Utilization, Cost, and Effects of Chiropractic Care on Medicare Program Costs American Chiropractic Association (June 2001) This June 2001 study was commissioned by the ACA, and is the first study of its type to compare the global, per capita Medicare expenditures of chiropractic patients to those of non-chiropractic patients receiving care in the federal Medicare program.
	Association of Pharmacologic and Nonpharmacologic Management of Acute Low Back Pain with Overdose Hospitalizations: A Nested Case-Control Study J Integrative and Complementary Medicine 2025 (Apr 3); ~ FULL TEXT Among Medicare beneficiaries with new episodes of aLBP, treatment with only nonpharmacologic therapies was protective of overdose hospitalizations. However, any treatment with opioids and/or gabapentinoids, alone or combined with nonpharmacologic therapies, was associated with increased odds of overdose hospitalization. Implementation research is needed to inform successful adoption of nonpharmacologic pain therapies especially in subgroups with increased risk of adverse outcomes.
	Comparative Cost Analysis of Neck Pain Treatments for Medicare Beneficiaries Arch Phys Med Rehabil 2025 (Feb 14):S0003-9993(25)00497-6 ~ FULL TEXT For older adults with new NP episodes, the initial SMT is associated with lower health care costs, particularly for Part A total and NP-related claims, with a less pronounced effect on Part B and D claims than PCP-related strategies. These results underscore the potential for health care cost savings based on the initial treatment approaches.
	Patterns of Initial Treatment and Subsequent Care Escalation Among Medicare Beneficiaries with Neck Pain: A Retrospective Cohort Study European Spine J 2024 (Dec 26) [EPUB] ~ FULL TEXT When compared to the primary care without analgesics cohort, the spinal manipulative therapy cohort was associated with a 64% lower rate (RR 0.36, 95% CI 0.35,0.37) for long-term care escalation encounters, while the primary care with prescription analgesics cohort was associated with an 8% higher rate (RR 1.08; 95% CI 1.05,1.10). Initial spinal manipulative therapy was associated with a significant reduction in downstream care escalation encounters among Medicare beneficiaries with new episodes of neck pain. Our study contributes to a growing body of evidence supporting the integration of non-pharmacological care strategies for neck pain management.
	Trends in Utilization and Cost of Nonpharmacological Pain Therapies in the United States Under Medicare Part B, 2000-2022 J Integr Complement Med 2024 (Jul 8) [EPUB] ~ FULL TEXT Many clinical practice guidelines for management of pain disorders now favor first-line use of nonpharmacological therapies (NPT). However, Medicare coverage of NPT is limited. Utilization and costs for physical therapy increased while those for spinal and osteopathic manipulation declined. Future research on NPT under Medicare should focus on equity of patient access and comparative outcomes.
	The Chiropractors' Dilemma in Caring for Older Patients with Musculoskeletal Complaints: Collaborate, Integrate, Coexist, or Separate? PLoS One 2024 (May 2); 19 (5): e0302519 ~ FULL TEXT The world's elderly population is growing at a rapid pace. This has led to an increase in demand on the health and welfare systems due to age-related disorders, with musculoskeletal complaints driving the need for rehabilitation services. However, there are concerns about health services' ability to meet this demand. While chiropractic care is gaining recognition for its benefits in treating older adults with musculoskeletal disorders, there is limited scientific literature on chiropractors' role and experiences in this area. To bridge this gap, we interviewed 21 chiropractors in Great Britain, the Netherlands, Norway, and Sweden. Inductive qualitative content analysis was used to analyse the interviews, and despite differences in integration and regulation between the countries, several common facilitators and barriers in caring for and managing older patients with musculoskeletal complaints emerged.
	The Perceived Barriers and Facilitators for Chiropractic Care in Older Adults with Low Back Pain; Insights from a Qualitative Exploration in a Dutch Context PLoS One 2023 (Apr 12); 18 (4): e0283661 ~ FULL TEXT We examined what factors limit and facilitate older adults when seeking chiroprctic care. Older adults are often unaware of the possibility of chiropractic care for their LBP, however this factor might not be limited to this age group. The results of this explorative study can help us improve the accessibility to chiropractic care for older adults. However, how awareness of chiropractic care could best be implemented requires further investigation.
