Chiropractic 2025:

Chiropractic 2025: Divergent Futures
Sometimes seen conditions include hyperlordosis of cervical or lumbar spine, kyphosis of thoracic spine, functional
and/or structural scoliosis, obesity, high blood pressure, fibromyalgia, bursitis or synovitis, carpal or tarsal tunnel
syndrome, sinus condition, osteoporosis/ osteomalacia, allergies, TMJ syndrome, dizziness/vertigo or loss of
equilibrium, thoracic outlet syndrome, spinal stenosis/neurogenic claudication, diabetes, menstrual disorder/PMS,
and congenital/developmental anomaly of any joint. Insurers do not cover chiropractic care for most of these items
and are not likely to do so until there is strong evidence of efficacy and cost-effectiveness. Many of these conditions
go beyond what a spine and musculoskeletal focused provider would treat. Some relate to a primary care role, others
to specific specialties.
Cost-Effectiveness and Outcomes Generation
Increasingly, cost-effectiveness research, as well as patient satisfaction, is being gathered at the site of care. In IAF’s
two earlier scenario reports we recommended that all practicing chiropractors generate outcomes on their care. There
is very slow movement in that direction. Chiropractors are in the process of adopting electronic health record (EHR)
systems. Increasingly, chiropractic networks associated with providers and insurers, such as American Specialty
Health (ASH) and OptumHealth, use the EHRs of those systems to gather information on specific chiropractors.
Chiropractors in the Army use the same EHRs that all other providers in the Army use. In addition to the EHR
record that OptumHealth’s DC members collect, OptumHealth plans to have patients complete a short survey on
outcomes and patient satisfaction. Recording outcomes, summarizing and comparing them across DCs and other
providers will grow both within practices, by networks and by community and patient groups. IAF forecasts that
in communities, both local ratings groups like Angie’s List and national organizations such as PatientsLikeMe will
have consumers/patients rate their providers and share this information. Ultimately these consumer groups will
require DCs and other providers to include summaries of their own results on their outcome measures that will be
used in the local comparisons of providers.
Chiropractors’ research also needs to focus on comparative effectiveness of the various methods used by DCs. For
example, how does flexion-distraction compare with standard manual manipulation for LBP? Does the Activator
device work as well as high velocity low amplitude (thrust) manipulation for neck pain and headaches? What is the
relative effectiveness of the soft tissue techniques used by DCs to treat muscle and tendon problems, such as Active
Release Technique, Graston Technique, post isometric relaxation, and the NIMMO technique? All of these various
manipulation and mobilization methods need to be sorted out clinically in terms of which techniques or tools worked
best for the treatment of which conditions. This includes determining if there are subsets of patients who respond
better to certain types of procedures over others. This identification of outcomes and patient subsets will require
effective use of EHRs, including the optimal utilization of the genomic, epigenetic, and biomonitoring data for
patients that EHRs will include in the years ahead.
Beyond individual DCs’ effectiveness and outcomes is the larger question of cost effectiveness of chiropractic care.
In the U.S., cost-effectiveness research has been conducted by DCs, other professionals, and insurance groups. A
retrospective claims analysis on Blue Cross Blue Shield of Tennessee’s intermediate and large group fully insured
population between October 2004 and September 2006 showed that DC-initiated treatment was much more costeffective
than MD-initiated treatment. 145 This cost-effectiveness has been confirmed by other studies as well. Martin
et al. (2012) used a national sample of patients suffering from spine conditions to study health care costs associated
with use of CAM, using the 2002-2008 Medical Expenditure Panel Survey. 146 They found that CAM users had lower
inpatient expenditures. Davis et al. (2013) found that the U.S. CAM market might in fact be more self-regulating
than the market for mainstream medicine, 147 and that any attempt to reduce national health care expenditure by
eliminating coverage for CAM (including chiropractors for back pain) would have little impact, if any, on national
health care expenditure. 148
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