Cross-Sectional Analysis of Per Capita Supply of
Doctors of Chiropractic and Opioid Use in
Younger Medicare Beneficiaries
J Manipulative Physiol Ther. 2016 (May); 39 (4): 263–266 ~ FULL TEXT
In this exploratory analysis, we found a strong inverse correlation between the per-capita supply of DCs and the proportion of younger Medicare beneficiaries who filled opioid prescriptions. Further, we found a strong inverse correlation between the per-capita spending on CMT and the proportion of younger Medicare beneficiaries who filled opioid prescriptions. Based upon our findings, we suggest that Medicare consider promoting a trial of CMT prior to use of conventional medical care for patients with neck or back pain. The rationale for use of CMT prior to medical care is that concurrent medical care might result in opioid prescriptions; however, further study that examines opioid use when CMT and conventional medical care are concurrently provided is warranted.

The Association Between Use of Chiropractic Care
and Costs of Care Among Older Medicare Patients
With Chronic Low Back Pain and
Multiple Comorbidities
J Manipulative Physiol Ther. 2016 (Feb); 39 (2): 63–75 ~ FULL TEXT
After propensity score weighting, total and per-episode day Part A, Part B, and Part D Medicare reimbursements during the chronic low back pain (cLBP) treatment episode were lowest for patients who used CMT alone; these patients had higher rates of healthcare use for low back pain but lower rates of back surgery in the year following the treatment episode. Expenditures were greatest for patients receiving medical care alone; order was irrelevant when both CMT and medical treatment were provided.

First-Contact Care With a Medical vs Chiropractic
Provider After Consultation with a Swiss
Telemedicine Provider: Comparison of Outcomes,
Patient Satisfaction, and Health Care Costs
in Spinal, Hip, and Shoulder Pain Patients
J Manipulative Physiol Ther. 2015 (Sep); 38 (7): 477–483 ~ FULL TEXT
JMPT's Editor-in-Chief Claire Johnson, DC, MEd, emphasized the importance of the latest findings:
“Comparative studies – in other words, research that compares the outcomes between two different providers or modalities – are rare for chiropractic care,” she said. “Thus, this study by Houweling, et al., is especially important if payers and policy-makers are to better understand the 'triple aim' as it relates to chiropractic. Specifically, this study helps us better understand what type of care provides better patient satisfaction, is more cost effective, and improves population health.”

Regional Supply of Chiropractic Care and Visits to
Primary Care Physicians for Back and Neck Pain
J Am Board Fam Med. 2015 (Jul); 28 (4): 481–490 ~ FULL TEXT
Despite the inherent limitations of our study, our findings offer important insights into the indirect effects of Medicare’s chiropractic care benefit on PCP services. Our finding that chiropractic care is associated with fewer visits to PCPs for back and/or neck pain is important for health policymakers to consider. Driven by both increased spending [11, 12] and a series of reports by the Office of the Inspector General, [11–14] Medicare’s chiropractic care benefit is currently being examined. In addition to providing important information regarding the impact of coverage of chiropractic care, our study also underscores the importance of evaluating the indirect effects of ambulatory health services. When extrapolated to the nation (based on our predictions from our adjusted model), we estimate that chiropractic care is associated with a reduction of 0.37 million visits to PCPs for back and/or neck pain at a total cost of $83.5 million (Table 3).

Chiropractic Care and the Risk of Vertebrobasilar
Stroke: Results of a Case-control Study in U.S.
Commercial and Medicare Advantage Populations
Chiropractic & Manual Therapies 2015 (Jun 16); 23: 19 ~ FULL TEXT
We found no significant association between exposure to chiropractic care and the risk of VBA stroke. We conclude that manipulation is an unlikely cause of VBA stroke. The positive association between PCP visits and VBA stroke is most likely due to patient decisions to seek care for the symptoms (headache and neck pain) of arterial dissection. We further conclude that using chiropractic visits as a measure of exposure to manipulation may result in unreliable estimates of the strength of association with the occurrence of VBA stroke.

