Patterns of Initial Treatment and Subsequent Care
Escalation Among Medicare Beneficiaries with
Neck Pain: A Retrospective Cohort StudyThis section is compiled by Frank M. Painter, D.C.
Send all comments or additions to: Frankp@chiro.org
FROM: European Spine J 2025 (Feb); 34 (2): 724730 ~ FULL TEXT
OPEN ACCESS Brian R Anderson Todd A MacKenzie Jon D Lurie 2
Leah Grout James M Whedon
Palmer Center for Chiropractic Research,
Palmer College of Chiropractic,
741 Brady St,
Davenport, IA, 52803, USA.
Purpose: To compare long-term care escalation encounters among three care patterns for new episodes of neck pain among Medicare beneficiaries.
Methods: We examined Medicare claims spanning a four-year period for beneficiaries with new episodes of neck pain beginning in 2019. All patients were continuously enrolled under Medicare parts A, B, and D and aged 65-99 years. We calculated the cumulative frequency and propensity- weighted rate ratios for escalated care encounters across three distinct, index-visit related neck pain treatment cohorts: 1) Spinal manipulative therapy; 2) Primary care without prescription analgesics within 7 days; 3) Primary care with prescription analgesics within 7 days.
Results: 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).
Conclusion: 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.
Keywords: Health care utilization; Neck pain; Prescription drugs; Primary care physicians; Spinal manipulation.
From the FULL TEXT Article:
Introduction
The prevalence of neck pain (NP) among adults over the age of 65 in the United States (US) is reported to be 9.7% [1], impacting approximately 3.9 million older adults and peaking between the ages of 7074 years. Healthcare spending related to neck pain has increased at a rate six times faster than its prevalence, suggesting a rise in the use of high-cost care options such as injection procedures and fusion surgeries. [24]
Medicare is a federal health insurance program primarily serving Americans aged 65 and over, providing coverage for inpatient (Part A) and outpatient (Part B) care. In 2021, around 64 million beneficiaries were enrolled in Medicare Parts A and B, with approximately 49 million also opting for prescription drug coverage (Part D). [5] Spinal Manipulative Therapy (SMT) is the only chiropractic service covered by Medicare, and chiropractors perform 97% of all SMT procedures reimbursed by the program. [6] Over a 10-year period, chiropractic users in the U.S. averaged 8.3 visits annually, with an average cost of $87 USD per visit, resulting in total yearly expenditures of $721 USD per user. [7]
Most studies on pain management among Medicare beneficiaries have focused on low back pain. Therefore, there is a critical need for more research on non-pharmacological management of NP, particularly in light of new clinical practice guidelines. [8] Such guidelines discourage the initial use of prescription drugs and emphasize non-pharmacological therapies such as SMT. [9] Physicians may also prescribe non-pharmacological care in the form of referrals and/or recommendations for self-care.
The comparative long-term value of therapies for NP is markedly influenced by their efficiency. The Institute of Medicine identified efficiency, or avoidance of waste, as one of the key domains of healthcare quality. [10] Spine care often involves highly specialized, expensive, and invasive interventions (e.g., imaging studies, injection procedures, prescription medications, and surgeries), for which the benefits over more conservative options are unclear. [11, 12] The observed trends in the adoption of such interventions among Medicare beneficiaries present notable concerns, with substantial increases in the utilization of spinal injection procedures [3], opioid medications [13], cervical discectomy and fusion procedures [4], and MRI studies. [14]
Because NP often becomes chronic, patients who suffer from persistent NP often seek long-term supportive care to manage their symptoms and preserve function, with SMT being a common treatment option. [15] However, the comparative long-term value of spinal manipulation as compared to prescription drugs is uncertain since there have been few studies of downstream effects [16], and randomized controlled trials lack sufficient follow-up to evaluate longterm outcomes. [17] For studies of chronic spinal pain, the National Institutes of Health recommends evaluation of clinical data for at least 12 months. [18]
In this study we assessed long-term efficiency by evaluating care escalation encounters, defined as interventions that represent an increase in the complexity of care and utilize resources that go beyond the usual course of treatment. [19] The rate of these encounters was compared among three mutually exclusive cohorts of Medicare beneficiaries between 2019 and 2021. These cohorts were identified based on index visit provider-treatment strategy combinations for a new episode of NP and included: chiropractic-spinal manipulative therapy (DC-SMT); and primary care with (PC-A) or without (PC-NA) analgesic medications. It was hypothesized that beneficiaries initiating treatment with DC-SMT would exhibit lower rates of care escalation encounters when compared to PC-A or PC-NA.