	Spinal Manipulative Therapy in Older Adults with Chronic Low Back Pain: An Individual Participant Data Meta-analysis European Spine Journal 2022 (Jul); 31 (7): 1821–1845 ~ FULL TEXT Spinal manipulative therapy (SMT) provides similar outcomes to recommended interventions for pain and functional status in the older adult with chronic low back pain (LBP). SMT should be considered a treatment for this patient population.
	Spinal Manipulation vs Prescription Drug Therapy for Chronic Low Back Pain: Beliefs, Satisfaction with Care, and Qualify of Life Among Older Medicare Beneficiaries J Manipulative Physiol Ther 2022 (Mar 26) [EPUB]~ FULL TEXT Among older Medicare beneficiaries with chronic low back pain, long-term recipients of spinal manipulative therapy (SMT) had higher self-reported rates of health-related quality of life (HRQoL) and greater satisfaction with their modality of care than long-term recipients of PDT. Participants who had longer-term management of care were more likely to have positive attitudes and beliefs toward the mode of care they received.
	Association Between Chiropractic Care and Use of Prescription Opioids Among Older Medicare Beneficiaries with Spinal Pain: A Retrospective Observational Study Chiropractic & Manual Therapies 2022 (Jan 31); 30: 5 ~ FULL TEXT Older Medicare enrollees with spinal pain who saw both a chiropractor and a primary care physician had less than half the risk of filling an opioid prescription, as compared to those who received primary medical care alone. The association was most pronounced among those who saw a chiropractor within the first 30 days of care.
	Long-Term Medicare Costs Associated With Opioid Analgesic Therapy vs Spinal Manipulative Therapy for Chronic Low Back Pain in a Cohort of Older Adults J Manipulative Physiol Ther 2021 (Dec 5); S0161-4754(21)00106-8 ~ FULL TEXT Adults aged 65 to 84 who initiated long-term treatment for cLBP via opioid analgesic therapy (OAT) incurred lower long-term costs for low back pain but higher long-term total healthcare costs under Medicare compared with patients who initiated long-term treatment with spinal manipulative therapy (SMT).
	Characteristics of Older Adults with Back Pain Associated with Choice of First Primary Care Provider: A Cross-sectional Analysis from the BACE-N Cohort Study BMJ Open 2021 (Sep 17); 11 (9): e053229 ~ FULL TEXT We found that nearly all older adults with back pain seeking primary care had experienced back pain previously, and recurring episodes were common. In general, patients with more severe back-related disability and other clinical symptoms and signs were more likely to visit a GP or a PT than a chiropractor. Our results suggest that important patient characteristics are associated with older adult’s choice of primary care providers due to back pain, which may affect the clinical course of back pain for these patients.
	The Effect of Reduced Access to Chiropractic Care on Medical Service Use for Spine Conditions Among Older Adults J Manipulative Physiol Ther 2021 (Aug 7); S0161-4754 (21) 00071-3 Individuals seeking chiropractic care have a high degree of confidence in the ability of chiropractors to improve their symptoms40 and have a strong preference for the service.17 Health services do not operate within a vacuum. Studies evaluating the service tend to neglect considering how the CMS's chiropractic care benefit affects the healthcare system at large. We found modest evidence of increased spine surgeries and primary care visits among older adults who lost access to chiropractic care after moving. This suggests that the chiropractic care benefit in Medicare may have an indirect effect on the use of other services for spine conditions. This has important implications for health policy decisions, because it suggests that CMS may be recapturing a sizeable proportion of the payout for the chiropractic care benefit through a reduction in medical service use.
