Lack of Provider Diversity May Impact Patient Outcomes

A recent zip code study by UnitedHealth Group (UHG) shows that income, race and accessibility of non-prescribing providers can influence whether patients with back pain are prescribed opioids or other nonconcordant care.

Zeroing in on the city of Atlanta, for example, researchers found a proof point. One low-income, primarily African-American zip code had a drastically lower rate of opioid use than neighboring zip codes with the same demographics. They soon discovered the reason: the practice of a single Black female doctor of chiropractic (DC). Note: DCs do not prescribe opioids or any pharmaceutical drugs.

“One provider can make a difference,” said David Elton, DC, chief strategy officer for UHG Ventures, who presented these findings at a symposium at the Alliance to Advance Comprehensive Integrative Pain Management. “How many zip codes in the U.S. are missing that provider?”

Non-Prescribing Providers Lack Diversity

It appears that many zip codes nationwide are indeed missing that provider. Doctors of chiropractic, for example, are overwhelmingly white (86%) and mostly male (66%). Similarly, nearly 80% of physical therapists are white.  

At the same time, whites access chiropractic care twice as often as Blacks and Asians, and at a higher rate than Hispanics. The same diversity researchers found that patients who seek care from a provider of the same racial and/or ethnic background tend to be more satisfied with their care.

DCs, however, are recognizing this diversity challenge and are beginning to address it. “To advance the profession further, we first must work together to diversify chiropractic in order to provide our services to the vastly changing and diverse populations of the United States,” wrote Micheala Edwards, DC, president of the American Black Chiropractic Association. “The time for our leaders to unite in these efforts is now.”

Preventing the First Opioid Prescription

Increasing the diversity among DCs and other non-prescribing providers can certainly help reduce the number of opioids and the personal and financial devastation caused by the overprescribing and misuse, which has been well-documented. While steps have been taken to correct the opioid problem, the crisis is far from over.

A July 2020 report from the American Medical Association found a nearly 40% decline in opioid prescriptions over the past five years, but overdose deaths have continued to increase, largely due to the growing use of illicit drugs, such as synthetic fentanyl.

The availability of non-prescriptive treatment is not a silver bullet for the opioid crisis, but it’s clear it can reduce prescribing while still addressing the pain management needs of patients.

A 2020 survey of chronic pain sufferers by the U.S. Pain Foundation showed that most patients are not getting access to the integrative and multidisciplinary pain care viewed as most effective. Providers typically most emphasized medications (38.4%) and interventional procedures (26.2%), while patients wish they most emphasized complementary and integrative health (39%), restorative therapies (36.6%) and medications (35.5%).

Cost is the biggest barrier to accessing treatments, including therapies that aren’t covered by insurance or with unaffordable copays or limits on visits. More than three-quarters of respondents indicated cost prevented them from accessing one or more treatment options (76.5%). Cost was most commonly a barrier to massage (52.8%), acupuncture (39%), physical therapy (29.4%) and chiropractic care (27%).

Creating a “Blue Zone”

Other research shows that creating healthy, pain-free environments within communities can help people make better choices about diet, exercise and relationships that lead to active, longer lives without the need for painkillers. Known as “Blue Zones,” these five heavily-studied communities tend to emphasize plant-based diets, movement throughout the day (not necessarily workouts), strong familial relationships and stress reduction as a way to avoid health problems common in most other parts of the world. Blue Zone research has found that the people in these communities have lower incidents of heart disease, diabetes, depression and chronic pain.

Specifically, one study of a Blue Zone community in California found lower incidents of degenerative arthritis and soft tissue disorders associated with a healthier diet in women and men. Similarly, consumption of legumes and plant-based proteins was associated with a greater reduced-rate of hip fractures. A case study found a Blue Zone lifestyle also contributed to lower incidents of obesity, which is associated with chronic pain.

Creating such Blue Zone communities, however, poses access challenges in regards to fresh vegetables, legumes and other unprocessed foods. However, as the Blue Zones initiatives point out, multistakeholder community involvement and policy changes by local school districts and governments can make access to these foods easier for residents.

Making Drug-Free Care Accessible Across All Demographics

Governments and healthcare providers can also help reduce the barriers to non-opioid care.

A 2020 report by the National Governors Association Center for Best Practices stated that it’s not enough for states just to crack down on opioids: “As states continue to monitor and regulate opioid prescribing, it is essential that policymakers promote access to effective pain management, including use of physical, psychological and multimodal pain treatments, as well as non-opioid pharmacologic therapies.”

It recommended states adopt measures to improve non-opioid pain management. They include: Studying current evidence, Medicaid coverage and access for non-opioid therapies, and nonpharmacologic interventions such as spinal manipulation therapy (chiropractic adjustments), physical therapy and acupuncture. Chiropractic adjustments are a form of spinal manipulative therapy, which is performed 94% of the time by DCs.

Based on its survey findings, the U.S. Pain Foundation also recommends improvements in the areas of advocacy and policy change, education and support. These include improving insurance coverage for multidisciplinary therapies, expanding telehealth and better training of patients and providers in care options.

Removing Barriers to Care

To increase the diversity in the non-prescribing healthcare providers, Dr. Edwards recommends that her colleagues need to work together to increase the number of people of color and women in the chiropractic profession. “Recruitment efforts for our schools must become the business of all of us; education of the masses about all that chiropractic has to offer has to improve,” she wrote. 

Similarly, a joint report from the American Black Chiropractic Association and the International Chiropractors Association titled, “Advancing Diversity as We Advance the Chiropractic Profession” calls for:

·      Developing and supporting opportunities in chiropractic admission criteria not only focused on grade point average, test scores, or time to complete a program but allowing consideration of minority students’ experiences and attributes.

·      Creating and supporting policies and practices that help to develop strategies to recruit minority faculty members to match the population needs.

·      Developing college environments that better support students of color and focus on minority recruitment efforts.

The report concludes that racial and ethnic diversity among DCs and other healthcare professionals can promote better access to healthcare and improved healthcare quality for underserved populations.

By expanding drug-free care access through a more diverse population of providers and removing other barriers to care, we can reduce the number of opioid prescriptions while helping patients regardless of their race, sex or income level to safely relieve their pain, improve mobility and achieve their health goals.