Deconstructing Chronic Low Back Pain in the
Older Adult - Shifting the Paradigm from
the Spine to the Person
Pain Medicine 2015 (May); 16 (5): 881–885 ~ FULL TEXT
Over the past decade, the estimated prevalence of low back pain (LBP) among older adults (typically defined as those ≥age 65) has more than doubled [1], and the utilization of advanced spinal imaging (e.g., computerized tomography (CT), magnetic resonance imaging [MRI]) and procedures guided by this imaging (e.g., epidural corticosteroids, spinal surgery) have continued to skyrocket. [1–3] Treatment outcomes, however, have not improved apace. Why? Part of the answer lies in the fact that treatment may in part be misdirected.
You may also enjoy the other 12 Deconstructing Chronic Low Back Pain Series

Risk of Stroke After Chiropractic Spinal
Manipulation in Medicare B Beneficiaries
Aged 66 to 99 Years With Neck Pain
J Manipulative Physiol Ther. 2015 (Feb); 38 (2): 93–101 ~ FULL TEXT
The proportion of subjects with stroke of any type in the chiropractic cohort was 1.2 per 1000 at 7 days and 5.1 per 1000 at 30 days. In the primary care cohort, the proportion of subjects with stroke of any type was 1.4 per 1000 at 7 days and 2.8 per 1000 at 30 days. In the chiropractic cohort, the adjusted risk of stroke was significantly lower at 7 days as compared to the primary care cohort (hazard ratio, 0.39; 95% confidence interval, 0.33–0.45), but at 30 days, a slight elevation in risk was observed for the chiropractic cohort (hazard ratio, 1.10; 95% confidence interval, 1.01–1.19). Among Medicare B beneficiaries aged 66 to 99 years with neck pain, incidence of vertebrobasilar stroke was extremely low. Small differences in risk between patients who saw a chiropractor and those who saw a primary care physician are probably not clinically significant.

Risk of Traumatic Injury Associated with
Chiropractic Spinal Manipulation in
Medicare Part B Beneficiaries Aged 66–99
Spine (Phila Pa 1976) 2015 (Feb 15); 40 (4): 264–270 ~ FULL TEXT
Among Medicare beneficiaries aged 66–99 with an office visit risk for a neuromusculoskeletal problem, risk of injury to the head, neck or trunk within 7 days was 76% lower among subjects with a chiropractic office visit as compared to those who saw a primary care physician.

Perceived Value of Spinal Manipulative
Therapy and Exercise Among Seniors With
Chronic Neck Pain: A Mixed Methods Study
J Rehabil Med. 2014 (Nov); 46 (10): 1022–1028 ~ FULL TEXT
Participants placed high value on their relationships with health care team members, supervision, individualized care, and the exercises and information provided as treatment. Change in symptoms did not figure as prominently as social and process-related themes. Percpetions of age, activities, and co-morbities influenced some seniors' expectations of treatment results, and comorbidities impacted perceptions of their ability to participate in active care. Relationship dynamics should be leveraged in clinical encounters to enhance patient satisfaction and perceived value of care.

Chiropractic Use in the Medicare Population:
Prevalence, Patterns, and Associations With
1-Year Changes in Health and
Satisfaction With Care
J Manipulative Physiol Ther. 2014 (Oct); 37 (8): 542–551 ~ FULL TEXT
This study provides evidence of a protective effect of chiropractic care against 1-year declines in functional and self-rated health among Medicare beneficiaries with spine conditions, and indications that chiropractic users have higher satisfaction with follow-up care and information provided about what is wrong with them.

Spinal Manipulative Therapy and Exercise For
Seniors with Chronic Neck Pain
Spine J. 2014 (Sep 1); 14 (9): 1879–1889 NCT00269308
Spinal manipulative therapy (SMT) with home exercise resulted in greater pain reduction after 12 weeks of treatment compared with both supervised plus HE and HE alone. Supervised exercise sessions added little benefit to the HE-alone program.

Short Term Treatment Versus Long Term
Management of Neck and Back Disability
in Older Adults Utilizing Spinal
Manipulative Therapy and Supervised
Exercise: A Parallel-group Randomized
Clinical Trial Evaluating Relative
Effectiveness and Harms
Chiropractic & Manual Therapies 2014 (May 23); 22: 21 ~ FULL TEXT
This is one of the first full-scale randomized clinical trials to compare short term treatment and long term management using SMT and exercise to treat spine-related disability in older adults. It builds on previous research by the investigative team showing improvement with three months of SMT and exercise in similar populations, which regressed to baseline values in long term follow up without further intervention 88. As back and neck pain in older adults are often chronic and among several co-morbidities [6, 8], we theorized that long term management may result in sustained improvement compared to short term treatment. Identifying the most favorable duration of treatment is a pragmatic question common to patients, clinicians, policy makers, and third-party payers alike. [25, 89] This is especially important to address in an older population, whose long term functional ability is essential to maintaining vitality and independence.