	Risk of Treatment Escalation in Recipients vs Nonrecipients of Spinal Manipulation for Musculoskeletal Cervical Spine Disorders: An Analysis of Insurance Claims J Manipulative Physiol Ther 2021 (Jun); 44 (5): 372–377 Among episodes of care for a cohort of individuals diagnosed with neck pain, nonrecipients of spinal manipulation had more than twice the risk of any treatment escalation compared to recipients of spinal manipulation. In the United States, over 90% of spinal manipulation is provided by doctors of chiropractic; therefore, these findings are relevant and should be considered in addressing solutions for neck pain. Additional research investigating the factors influencing treatment escalation is necessary to guide decreasing the use of high-cost and guideline-incongruent procedures in people with neck pain.
	Increased Use of Complementary and Alternative Therapies for Back Pain Following Statewide Medicaid Coverage Changes in Oregon J Gen Intern Med 2021 (Mar); 36 (3): 676–682 ~ FULL TEXT Shifting care of back pain to evidence-based CAM therapies is a promising route to treating symptoms more effectively and avoiding treatments, such as opioid therapies, with low efficacy and potential harms. Oregon’s back pain policy appears successful in boosting use of CAM therapies in this patient population, although disparities in use were noted for minority patient populations, men, and those living in rural areas. The impact of policy-related uptake of these therapies on prescription opioid use and other health outcomes for patients with back pain remains to be seen.
	Temporal Trends and Geographic Variations in the Supply of Clinicians Who Provide Spinal Manipulation to Medicare Beneficiaries: A Serial Cross-Sectional Study J Manipulative Physiol Ther 2021 (Mar); 44 (3): 177–185 ~ FULL TEXT Most clinicians who bill for SM services to Medicare beneficiaries are chiropractors. The supply of Medicare-active SM providers varies widely by state. The overall supply of SM providers under Medicare is declining, while the supply of nonchiropractors who provide SM is growing. Since SM is recommended for first-line treatment of low back pain, adequate access to SM is needed to provide equitable spine care for older US adults. The supply of clinicians who provide SM under Medicare deserves further attention.
	Initial Choice of Spinal Manipulation Reduces Escalation of Care for Chronic Low Back Pain Among Older Medicare Beneficiaries Spine (Phila Pa 1976) 2021 (May 11) [EPUB] ~ FULL TEXT SMT was associated with lower rates of escalation of care as compared to Opioid Analgesic Therapy (OAT). Among older Medicare beneficiaries who initiated long-term care for cLBP with opioid analgesic therapy, the adjusted rate of escalated care encounters was significantly higher as compared to those who initiated care with spinal manipulative therapy. Level of Evidence: 3.
	"Like Peanut Butter and Jelly": A Qualitative Study of Chiropractic Care and Home Exercise Among Older Adults with Spinal Disability BMC Geriatrics 2021 (Apr 23); 21 (1): 271 Older adults valued non-pharmacological treatment options that aided them in controlling spine-related symptoms, while empowering them to maintain clinical benefit gained after a course of chiropractic spinal manipulation and exercise. The complimentary nature of provider-delivered and active care modalities may be an important consideration when developing care plans. This study underscores the importance of understanding participants' values and experiences when interpreting study results and applying them to practice.
	The Profile of Older Adults Seeking Chiropractic Care: A Secondary Analysis BMC Geriatrics 2021 (Apr 23); 21 (1): 271~ FULL TEXT From 6,781 chiropractor–adult patient encounters across two countries, one in six chiropractic patients were aged ≥65 years. Among older adult patients, back pain was the most common problem diagnosed by chiropractors (accounting for 82 in every 100 encounters). Neck pain and lower limb problems were the next most common presentation to chiropractors. Soft tissue therapy was the most commonly used technique and 29% of older patients were recommended exercise. Among older adults, back pain is the most common problem in chiropractic practice, and future research should explore the clinical course of back pain in older patients seeking chiropractic care.
