) Changing Circumstances Surrounding Opioid-Related Deaths in Ontario during the COVID-19 Pandemic.

[4] Deyo, R.A., Von Korff, M., Duhrkoop, D. (2015). Opioids for low back pain. Thebmj. (350):g6380

[5] Borgundvaag, B., McLeod, S., Khuu, W., Varner, C., Tadrous, M. and Gomes, T. (2018). Opioid prescribing and adverse events in opioid-naive patients treated by emergency physicians versus family physicians: a population-based cohort study. CMAJ Open. 6(1): E110-E117

[6] Shaheed, C.A., Maher, C.G., Williams, K.A., Day, R., McLachlan, A.J. (2016). Efficacy, Tolerability, and Dose-Dependent Effects of Opioid Analgesics for Low Back Pain: A Systematic Review and Meta-analysis. JAMA Intern Med. 176(7):958-968

[7] Foster, N.E., Anema, J.R., Cherkin, D., Chou, R., Cohen, S.P., Gross, D.P., et al. (2018). Prevention and treatment of low back pain: evidence, challenges, and promising directions. The Lancet. 391(10137): 2368–2383.

[8] Primary Care Low Back Pain Pilot Evaluation: Final Report.

[9] Partnership4BetterHealth, OCA Patient and Family Advisory council.

[10] Environics Research, as commissioned by the Ontario Chiropractic Association. (2019). Attitudes of Ontarians Toward Chiropractic Care. 13