The Comparative Effect of Episodes of Chiropractic
and Medical Treatment on the Health of Older Adults
J Manipulative Physiol Ther 2014 (Mar); 37 (3): 143–154 ~ FULL TEXT
This study provides evidence of the comparative effectiveness of chiropractic care relative to medical-only services on the functional health of older adults during acute episodes of back care. Our results are the first to show the importance of examining chiropractic use within an episode of care in traditional practice settings, rather than focusing on visit frequency alone. Moreover, we evaluated the effects of the treatments received during the episodes on ADLs, IADLs, and LBFs, which are critically important measures that inform patients, clinicians, and payers about the benefits and harms of certain treatments relative to others. Given the literature supporting a minimally effective chiropractic treatment level for back problems, this research provides additional support that such therapeutic levels are indeed beneficial in terms of protecting older persons from functional declines and self-rated health over as much as 2 years.

Epidural Steroid Injections: Are long-term
Risks Worth Short Term Benefits?
ACA News (February 2014) ~ FULL TEXT
While it is true that epidural steroid injections (ESI) are not FDA approved, Medicare, Medicaid, workers’ compensation and most other insurers continue to pay hundreds of millions of dollars per year for this controversial procedure. Ironically, on every vial of Kenalog (a popular steroid used for epidural injections) there is actually a warning against its use for epidural injections, yet proceduralists continue to use it.

Our No. 1 Medicare Documentation Error
Dynamic Chiropractic (January 15, 2014) ~ FULL TEXT
We have all heard that chiropractic documentation is being reviewed by multiple Medicare contractors and that we are failing these reviews miserably. So, where are we going wrong? In this and subsequent articles, let's address the top reasons we are failing review, starting with the No. 1 reason – our treatment plan documentation.

Chiropractic Use and Changes in Health Among
Older Medicare Beneficiaries: A Comparative
Effectiveness Observational Study
J Manipulative Physiol Ther 2013 (Nov); 36 (9): 572–584 ~ FULL TEXT
The evidence in this study suggests that chiropractic treatment has comparable effects on functional outcomes when compared with medical treatment for all Medicare beneficiaries, but increased risk for declines in self-rated health among beneficiaries with back conditions.

Trends in the Use and Cost of Chiropractic
Spinal Manipulation Under Medicare Part B
Spine J. 2013 (Nov); 13 (11): 1449–1454 ~ FULL TEXT
The number of Medicare beneficiaries who used chiropractic spinal manipulation grew 13% from 2002 to 2004, remained flat through 2007, and then declined 5% through 2008. An estimated 1.7 million beneficiaries (6.9%) used 18.6 million allowed chiropractic services in 2008. In inflation-adjusted dollars, allowed charges per user increased 4% through 2005 and then declined by 17% through 2008; payments per user increased by 5% from 2002 to 2005 and then declined by 18% through 2008. Expenditures for chiropractic in 2008 totaled an estimated $420 million. Longitudinal trends in allowed claims for spinal manipulation varied by procedure: the relative frequency of treatment of one to two spinal regions declined from 43% to 29% of services, treatment of three to four regions increased from 48% to 62% of services, and treatment of five regions remained flat at 9% of services.

Straight Chiropractic Philosophy As A Barrier
To Medicare Compliance: A Discussion of
5 Incongruent Issues
J Chiropractic Humanities 2013 (Oct 24); 20 (1): 19–26 ~ FULL TEXT
The number of Medicare beneficiaries who used chiropractic spinal manipulation grew 13% from 2002 to 2004, remained flat through 2007, and then declined 5% through 2008. An estimated 1.7 million beneficiaries (6.9%) used 18.6 million allowed chiropractic services in 2008. In inflation-adjusted dollars, allowed charges per user increased 4% through 2005 and then declined by 17% through 2008; payments per user increased by 5% from 2002 to 2005 and then declined by 18% through 2008. Expenditures for chiropractic in 2008 totaled an estimated $420 million. Longitudinal trends in allowed claims for spinal manipulation varied by procedure: the relative frequency of treatment of one to two spinal regions declined from 43% to 29% of services, treatment of three to four regions increased from 48% to 62% of services, and treatment of five regions remained flat at 9% of services.

Beyond Spinal Manipulation: Should Medicare
Expand Coverage for Chiropractic Services?
A Review and Commentary on the
Challenges for Policy Makers
J Chiropractic Humanities 2013 (Aug 28); 20 (1): 9–18 ~ FULL TEXT
The literature search yielded 29 peer-reviewed articles and 7 federal government reports. Our review of these documents revealed 3 key barriers to full coverage of chiropractic services under Medicare: inadequate documentation of chiropractic claims, possible provision of unnecessary preventive care services, and the uncertain costs of expanded coverage. Our recommendations to address these barriers include the following: individual chiropractic physicians, as well as state and national chiropractic organizations, should continue to strengthen efforts to improve claims and documentation practices; and additional rigorous efficacy/effectiveness research and clinical studies for chiropractic services need to be performed. Research of chiropractic services should target the triple aim of high-quality care, affordability, and improved health.

