Patterns and Costs of Physical Medicine: Comparison of Chiropractic 
and Physician-Directed Care

This study examines the patterns and sequences of physical medicine (PM) care delivered to injured workers and paid for under state workers’ compensation systems. We look at several different patterns but focus on the two most common: chiropractors as the sole treating provider and physicians who provide physical medicine services or refer to other providers — usually physical therapists.

Physical medicine services are typically delivered to more than one-quarter of injured workers (including about half of those who are away from work for more than a week due to their injuries) and represent about 20 percent of total medical costs in workers’ compensation. These services may be delivered by any one or combination of several types of medical providers, including chiropractors, physical therapists, physicians, and hospital-based providers. Examples of the types of physical medicine services delivered include manipulations and adjustments, supervised exercise, hot and cold packs, electrostimulation, and massage.

The study addresses a number of questions:

•  What types of injuries receive physical medicine care? Who provides it?
• What are the duration, intensity, and timing of this care?
• How do the costs of similar cases compare when physical medicine care is provided by a chiropractor or is physician directed?
• Which provider pattern achieves a given outcome (duration of temporary disability) at the least cost?

SUMMARY OF MAJOR FINDINGS

What types of injuries receive physical medicine care? Who provides it?

• Not surprisingly, physical medicine services are most often used for back injuries, representing 41 percent of all injuries that receive such services (Table A). Back injuries represent one-quarter of workers’ compensation injuries, so they are disproportionately more likely to receive PM services.
• Sprains and strains are 35 percent of all workers’ compensation injuries, representing one-half of claims with physical medicine services and 41 percent of physical medicine costs. Although disc injuries are only 2 percent of all injuries, they account for 11 percent of physical medicine costs.
• In most cases, physicians manage care and arrange for physical medicine, either within or outside their organizations (Table B). Chiropractors are involved in about 13 percent of the cases, two-thirds of which are under the exclusive care of chiropractors.

What are the duration, intensity, and timing of this care?

• There is tremendous variation in the durations of physical medicine services. In nearly one-half of cases, the duration is two weeks or less. At the other extreme, in one in eight cases, the time from the first treatment to the last is 15 weeks or more.
• Cases in which physicians manage treatment and PM services are provided either internally, externally by physical therapists, or through hospital providers generally have the shortest durations of PM treatment. Between half and two-thirds of cases receive 2 weeks or less of services, and more than three-quarters receive 4 weeks or less. About 5 percent have durations of physical medicine services of 15 weeks or more.
• Cases treated exclusively by chiropractors have much longer durations of PM services. Nearly one-quarter have durations of 15 weeks or more. Only 35 percent have durations of 4 weeks or less.
• Cases treated by both chiropractors and physicians, either sequentially or concurrently, have the longest durations of PM treatment. Forty-three percent have durations of 15 weeks or more, and only 25 percent have durations of 4 weeks or less.
• The typical treatment begins with nearly five visits in the first two weeks (about 2.5 per week) and declines quickly to less than four visits per 2-week interval. For most of the duration of the claim, there are typically three to four visits per 2-week interval.
• Although the durations of treatment show important differences among provider patterns, the intensity of treatment is more similar than different.
• More than half of the time, workers with back strains and sprains who receive PM services begin them within 1 week of the injury.
• Earlier intervention is more common when the treating provider is a chiropractor or when it is a physician that refers for PM services to a provider within his or her own organization.

How do costs compare in similar cases when treated by different providers?

• In general, back SSP cases in which chiropractors are the exclusive providers have total costs per claim that are 16–25 percent higher, after case-mix adjusting, than cases in which care is directed by physicians in California, Connecticut, and Texas (Table C). In Massachusetts, the cost differences are not statistically significant. In Florida, the costs of chiropractor-treated cases are 21 percent lower. Reimbursement regulations may be one important reason for the Florida difference, as discussed later in the report.
• Medical costs for physician-directed cases are 17–21 percent lower than those for chiropractor-treated cases, after case-mix adjusting. Again, Florida is an exception — similar chiropractor-treated cases have 20 percent lower medical costs.
• The differences in indemnity costs for chiropractic and physician-directed cases are small and, for the most part, statistically insignificant after case-mix adjusting. A notable exception is Texas, where indemnity costs are 44 percent higher in chiropractor-treated cases than in physician-directed cases.
• The duration of disability is shorter in chiropractor-treated cases compared with physician-directed cases by 16 percent in California, after case-mix adjusting. Despite having shorter duration, indemnity costs are not lower, because chiropractor-treated cases are more likely to result in permanent partial disability (PPD) or lump-sum payments than are physician-directed cases.
• Cases treated by chiropractors are less likely to become indemnity claims than are physician-directed cases, except in Texas, where they are more likely to become indemnity cases.

Does either provider pattern achieve a given outcome (duration of temporary disability) at lower cost?

• Physician-directed care achieves the same duration of temporary disability as chiropractic care at about 30 percent lower total cost per claim in California, Connecticut, and Texas, after case-mix adjusting (Table D). There are no significant differences in Massachusetts. In Florida, chiropractor-treated cases achieve the given outcome at 10 percent lower costs.
• Medical costs per claim in physician-directed cases are about 25 percent lower to achieve the same duration of temporary disability as chiropractor-treated cases (in California, Connecticut, and Texas), after case-mix adjusting. Indemnity costs per indemnity claim are about 20 percent lower in physician-directed cases in Connecticut and Texas but not in the other states.
• In Florida, chiropractor-treated cases achieve the same duration of temporary disability with lower medical costs and similar indemnity costs compared with physician-directed cases.