Out-Of-Pocket Expenditures on Complementary Health Approaches Associated With Painful Health Conditions in a Nationally Representative Adult Sample

Published:August 27, 2015DOI:


      • Many adults in the United States used complementary approaches to manage their pain.
      • In 2007, U.S. adults spent $14.9 billion for this reason.
      • $7.5 billion was spent on visits to providers, eg, chiropractors, acupuncturists.
      • $5.2 billion was spent for nonvitamin, nonmineral dietary supplements.
      • Costs were comparable with those seen for out-of-pocket expenditures on conventional care.


      National surveys suggest that millions of adults in the United States use complementary health approaches such as acupuncture, chiropractic manipulation, and herbal medicines to manage painful conditions such as arthritis, back pain, and fibromyalgia. Yet, national and per person out-of-pocket (OOP) costs attributable to this condition-specific use are unknown. In the 2007 National Health Interview Survey, the use of complementary health approaches, the reasons for this use, and the associated OOP costs were captured in a nationally representative sample of 5,467 adults. Ordinary least square regression models that controlled for comorbid conditions were used to estimate aggregate and per person OOP costs associated with 14 painful health conditions. Individuals using complementary approaches spent a total of $14.9 billion (standard error [SE] = $.9 billion) on these approaches to manage these painful conditions. Total OOP expenditures by those using complementary approaches for their back pain ($8.7 billion, SE = $.8 billion) far outstripped OOP expenditures for any other condition; the majority of these costs ($4.7 billion, SE = $.4 billion) were for visits to complementary providers. Annual condition-specific per person OOP costs varied from a low of $568 (SE = $144) for regular headaches to a high of $895 (SE = $163) for fibromyalgia.


      Adults in the United States spent $14.9 billion on complementary health approaches (eg, acupuncture, chiropractic manipulation, and herbal medicines) to manage painful conditions including back pain ($8.7 billion). This back pain estimate is almost one-third of the total conventional health care expenditure for back pain ($30.4 billion) and two-thirds higher than conventional OOP expenditures ($5.1 billion).

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      1. Agency for Healthcare Research and Quality. Total Expenses and Percent Distribution for Selected Conditions by Source of Payment: United States, 2007. Medical Expenditure Panel Survey Household Component Data. Generated interactively: February 9, 2015

      2. Agency for Healthcare Research and Quality. Total Health Services-Mean and Median Expenses per Person With Expense and Distribution of Expenses by Source of Payment: United States, 2007. Medical Expenditure Panel Survey Household Component Data. Generated interactively: February 9, 2015

        • Astin J.A.
        Why patients use alternative medicine: results of a national study.
        JAMA. 1998; 279: 1548-1553
        • Barber J.A.
        • Thompson S.G.
        Analysis of cost data in randomized trials: an application of the non-parametric bootstrap.
        Stat Med. 2000; 19: 3219-3236
        • Barnes P.M.
        • Bloom B.
        • Nahin R.L.
        Complementary and alternative medicine use among adults and children: United States, 2007.
        Natl Health Stat Report. 2008; 12: 1-23
        • Barnes P.M.
        • Powell-Griner E.
        • McFann K.
        • Nahin R.L.
        Complementary and alternative medicine use among adults: United States, 2002.
        Adv Data. 2004; 343: 1-19
        • Bercovitz A.
        • Sengupta M.
        • Jones A.
        • Harris-Kojetin L.D.
        Complementary and alternative therapies in hospice: the National Home and Hospice Care Survey: United States, 2007.
        (National Health Statistics Reports; no 33) National Center for Health Statistics, Hyattsville, MD2010
        • Berk M.L.
        • Monheit A.C.
        The concentration of health care expenditures, revisited.
        Health Aff (Millwood). 2001; 20: 9-18
        • Black L.I.
        • Clarke T.C.
        • Barnes P.M.
        • Stussman B.J.
        • Nahin R.L.
        Use of complementary health approaches among children aged 4-17 years in the United States: National Health Interview Survey, 2007-2012.
        (National Health Statistics Reports; no 78) National Center for Health, Hyattsville, MD2015: 19
        • Brandle M.
        • Zhou H.
        • Smith B.R.
        • Marriott D.
        • Burke R.
        • Tabaei B.P.
        • Brown M.B.
        • Herman W.H.
        The direct medical cost of type 2 diabetes.
        Diabetes Care. 2003; 8: 2300-2304
        • Briggs A.
        • Gray A.
        The distribution of health care costs and their statistical analysis for economic evaluation.
        J Health Serv Res Policy. 1998; 3: 233-245
        • Buntin M.B.
        • Zaslavsky A.M.
        Too much ado about two-part models and transformation? Comparing methods of modeling Medicare expenditures.
        J Health Econ. 2004; 23: 525-542
      3. Callahan LF, Wiley-Exley EK, Mielenz TJ, Brady TJ, Xiao C, Currey SS, Sleath BL, Sloane PD, DeVellis RF, Sniezek J. Use of complementary and alternative medicine among patients with arthritis. Prev Chronic Dis. 6:A44.