Cross-Referencing Regions of Complaint,
PART Findings, Diagnoses and CPT Codes
Dynamic Chiropractic (June 15, 2013) ~ FULL TEXT
In 2012 the Centers for Medicare and Medicaid Services and CMS-contracted reviewers performed chiropractic Medicare reviews nationwide. The results of their efforts were not good news for the chiropractic profession. Volumes have already been written about this concern. Here, I offer a set of questions to help guide doctors in documenting the number of patient complaints, subluxations, diagnoses, regions adjusted and the appropriate billing codes. This series of questions is accompanied by comments and tables to clarify the importance of each question.

Aging Baby Boomers and the Rising Cost of
Chronic Back Pain: Secular Trend Analysis
of Longitudinal Medical Expenditures
Panel Survey Data for Years 2000 to 2007
J Manipulative Physiol Ther. 2013 (Jan); 36 (1): 2–11 ~ FULL TEXT
The prevalence of back pain, especially chronic back pain, is increasing. To the extent that the growth in chronic back pain is caused, in part, by an aging population, the growth will likely continue or accelerate. With relatively high cost per adult with chronic back pain, total expenditures associated with back pain will correspondingly accelerate under existing treatment patterns. This carries implications for prioritizing health policy, clinical practice, and research efforts to improve care outcomes, costs, and cost-effectiveness and for health workforce planning.

Use of Chiropractic Spinal Manipulation in Older
Adults is Strongly Correlated with Supply
Spine (Phila Pa 1976). 2012 (Sep 15); 37 (20): 1771–1777
The supply of US chiropractors and utilization of CSM by older US adults varied widely by region. The variations cannot be entirely explained by basic patient characteristics or clinical indication, and there is insufficient evidence to explain the variation by patient preferences. Increased chiropractic supply was associated with increased CSM use, but not with increased CSM utilization intensity. Utilization of chiropractic care is likely sensitive to both supply and patient preference. To better inform the most advantageous allocation and patient-centered utilization of chiropractic resources, more research is needed on how and why patients do or do not choose chiropractic care.

The Medicare Hurdle That Continues to Block
Our Professional Progress
Dynamic Chiropractic (April 9, 2012) ~ FULL TEXT
The rules for Medicare are spelled out in section 240 of chapter 15 of the Medicare Benefit Policy Manual [3] and in your local carrier's or administrator's Local Coverage Determination (LCD). The terminology is generally consistent; however, it can be confusing based on how the language is misinterpreted by chiropractors and those who teach documentation and coding seminars. Contrary to what many believe, Medicare documentation is not subluxation-based, even though parts of section 240 can mislead one in this direction. Why do we say this? Because "subluxation-based" to chiropractors is a different concept compared to subluxation-based to Medicare, and this fact is clearly spelled out in the rules.

Chiropractic Episodes and the Co-occurrence of
Chiropractic and Health Services Use
Among Older Medicare Beneficiaries
J Manipulative Physiol Ther 2012 (Mar); 35 (3): 168–175 ~ FULL TEXT
Treatment for back-related musculoskeletal conditions was sought from a variety of providers, but there was little co-occurrent service use or coordinated care across provider types within care episodes. Chiropractic treatment dosing patterns in everyday practice were much lower than that used in clinical trial protocols designed to establish chiropractic efficacy for back-related conditions.

The Role of Chiropractic Care in Older Adults
Chiropractic & Manual Therapies 2012 (Feb 21); 20 (1): 3 ~ FULL TEXT
While there is already substantial published research to assist the evidence-based DC in his/her care plan for the older adult, there is a need for well designed clinical trials and large observational studies to identify the most beneficial treatments, particularly for complementary and alternative interventions such as manual therapy including, but not limited to, spinal manipulative therapy and acupuncture.

