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This section was compiled by Frank M. Painter, D.C.
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Medicare Articles & Guideline Information

The Muse Report:
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.

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.

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
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.

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 American Board of Family Medicine 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!


Medicare LINKS

Centers for Medicare & Medicaid Services (CMS)
This index page links you to information on the Medicare program. Each link represents a topic. Topic links are grouped by category. Each topic contains from 1 to 20 pages of information. The first page of each topic starts with an Overview. At the bottom of every page, downloads and lists of related links offer you more information.

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