        • Chandran A.
        • Schaefer C.
        • Ryan K.
        • Baik R.
        • McNett M.
        • Zlateva G.
        The comparative economic burden of mild, moderate, and severe fibromyalgia: results from a retrospective chart review and cross-sectional survey of working-age U.S. adults.
        J Manag Care Pharm. 2012; 18: 415-426
        • Cherkin D.C.
        • Deyo R.A.
        • Sherman K.J.
        • Hart L.G.
        • Street J.H.
        • Hrbek A.
        • Davis R.B.
        • Cramer E.
        • Milliman B.
        • Booker J.
        • Mootz R.
        • Barassi J.
        • Kahn J.R.
        • Kaptchuk T.J.
        • Eisenberg D.M.
        Characteristics of visits to licensed acupuncturists, chiropractors, massage therapists, and naturopathic physicians.
        J Am Board Fam Pract. 2002; 15: 463-472
        • Clarke T.C.
        • Black L.I.
        • Stussman B.J.
        • Barnes P.M.
        • Nahin R.L.
        Trends in the use of complementary health approaches among adults: United States, 2002-2012.
        (National Health Statistics Reports; no 79) National Center for Health Statistics, Hyattsville, MD2015: 16
        • Davis M.A.
        • Martin B.I.
        • Coulter I.D.
        • Weeks W.B.
        US spending on complementary and alternative medicine during 2002-08 plateaued, suggesting role in reformed health system.
        Health Aff (Millwood). 2013; 32: 45-52
        • de Burgh S.
        • Berry G.
        Treating grouped data as continuous in alcohol consumption measures.
        Addiction. 1998; 92: 667-672
        • Egede L.E.
        • Ye X.
        • Zheng D.
        • Silverstein M.D.
        The prevalence and pattern of complementary and alternative medicine use in individuals with diabetes.
        Diabetes Care. 2002; 25: 324-329
        • Eisenberg D.M.
        • Davis R.B.
        • Ettner S.L.
        • Appel S.
        • Wilkey S.
        • Van Rompay M.
        • Kessler R.C.
        Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey.
        JAMA. 1998; 280: 1569-1575
        • Eisenberg D.M.
        • Kessler R.C.
        • Foster C.
        • Norlock F.E.
        • Calkins D.R.
        • Delbanco T.L.
        Unconventional medicine in the United States. Prevalence, costs, and patterns of use.
        N Engl J Med. 1993; 328: 246-252
        • Gaskin D.J.
        • Richard P.
        The economic costs of pain in the United States.
        J Pain. 2012; 13: 715-724
        • Heitjan D.F.
        Inference from grouped continuous data: a review.
        Stat Sci. 1989; 4: 164-179
        • King W.I.
        • Lawrence L.
        The relationship in a frequency polygon of the average of any class to the mid-point of the corresponding class-interval.
        J Am Stat Assoc. 1928; 23: 435-439
        • Kotlarz H.
        • Gunnarsson C.L.
        • Fang H.
        • Rizzo J.A.
        Insurer and out-of-pocket costs of osteoarthritis in the US: evidence from national survey data.
        Arthritis Rheum. 2009; 60: 3546-3553
        • Institute of Medicine
        Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research.
        The National Academies Press, Washington, DC2011
        • Lafferty W.E.
        • Bellas A.
        • Corage Baden A.
        • Tyree P.T.
        • Standish L.J.
        • Patterson R.
        The use of complementary and alternative medical providers by insured cancer patients in Washington State.
        Cancer. 2004; 100: 1522-1530
        • Lafferty W.E.
        • Tyree P.T.
        • Bellas A.S.
        • Watts C.A.
        • Lind B.K.
        • Sherman K.J.
        • Cherkin D.C.
        • Grembowski D.E.
        Insurance coverage and subsequent utilization of complementary and alternative medicine providers.
        Am J Manag Care. 2006; 12: 397-404
        • Lind B.K.
        • Lafferty W.E.
        • Tyree P.T.
        • Diehr P.K.
        • Grembowski D.E.
        Use of complementary and alternative medicine providers by fibromyalgia patients under insurance coverage.
        Arthritis Rheum. 2007; 57: 71-76
        • Lind B.K.
        • Lafferty W.E.
        • Tyree P.T.
        • Sherman K.J.
        • Deyo R.A.
        • Cherkin D.C.
        The role of alternative medical providers for the outpatient treatment of insured patients with back pain.
        Spine. 2005; 30: 1454-1459
      4. Lumley T, Diehr P, Emerson S, Chen L. The importance of the normality assumption in large public health data sets. Annu Rev Public Health. 23:151–169.

