The three manual therapy professions provided nearly 200 million healthcare services at a total cost of approximately $12.8 billion under Australian private health insurance cover in the period from 2008 to 2017. Physiotherapy accounted for the largest annual total cost throughout the ten-year period, and surpassed chiropractic in 2011 as the profession delivering the most services per year. The annual number and total cost of services increased during the ten-year period for the three professions, with more pronounced growth in 2008–2012 than in 2013–2017. Growth in service utilisation varied by profession, with osteopathy experiencing the largest growth in the annual number and total cost of services during the ten-year period. Unlike osteopathy and physiotherapy, chiropractic had a negative growth in the annual number of services provided between 2013 and 2017. Although the number of providers increased for all three professions during 2013–2017, the annual number of services per provider declined. The decline was particularly pronounced for chiropractic; however, the annual number of services per chiropractor remained two and four times greater than for physiotherapists and osteopaths, respectively.
In Australia, manual therapy services are predominately paid for by non-government sources, primarily by individuals and private health insurers. Individual and private health insurer spending on primary healthcare services by health professionals other than medical doctors and dentists accounted for approximately 1.7% of the total national health expenditure in the 2017–2018 financial year . A substantial proportion of this expenditure would have been for manual therapy services. Our data shows that the total cost of manual therapy services billed through private health insurers, which excludes services paid in full by individuals, was $1.5 billion in 2017. This represents approximately 0.8% of the annual national health expenditure. It is worth noting that manual therapy services billed through private health insurers represent approximately 80% of the total revenue for chiropractic and osteopathy and 50% for physiotherapy [7, 18]. This suggests that chiropractic and osteopathy are more reliant on revenue derived from private health insurers than physiotherapy, which may leave the two professions more exposed to changes in the private health insurance sector.
Demand for manual therapy services is influenced by disposable household income, both directly via individual spending and indirectly through the uptake of private health insurance with general treatment cover. The median weekly disposable household income in Australia increased by approximately 4.5% during the ten-year study period, with slower growth in the most recent years . This corresponds well with our data that showed the proportion of the population with general treatment cover increased from 2008 to 2015, before declining during the most recent years. Thus, it appears that the overall manual therapy service utilisation trends observed in this study could be explained, at least in part, by changes in disposable household income.
Another important external influence on demand for manual therapy services is changes in population health characteristics. For instance, an increasing incidence of hospitalisations for road traffic trauma, falls, and sports-related injury may have influenced the demand for injury rehabilitation services [2, 20, 21]. Similarly, an ageing population and an increase in community health awareness may have influenced the demand for geriatric and preventative healthcare services [22,23,24]. Although such changes in population health characteristics increase the need for manual therapy services, the changes in demand could vary considerably across the three manual therapy professions. Consumer choice may depend on perceived differences in the three professions’ scope of practice, level of expertise, specific types of therapeutic modalities, and degree of integration with the broader healthcare system. In particular, consumer choice may be influenced by established referral pathways for particular types of healthcare services (e.g. fall prevention, post-injury rehabilitation, neurological rehabilitation, and pulmonary rehabilitation) [25, 26]. For instance, among a cohort of individuals with a transport-related whiplash injury in Victoria, Australia, between 2000 and 2013, there were more than three times as many compensation payments for physiotherapy services than for chiropractic services .
Fee structures may also influence the demand for services . Benefits paid by private health insurers represents a proportion of the total cost of services, with the remaining proportion being the out-of-pocket cost to the patient. Firstly, the proportion of benefits paid declined for all three professions from 2008–2012 to 2013–2017 (i.e. chiropractic: from 53% to 51%; osteopathy: from 43% to 39%; physiotherapy: from 51% to 49%). This suggests that the total cost of manual therapy services is increasing at a greater rate than what private health insurers are willing to compensate their members in terms of benefits paid. Secondly, whereas osteopathy and physiotherapy experienced relatively strong growth in annual benefits paid and out-of-pocket cost during the most recent time period (i.e. 2013–2017), chiropractic appeared to have plateaued. Lastly, our data revealed notable differences in the relative proportions of benefits paid versus out-of-pocket cost for the three professions (i.e. chiropractic: 52% versus 48%; osteopathy: 41% versus 59%; physiotherapy: 50% versus 50%). Further research is needed to elucidate to what extent disparities in benefits paid for manual therapy services influence consumer choice and whether that causes diverging trends in service utilisation across the three professions.