A Longitudinal Study of Chiropractic Use
Among Older Adults in the United States
Chiropractic & Osteopathy 2010 (Dec 21); 18: 34 ~ FULL TEXT
There is substantial heterogeneity in the patterns of use of chiropractic services among older adults. In spite of the variability of use patterns, however, there are not many characteristics that distinguish high volume users from lower volume users. While high volume users accounted for a significant portion of claims, the enforcement of a hard cap on annual visits by Medicare would not significantly decrease overall claim volume. Further research to understand the factors causing high volume chiropractic utilization among older Americans is warranted to discern between patterns of "need" and patterns of "health maintenance".
You may also enjoy these 3 articles from the Cost-Effectiveness Triumvirate

Medical Errors Kill 15,000
Medicare Patients a Month
AOL Health (November 2010) ~ FULL TEXT
A new report from the Department of Health and Human Services, Office of the Inspector General reveals that 13 percent of Medicare patients in the U.S. experience an adverse event each month in American hospitals, and some 15,000 of them die as a result. [1]

Best Practices Recommendations for
Chiropractic Care for Older Adults:
Results of a Consensus Process
J Manipulative Physiol Ther 2010 (Jul); 33 (6): 464–473 ~ FULL TEXT
A multidisciplinary panel of experienced chiropractors was able to reach a high level (80%) of consensus on evidence-informed best practices for the chiropractic approach to evaluation, management, and manual treatment for older adult patients.
These recommendations have been updated by the 2017 article:
Best Practices for Chiropractic Care for Older Adults:
A Systematic Review and Consensus Update

Trends, Major Medical Complications, and
Charges Associated with Surgery for
Lumbar Spinal Stenosis in Older Adults
JAMA. 2010 (Apr 7); 303 (13): 1259–1265 ~ FULL TEXT
There is a lack of evidence-based support for the efficacy of complex fusion surgeries over conservative surgical decompression for elderly stenosis patients. There is, however, a significant financial incentive to both hospitals and surgeons to perform the complex fusions. Spinal stenosis is the most frequent cause for spinal surgery in the elderly. There has been a slight decrease in these surgeries between 2002 and 2007. However, there has also been an overall 15 fold increase in the more complex spinal fusions (360 degree spine fusions).

Correctly Completing a Medicare Claim
Dynamic Chiropractic (June 3, 2009) ~ FULL TEXT
This article takes a step-by-step analysis on what goes in each box on the HCFA form, and reviews the proper use of modifiers.

American Chiropractic Association Responds
to the May 2009 OIG Report
ACA News (June 10, 2009) ~ FULL TEXT
In a response released today, the American Chiropractic Association (ACA) refuted the findings and recommendations outlined in a May 2009 report released by the Department of Health and Human Services Office of the Inspector General (OIG), noting the methods used by the OIG may have resulted in an overestimate of inappropriate claims. In commenting on the report, ACA said the OIG’s decision to restrict data collection to only those episodes of chiropractic care resulting in claims of more than 12 visits by the same doctor, likely skewed the data pool by focusing on a subpopulation previously identified to be more problematic. As a point of comparison, an OIG report released in 2005 investigated data collected from a global sample of claims.
Review OIG's 2009 Full Report or the 2005 Full Report now.

Patients in Medicare Demonstration Project
Give Their Chiropractors High Marks
ACA News ~ January 26, 2010 ~ FULL TEXT
According to long-awaited results from a congressionally mandated pilot project testing the feasibility of expanding chiropractic services in the Medicare program, patients have a high rate of satisfaction with the care they receive from doctors of chiropractic. When asked to rate their satisfaction on a 10-point scale, 87 percent of patients in the study gave their doctor of chiropractic a level of 8 or higher. What’s more, 56 percent of those patients rated their chiropractor with a perfect 10.
Would you like to read the full report?

Chiropractic and Exercise for Seniors With
Low Back Pain or Neck Pain: The Design
of Two Randomized Clinical Trials   NCT00269308   and   NCT00269321
BMC Musculoskelet Disord. 2007 (Sep 18); 8: 94 ~ FULL TEXT
To our knowledge, these are the first randomized clinical trials to comprehensively address clinical effectiveness, cost-effectiveness, and patients' perceptions of commonly used treatments for elderly LBP and NP sufferers. This article presents the rationale and design of two mixed methods clinical trials, each consisting of an RCT, with cost-effectiveness and qualitative studies conducted alongside the central trial. Both are anticipated to be completed in 2007, at which time the results will be made available.

Medicare Do's and Don'ts   (PDF)
American Chiropractic Association and Susan McClelland
A step-by-step approach to use of modifiers, and HCFA requirements. This 2 page Acrobat document (93 KB) covers all the most recent information updates amd recommendations. Thanks to the ACA and Susan McClelland for preparing these materials!

President Bush Signs Legislation Reversing
Medicare Physician Fee Cuts
American Chiropractic Association Press Release
President Bush has signed legislation that not only reverses the current 4.4 percent Medicare physician payment reduction, which went into effect on the first of year, but will also provide automatic reprocessing of claims retroactive to Jan. 1, 2006. The legislation was included in the Deficit Reduction Act.

The Endless Medicare Saga
This is the Medicared articles collected before the Demonstration Project. Know your history!