	Full-Coverage Chiropractic in Medicare: A Proposal to Eliminate Inequities, Improve Outcomes, and Reduce Health Disparities Without Increasing Overall Program Costs J Chiropractic Humanities 2020 (Dec 7); 27: 29–36~ FULL TEXT Chiropractic care for Medicare beneficiaries has been associated with enhanced clinical outcomes such as faster recovery, fewer back surgeries a year later, reduced opioid-associated disability, fewer traumatic injuries and falls, and slower declines in activities of daily living and disability over time. Further evidence points to lower costs, fewer medical physician visits for low back pain, less opioid-related expense, and less back-surgery expense with chiropractic utilization. Use is lower among vulnerable populations: seniors, lower income women, and black and Hispanic beneficiaries who may be most affected by current inequities associated with the limited coverage. In this era of evidence-based and patient-centered care, beneficiaries who receive chiropractic care are very satisfied with the care they receive. The current evidence suggests a need for change in US policy toward chiropractic in Medicare and support for HR 3654. Ending inequities by providing patients full coverage for chiropractic services has the potential to enhance care outcomes and reduce health disparities without increasing program costs.
	Cost Comparison of Two Approaches to Chiropractic Care for Patients with Acute and Sub-acute Low Back Pain Care Episodes: A Cohort Study Chiropractic & Manual Therapies 2020 (Dec 14);   28 (1):   68~ FULL TEXT Low back pain (LBP) imposes a costly burden upon patients, healthcare insurers, and society overall. Spinal manipulation as practiced by chiropractors has been found be cost-effective for treatment of LBP, but there is wide variation among chiropractors in their approach to clinical care, and the most cost-effective approach to chiropractic care is uncertain. To date, little has been published regarding the cost effectiveness of different approaches to chiropractic care. Thus, the current study presents a cost comparison between chiropractic approaches for patients with acute or subacute care episodes for low back pain.
	Primary Care for Low Back Pain: We Don't Know the Half of It Pain. 2020 (Apr); 161 (4): 663–665 ~ FULL TEXT In a new systematic review, Kamper et al. [What is Usual Care for Low Back Pain?] (See it directly below this article) tackle the first question in relation to first-contact care for patients with low back pain provided by family practice and emergency department physicians. As the authors state, low back pain has major significance for the international pain community. It is the leading single cause of years lost to disability globally, [17] and there is good evidence for what constitutes best first-contact treatment. [6] The review selected best-quality studies of routine health care data to investigate whether first-contact physicians are putting back pain guidelines into practice (“usual care”). The results paint a bleak picture: only a minority of patients apparently receive simple positive messages to stay active and exercise, while inappropriate use of analgesia and imaging persists. The review adds to evidence that the care doctors give patients with low back pain is dominated by guideline-discordant interventions that are unnecessary, expensive, and “low-value” (ie, harm is more likely than benefit). [2, 3, 16] Refer to our extensive collection, titled: Initial Provider/First Contact
	What is Usual Care for Low Back Pain? A Systematic Review of Health Care Provided to Patients with Low Back Pain in Family Practice and Emergency Departments Pain. 2020 (Apr); 161 (4): 694–702 ~ FULL TEXT International clinical practice guidelines for low back pain (LBP) contain consistent recommendations including universal provision of information and advice to remain active, discouraging routine referral for imaging, and limited prescription of opioids. This systematic review describes usual care provided by first-contact physicians to patients with LBP. Studies that reported the assessments and care provided to people with LBP in family practice and emergency departments (EDs) from January 2000 to May 2019 were identified by searches of PubMed, EMBASE, and CINAHL. Study quality was assessed with reference to representativeness of samples, potential misclassification of patients, potential misclassification of outcomes, inconsistent data and precision of the estimate, and the findings of high-quality studies were prioritized in the data synthesis. Less than 20% of patients with LBP received evidence-based information and advice from their family practitioner. Around 1 in 4 patients with LBP received referral for imaging in family practice and 1 in 3 in EDs. Up to 30% of patients with LBP were prescribed opioids in family practice and up to 60% in EDs. Refer to our extensive collection, titled: Initial Provider/First Contact
	Back Complaints in the Elders - Chiropractic (BACE-C): Protocol of an International Cohort Study of Older Adults with Low Back Pain Seeking Chiropractic Care Chiropractic & Manual Therapies 2020 (Apr 1); 28 (1): 17 ~ FULL TEXT This study, to our knowledge, is the first large-scale, prospective, multicenter, international cohort study to be conducted in a chiropractic setting to focus on older adults with low back pain consulting a chiropractor. By understanding the clinical course, satisfaction and safety of chiropractic treatment of this common debilitating condition in the aged population, this study will provide input for informing future clinical trials.