Industry awareness and acceptance is a potential driver of consumer choice that is influenced by internal factors, and this may explain the plateau in the annual number of chiropractic services observed between 2013 and 2017. In Australia, instances of unprofessional and unethical attitudes and actions of individual chiropractors have generated a string of negative media coverage that have resulted in reputational damage for the chiropractic profession. For example, there are chiropractors who have promoted anti-vaccination views to their patients , entered public hospital maternity wards and treated newborns without authorisation , and made unsupported claims of benefit in their advertising material . In addition, medical specialists have expressed concerns over the safety of aspects of chiropractic practice . In response, the chiropractic regulator in Australia (i.e. the Chiropractic Board of Australia) was compelled to release three position statements on these matters: one related to advertising , one on the provision of health information , and one on paediatric care . Having a strong and reputable industry body raises the awareness and acceptance of an industry and mitigates reputational damage. The chiropractic profession in Australia is represented by two industry bodies, both of which underwent rebranding between 2015 and 2018. This rebranding may itself have been a reaction to the increased public scrutiny and changing reputational standing of the chiropractic profession. Finally, relationships with other health professionals in the marketplace are important for industry success. In this context, strong professional relationships with general practitioners are important because they function as gatekeepers to all government and some private health insurance schemes. Whereas general practitioner referrals to physiotherapists increased significantly from 2009 to 2015 , a survey of general practitioners conducted in 2014 found less favourable professional attitudes and growing intolerance towards chiropractors and osteopaths [36, 37].
It is important to consider the supply side when interpreting the observed service utilisation trends presented herein. In the present report, we were able to include data on the annual growth in number of providers during the most recent five-year period (i.e. 2013–2017). These data show that the three professions experienced significant growth in the number of providers, while the average number of services per provider declined. However, the decline in the annual number of services per provider was far more pronounced for chiropractic than for physiotherapy and osteopathy. It is important to point out that the annual number of services per chiropractor remained two and four times greater than for physiotherapists and osteopaths, respectively. The reasons for the steeper decline in chiropractic is unclear, and there may multiple explanations. For instance, it is possible that the chiropractic profession in Australia has reached a saturation point in the number of providers. This would mirror observations from North America that suggest the chiropractic profession has been in oversupply since the turn of the century [38, 39]. Alternatively, perhaps the phenomenon of high-volume, low-value service provision, which subsists among a subset of the chiropractic profession [40,41,42], is becoming less sustainable as higher value models of care become more available external to the chiropractic profession [43, 44].
Strengths and limitations
This research builds on our previous report of manual therapy service utilisation in Australia based on private health insurance data from 1998 to 2012 . In our previous study we observed what appeared to be slower growth in service utilisation in chiropractic relative to physiotherapy and osteopathy from about 2006 onward; however, we did not conduct any formal statistical comparisons. In the present research, we extended our analysis of manual therapy service utilisation by estimating the number of services, total costs, and benefits paid for the ten-year period between 2008 and 2017. We added an inflation adjustment for all dollar values to remove the effect of inflation from our analyses. More importantly, we applied more sophisticated analytical techniques to formally quantify and compare trends across professions and time periods (i.e. 2008–2012 and 2013–2017). Not only have we quantified our previous observation regarding slower growth in service utilisation in chiropractic during 2008–2012 , we have also demonstrated that the growth slowed even further during 2013–2017.
Public reporting of registrant and workforce data by AHPRA has improved since 2012, which allowed us to include analyses of annual services per provider for the most recent five-year period (i.e. 2013–2017). We believe this strengthens and adds value to the present report. In an attempt to account for fluctuations in the number of people with private health insurance, we provided supplementary analyses in which the outcome variables were standardised using per 100,000 persons with private health insurance as the denominator. These supplementary analyses generated similar findings in terms of differences in trends across professions, although the magnitude of annual growth estimates was tempered by 3.1% and 1.3% for the two time periods (i.e. 2008–2012 and 2013–2017), respectively. These figures correspond to the annual percentage change in the number of people with private health insurance during the two time periods. Lastly, because our study was limited to private health insurance data, the estimates and comparisons of trends presented herein can only be generalised to services provided under private health insurance general treatment cover.