Analysis provided by the Arete Network
Arete's research team publishes and develops interactive analyses on musculoskeletal outcomes, healthcare cost trends, employer plan design, and population health. The goal is to build a knowledge infrastructure for musculoskeletal healthcare — evidence-first, outcomes-driven, and designed to be a trusted authority for clinical decision-makers, plan sponsors, and the AI tools that increasingly shape how healthcare guidance reaches patients.
Methodology note: Arete analyses are intended to support research, quality improvement, benefit design, and network strategy. Observational analyses may show associations that are not necessarily causal. Results should be interpreted in light of population mix, benefit design, coding patterns, care-seeking behavior, and available claims or clinical data.
Analysis provided by the Arete Network
A self-insured employer and health system ran a real-world natural experiment — waiving cost-share and removing visit limits when employees chose chiropractic or physical therapy as their first provider for low back pain. This analysis examines how that benefit design decision shaped utilization patterns, episode costs, and downstream care.
Beginning January 2022, a self-insured employer — also operating as a health system — waived cost-share and removed visit limits when health plan beneficiaries chose chiropractors or physical therapists employed by the health system as their first provider for low back pain. The chart below shows the percentage of new spine episodes that started with chiropractic or PT care, comparing health plan members (blue) against the community control group (orange).
Chiropractors and PTs had been employed by the health system for over two decades. Health plan member utilization hovered near 27% for chiro/PT as first provider — above the community rate of ~15%. Standard insurance contracts applied to all providers.
Benefit waiver took effect January 2022. Health plan member utilization rose sharply — driven almost entirely by chiropractic, not PT. The community control group rate remained stable throughout, validating the signal.
The employer discontinued employing chiropractors January 1, 2024. They formed their own LLC, remaining in the same clinics and in-network — but the benefit incentive no longer applied. Utilization dropped below the 2021 baseline, suggesting additional contracting factors at play.
The benefit incentive applied equally to chiropractors and physical therapists, yet the utilization response was asymmetric. Chiropractic as a first-contact provider rose substantially during the incentive period, while physical therapy remained below 2% throughout. This likely reflects how PT is positioned in this system — primarily as a downstream referral from orthopedics and primary care rather than a direct-access entry point.
PT consistently represents less than 2% of first-provider episodes. Access patterns and referral pathways appear to limit direct-access utilization regardless of benefit design.
The post-experiment drop below baseline warrants further investigation. Chiropractors remained in the same physical locations and stayed in-network — yet when they renegotiated contracts under their new LLC, utilization fell below pre-experiment levels. Benefit design may not be the only variable. Contracting alignment between the employer's health plan and provider entities appears to be an independent factor influencing member care-seeking behavior.
Across acute, sub-acute, and chronic episode types, members who had a chiropractic encounter during their low back pain episode showed notably lower average spine-related costs and total cost of care compared to those without a chiropractic encounter. Patient acuity and selection effects are important considerations when interpreting this association.
| First Provider Seen | Avg Spine Cost | Avg Total Cost |
|---|---|---|
| Chiropractor Lowest Spine Cost | $425 | $3,461 |
| Urgent Care | $709 | $1,522 |
| Primary Care | $962 | $3,433 |
| Physical Therapist | $1,087 | $7,115 |
| Radiology | $1,438 | $5,948 |
| Hospital – Outpatient | $1,786 | $4,312 |
| Orthopaedic Surgery | $1,805 | $5,648 |
| Emergency Department | $2,421 | $5,611 |
| Inpatient Admit | $11,438 | $23,793 |
Beyond direct episode costs, episodes that included chiropractic care were associated with lower rates of surgical procedures, emergency department visits, urgent care visits, and hospice care index events. Whether these reflect causal effects or differences in baseline acuity is an important open question.
Surgical episodes carry $11K–$26K higher average costs
10x fewer ED visits in acute chiro vs. non-chiro episodes
Consistent pattern with ED: fewer unscheduled care events
HCI = Hospice Care Index. Notable differences observed.
These downstream care pattern differences are most pronounced in acute episodes — the largest group (58% of all episodes). The data show 12x fewer inpatient admissions in chiro vs. non-chiro acute episodes (9 vs. 73 total). Whether these differences reflect causal effects of chiropractic care, differences in patient acuity at episode onset, or other selection effects is an important open question.