	Chiropractic Treatment of Older Adults with Neck Pain with or without Headache or Dizziness: Analysis of 288 Australian Chiropractors' Self-reported Views Chiropractic & Manual Therapies 2019 (Dec 18); 27: 65 ~ FULL TEXT This is the first known study to investigate chiropractic care of older adults living with neck pain. The findings suggest that chiropractors use well-established manual and physical therapy techniques to manage neck pain in older adults. The favourable outcomes reported by participants highlight a potential role for using non-pharmacological multimodal therapeutic approaches for the management of neck pain in older adults. The findings also indicate that this target group of patients may frequently integrate chiropractic care with other health services in order to manage their neck pain. Understanding the patient’s motivation for using multiple services may shed light on the health care needs of this population. Further research should also explore how chiropractic treatment of neck pain in older adults impacts patient experience, and other patient-reported outcomes. Given the high prevalence of neck pain in older people, the evidence for the effectiveness of manual and physical treatments for neck pain, the reported demand for chiropractic care in this population, the barriers to pain relief, and concerns among older adults regarding polypharmacy, further studies are needed to provide a more solid evidence-base upon which clinical guidelines for chiropractic management and/or co-management of this condition can be developed. Until then, we recommend that the current clinical guidelines be followed.
	Cost-Efficiency and Effectiveness of Including Doctors of Chiropractic to Offer Treatment Under Medicaid: A Critical Appraisal of Missouri Inclusion of Chiropractic Under Missouri Medicaid J Chiropractic Humanities 2019 (Dec 10); 26: 31–52 ~ FULL TEXT Using a dynamic scoring model to incorporate savings from 3 primary sources, we found that (1) chiropractic care provides better outcomes at lower cost, (2) chiropractic treatment and care leads to a reduction in costs of spinal surgery, and (3) chiropractic care leads to cost savings from reduced use and abuse of opioid prescription drugs.
	Prevalence of Low Back Pain in the Elderly Population: A Systematic Review Clinics (Sao Paulo) 2019 (Oct 28); 74: e789 ~ FULL TEXT This systematic review indicates a high prevalence of LBP in the elderly population and that functional disability affects factors that are important for independence. However, the investigated studies present diverse methodologies, and different definitions of LBP were used, suggesting that more research should be carried out with scientific accuracy, methodological quality and low risk of bias to contribute towards developing preventive actions for the elderly population affected by LBP. Finally, such studies will provide information to devise public policy plans by health managers and professionals.
	Care for Low Back Pain: Can Health Systems Deliver? Bulletin of the World Health Organization 2019 (Jun 1); 97 (6): 423–433 ~ FULL TEXT Delivery of guideline-concordant care for low back pain requires system-wide changes. Strong governance at each level of the health system will be key to redefining how society views and manages low back pain. Health systems should prioritize policies that: empower clinicians and consumers to make well-informed choices; encourage clinicians to deliver the right care to those who need it most; provide financial support to evidence-based non-pharmacological treatment; and regulate the influence of those with vested interests in the current situation. Small adjustments to health policy will not work in isolation. Workplace systems, legal frameworks, personal beliefs, politics and the overall societal context in which we experience health, will also need to change. Addressing system-level barriers to guideline-based care could be cost-neutral; every year health systems waste billions of dollars on unnecessary tests and treatments for low back pain. Although disinvestment is difficult, redistributing funds to support guideline-concordant care is a promising way forward. Because current approaches to treatment often lack formal evidence, we strongly encourage careful evaluation of any new approach to funding or service delivery.