        • Luo X.
        • Pietrobon R.
        • Sun S.X.
        • Liu G.G.
        • Hey L.
        Estimates and patterns of direct health care expenditures among individuals with back pain in the United States.
        Spine. 2004; 29: 79-86
        • Nahin R.L.
        • Barnes P.M.
        • Stussman B.J.
        • Bloom B.
        Costs of complementary and alternative medicine (CAM) and frequency of visits to CAM practitioners: United States, 2007.
        (National Health Statistics Reports; no 18) National Center for Health Statistics, Hyattsville, MD2009: 14
        • Nahin R.L.
        • Byrd-Clark D.
        • Stussman B.J.
        • Kalyanaraman N.
        Disease severity is associated with the use of complementary medicine to treat or manage type-2 diabetes: data from the 2002 and 2007 National Health Interview Survey.
        BMC Complement Altern Med. 2012; 12: 193
        • Nahin R.L.
        • Dahlhamer J.M.
        • Stussman B.J.
        Health need and the use of alternative medicine among adults who do not use conventional medicine.
        BMC Health Serv Res. 2010; 10: 220-221
        • Nutritional Business Journal
        Supplement Business Report.
        Penton Media, New York, NY2008
        • Pleis J.R.
        • Lucas J.W.
        Summary health statistics for U.S. adults: National Health Interview Survey, 2007.
        Vital Health Stat 10. 2009; : 1-159
        • Powers C.A.
        • Meyer C.M.
        • Roebuck M.C.
        • Vaziri B.
        Predictive modeling of total healthcare costs using pharmacy claims data: a comparison of alternative econometric cost modeling techniques.
        Med Care. 2005; 43: 1065-1072
        • Quandt S.A.
        • Chen H.
        • Grzywacz J.G.
        • Bell R.A.
        • Lang W.
        • Arcury T.A.
        Use of complementary and alternative medicine by persons with arthritis: results of the National Health Interview Survey.
        Arthritis Rheum. 2005; 53: 748-755
        • Ramsey S.D.
        • Spencer A.C.
        • Topolski T.D.
        • Belza B.
        • Patrick D.L.
        Use of alternative therapies by older adults with osteoarthritis.
        Arthritis Rheum. 2001; 45: 222-227
        • Ritter P.L.
        • Stewart A.L.
        • Kaymaz H.
        • Sobel D.S.
        • Block D.A.
        • Lorig K.R.
        Self-reports of health care utilization compared to provider records.
        J Clin Epidemiol. 2001; 54: 136-141
        • Roberts R.O.
        • Bergstralh E.J.
        • Schmidt L.
        • Jacobsen S.J.
        Comparison of self-reported and medical record health care utilization measures.
        J Clin Epidemiol. 1996; 49: 989-995
        • Simon G.E.
        • Katon W.J.
        • Lin E.H.
        • Ludman E.
        • VonKorff M.
        • Ciechanowski P.
        • Young B.A.
        Diabetes complications and depression as predictors of health service costs.
        Gen Hosp Psychiatry. 2005; 27: 344-351
        • Stagnitti M.N.
        Trends in Person Characteristics and Expenditures for Persons under Age 65 Reporting Migraine Headaches, 1997 and 2007.
        Agency for Healthcare Research and Quality (AHRQ), Rockville, MD2011 (Available at:) (Accessed February 11, 2015)
        • Stussman B.J.
        • Bethell C.D.
        • Gray C.
        • Nahin R.L.
        Development of the adult and child complementary medicine questionnaires fielded on the National Health Interview Survey.
        BMC Complement Altern Med. 2013; 13: 328
        • Wolsko P.M.
        • Eisenberg D.M.
        • Davis R.B.
        • Kessler R.
        • Phillips R.S.
        Patterns and perceptions of care for treatment of back and neck pain: results of a national survey.
        Spine. 2003; 28: 292-297
        • Von Fintel D.
        Dealing with earning bracket responses in household surveys - how sharp are midpoints imputations?.
        S Afr J Econ. 2007; 75: 292-312
        • Zhou X.H.
        • Melfi C.A.
        • Hui S.L.
        Methods for comparison of cost data.
        Ann Intern Med. 1997; 127: 752-756