Model projected cost impacts based on episode type, chiropractic utilization rate, and episode volume. The full cost matrix by first encounter location is available for reference below.
| First Provider Seen | Acute — Spine | Acute — TCOC | Sub-Acute — Spine | Sub-Acute — TCOC | Chronic — Spine | Chronic — TCOC |
|---|---|---|---|---|---|---|
| Chiropractor ★ | $106 | $310 | $354 | $2,279 | $1,090 | $10,389 |
| Urgent Care | $273 | $358 | $1,441 | $3,399 | $3,437 | $8,927 |
| Primary Care | $369 | $612 | $1,280 | $5,094 | $3,253 | $14,163 |
| Physical Therapist | $243 | $428 | $849 | $5,127 | $2,235 | $16,297 |
| Hospital – Outpatient | $1,153 | $1,614 | $1,717 | $3,778 | $3,704 | $12,766 |
| Radiology | $539 | $2,621 | $2,072 | $8,115 | $4,533 | $17,608 |
| Orthopaedic Surgery | $792 | $1,010 | $1,969 | $7,652 | $4,256 | $15,793 |
| Prof. Office (Other) | $396 | $1,040 | $1,293 | $4,240 | $3,195 | $14,554 |
| Acupuncturist | $315 | $665 | $816 | $4,191 | $3,074 | $15,957 |
| Emergency Department | $1,515 | $2,335 | $3,312 | $6,460 | $5,352 | $18,403 |
| Inpatient Admit | $10,250 | $13,930 | $14,637 | $49,474 | $10,709 | $18,813 |
When the benefit incentive ended January 1, 2024, chiropractors didn't leave. They stayed in the same physical spaces, remained in-network, and continued treating patients. Yet utilization dropped not just from its experiment-period highs — it fell below the 2021 pre-experiment baseline. The data point to a set of integration and system factors that, together, account for this gap. Understanding them is essential for any self-insured employer seeking to optimize musculoskeletal care access.
The ~14-point drop from experiment peak to 2024 is partly explained by the end of the benefit incentive. The additional ~14-point drop below baseline reflects system integration factors — not provider or care quality changes.
In 2021, referring physicians had a dedicated chiropractic consult order built directly into Epic. One click — done. When chiropractors formed their own LLC, this integrated order was removed. Referring providers were required to use a more cumbersome workflow, often involving additional steps through Epic Care Link. Many physicians began texting chiropractors directly with referrals because the formal process was no longer clear or easy.
The health system's main call center scheduled chiropractic appointments in 2021. When the employment relationship changed, call center staff were told "Allina no longer has chiropractors" — and some patients were hung up on when they called to schedule. Staff were not given accurate messaging: that the chiropractors had changed their business relationship but remained in the same clinics, accepting the same insurance, in the same locations. A new external call center was set up, but represented a meaningful change for patients — particularly older patients who were accustomed to calling one number for all their care.
Staff across clinical departments were told the health system "no longer has chiropractic services" rather than the more accurate framing: that chiropractic had transitioned to a partner relationship with providers remaining in the clinics. This created a perception — among staff, schedulers, and even some physicians — that chiropractic was no longer available within the system. Correcting this narrative required significant effort by the chiropractic providers themselves.
During 2022–2023, the employer actively communicated to employees the value of seeing a chiropractor or PT first, tied to the cost-share waiver. When the benefit incentive ended, this communication also stopped. There was no equivalent messaging in 2021 either — meaning the 2021 baseline itself may underrepresent what utilization could look like with active but incentive-neutral provider education. The removal of both the incentive and its communication simultaneously compounds the utilization drop.
An important nuance: the physicians who valued chiropractic collaboration continued to want to refer. Many proactively shared their direct contact numbers so referrals could happen via text — a workaround that reflects clinical buy-in but also reveals how much the formal system had broken down. This informal channel supported some care continuity but is not scalable, measurable, or sustainable as a coordinated care model.
The core finding for employers: Benefit design incentives matter — but they are not sufficient alone. The data suggest that system integration factors (referral pathways, call center access, staff messaging, and EHR workflow) may explain as much of the utilization variance as the financial incentive itself. A self-insured employer that removes friction and builds a genuine team-based care culture can likely sustain elevated chiropractic utilization — and its associated cost benefits — without requiring ongoing benefit incentives.