	Spinal Manipulative Therapy and Exercise for Older Adults with Chronic Low Back Pain: A Randomized Clinical Trial NCT00269321 Chiropractic & Manual Therapies 2019 (May 15); 27: 21 ~ FULL TEXT 241 participants were randomized and 230 (95%) provided complete primary outcome data. The primary analysis showed group differences in pain over the one-year were small and not statistically significant. Pain severity was reduced by 30 to 40% after treatment in all 3 groups with the largest difference (eight percentage points) favoring SMT and home exercise over home exercise alone. Group differences at other time points ranged from 0 to 6 percentage points with no consistent pattern favoring one treatment. One-year post-treatment pain reductions diminished in all three groups. Secondary self-report outcomes followed a similar pattern with no important group differences, except satisfaction with care, where the two combination groups were consistently superior to home exercise alone.
	Best Practices for Chiropractic Care for Older Adults: A Systematic Review and Consensus Update J Manipulative Physiol Ther 2017 (May); 40 (4): 217–229 ~ FULL TEXT A total of 199 articles were found; after exclusion criteria were applied, 6 articles about effectiveness or efficacy and 6 on safety were added. The Delphi process was conducted from April to June 2016. Of the 37 Delphi panelists, 31 were DCs and 6 were other health care professionals. Three Delphi rounds were conducted to reach consensus on all 45 statements. As a result, statements regarding the safety of manipulation were strengthened and additional statements were added recommending that DCs advise patients on exercise and that manipulation and mobilization contribute to general positive outcomes beyond pain reduction only. This is an update of the 2010 Consensus Document titled: Recommendations for Chiropractic Care for Older Adults: Results of a Consensus Process

The Cost-Effectiveness Triumvirate
	Variations in Patterns of Utilization and Charges for the Care of Headache in North Carolina, 2000–2009: A Statewide Claims' Data Analysis J Manipulative Physiol Ther. 2016 (May); 39 (4): 229–239 ~ FULL TEXT Overall utilization and average charges for the treatment of headache increased considerably from 2000 to 2005 and then decreased in each subsequent year. Policy changes that took place between 2005 and 2007 may have affected utilization rates of certain providers and their associated charges. MD care accounted for the majority of total allowed charges throughout the decade. In general, patterns of care involving multiple providers and referral care incurred the largest charges, whereas patterns of care involving single or nonreferral providers incurred the least charges. MD-only, DC-only, and MD-DC care were the least expensive patterns of headache care; however, risk-adjusted charges (available 2006-2009) were significantly lower for DC-only care compared with MD-only care.
	Variations in Patterns of Utilization and Charges for the Care of Neck Pain in North Carolina, 2000 to 2009: A Statewide Claims' Data Analysis J Manipulative Physiol Ther. 2016 (May); 39 (4): 240–251 ~ FULL TEXT Increases in utilization and charges were the highest among patterns involving MDs, PTs and referral providers. These findings are consistent with previous studies showing that medical specialty, diagnostic imaging, and invasive procedures (eg, spine injections, surgery) [17, 19, 20, 21] are significant drivers of increasing spine care costs. When costs are viewed vertically as if in “silos” (eg, DC-only costs, MD-only costs), increasing utilization of one particular provider is seen as a net cost increase. However, when costs are viewed across the silos, as this study has done, an increase in utilization of one provider group can result in a net cost decrease given its effect on the patient population. This is an opportunity to view costs laterally versus a confined, vertical analysis.
	Variations in Patterns of Utilization and Charges for the Care of Low Back Pain in North Carolina, 2000 to 2009: A Statewide Claims' Data Analysis J Manipulative Physiol Ther. 2016 (May); 39 (4): 252–262 ~ FULL TEXT A major strength of the study was the large amount of low back pain claims made available to us for analysis. The data were from 3,159,362 claims generated by approximately 66,0000 persons over the 2000–2009 decade in North Carolina, in several different pathways of healthcare services. This study and the series of papers it has generated on the treatment of low back pain, neck pain [25] and headache, [26] provides unique economic examination for healthcare policy makers and legislators. When costs are viewed vertically as if in “silos” (eg, DC-only costs, MD-only costs), increasing utilization of one particular provider is seen as a net cost increase. However, when costs are viewed across the silos, as this study has done, an increase in utilization of one provider group can result in a net cost decrease given its effect on the patient population. This is an opportunity to view costs laterally versus a confined, vertical analysis.