Discussion
Table 1
page 4The demographic and clinical characteristics of our study cohorts, as presented in Table 1, are in concordance with the limited available literature evaluating NP among Medicare beneficiaries. The DC-SMT cohort demonstrated younger ages, a higher proportion of males, limited ethnic diversity, fewer comorbid conditions, and fewer indicators of low-income status when compared to the other cohorts. Corroborating our observations, Whedon et al. [30] found that Medicare beneficiaries with NP opting for SMT, as opposed to medical care, were significantly younger, predominantly male, almost exclusively white (97%), and exhibited a lower average CCI score. Similarly, in their systematic review on disparities in chiropractic care utilization, Gliedt et al. [31] identified that individuals seeking chiropractic care were more likely to be White and belong to the highest income bracket. Finally, Weigel et al. [32] observed that Medicare beneficiaries receiving SMT for spine-related conditions, compared to those receiving medical care, were more likely to be white (96% versus 87%) and belong to the highest income quartile (41% versus 31%).
A systematic review by Farabaugh et al. [33] compared costs and healthcare utilization among adults with spine-related disorders utilizing chiropractic versus medical care. Consistent with our results, this review revealed large scale differences in healthcare utilization favoring chiropractic care. Specifically, 15 studies reported lower utilization of diagnostic imaging, eight indicated a reduction in surgeries, seven showed decreased hospitalizations, five pointed to fewer injection procedures, five highlighted reduced referrals for specialist consultations, and two demonstrated fewer ED visits in patients utilizing chiropractic versus medical care. Among the 44 studies reviewed, six focused on Medicare populations and six evaluated NP related diagnoses. A recent study not included in the aforementioned systematic review evaluated escalated care encounters for new episodes of NP associated with different initial providers. [15]
The authors concluded that initiating care with PCPs, as opposed to chiropractors, was associated with a statistically significant increase in the odds of care escalation encounters: x-rays (89%); computed tomography scans (540%); magnetic resonance imaging scans (450%); injection procedures (510%); and surgical interventions (570%).
A substantial proportion (63%) of participants in our investigation opted for chiropractic care (SMT) over primary care (37%) as the initial treatment modality for NP, a finding which aligns with two previous studies. Fenton et al. reported that chiropractors constituted the first line of care for 45% of patients presenting with new episodes of NP, in contrast to 33% initiating with PCPs. Similarly, Whedon et al. [30] observed that, over a one-year period, 65% of individuals experiencing NP sought chiropractic care (SMT), whereas 45% consulted a PCP. Finally, a recent scoping review evaluating chronic pain management strategies among Medicare beneficiaries found that SMT was the most common noninvasive, nonpharmacological option among the 33 included studies. [8]
The observation that 92% of index visits meeting our inclusion criteria were addressed through conservative, non-pharmacological interventions underscore alignment with guideline-recommended practices for managing NP. Despite only 8% of beneficiaries initially receiving pharmacotherapy, utilization of over-the-counter medications was not assessed and cannot be ruled out.
This study's scope was limited by the exclusion of Medicare Advantage plans, which represented approximately 40% of the Medicare beneficiary demographic in 2021. [5] This exclusion could affect the generalizability of our findings across Medicare populations. Although conservative care is appropriate for most NP cases, specific clinical scenarios may necessitate escalated care. However, administrative claims data lack the detailed clinical granularity required to precisely identify such instances. Additionally, the absence of data on non-prescription medication use may have led to conservative estimates of analgesic utilization.
Although we employed robust methodological strategies to reduce selection bias among the treatment cohorts, inherent limitations regarding retrospective observational studies prevent elimination of all potential confounders. Furthermore, administrative claims data do not include direct measures of clinical status such as NP severity or functional limitations. While not evaluated in the current study, cost considerations are important when selecting between treatment options. Finally, observational study designs inherently restrict the ability to ascertain causal relationships.
Conclusion
Initial chiropractic care, in the form of SMT, was associated with significantly reduced downstream care escalation encounters when compared to initial primary care with or without analgesic medications. Our study contributes to a growing body of evidence supporting the integration of non-pharmacological care into healthcare strategies for NP management.
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