Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

JUNE GIBBS BROWN 

Inspector General 

JUNE 2000 

OEI-04-97-00495 

CHIROPRACTIC CARE 

Comparison of Medicare Managed Care and 

Fee-For-Service 
OFFICE OF INSPECTOR GENERAL 

Public Law 95-452, as amended by Public Law 100-504, mandated the mission of the Office of 

Inspector General (OIG). That mission is to protect the integrity of the Department of Health and 

Human Services programs as well as the health and welfare of beneficiaries served by them. This 

statutory mission is carried out through a nationwide program of audits, investigations, 

inspections, sanctions, and fraud alerts. The Inspector General informs the Secretary of program 

and management problems and recommends legislative, regulatory, and operational approaches to 

correct them. 

Office of Evaluation and Inspections 

The Office of Evaluation and Inspections (OEI) is one of several components of the Office of 

Inspector General. It conducts short-term management and program evaluations (called 

inspections) that focus on issues of concern to the Department, the Congress, and the public. The 

inspection reports provide findings and recommendations on the efficiency, vulnerability, and 

effectiveness of departmental programs. 

OEI's Atlanta Regional Office prepared this report under the direction of Jesse J. Flowers, 

Regional Inspector General, and Christopher H. Koehler, Deputy Regional Inspector General. 

Principal OEI staff included: 

Allison Grablowsky, Lead Analyst Brian Ritchie, Program Analyst

Tricia Davis, Program Specialist Barbara Tedesco, Mathematical Statistician

Scott Horning, Program Analyst Joe Townsel, Program Analyst

Graham Rawsthorn, Team Leader

To obtain copies of this report, please call the Atlanta Regional Office at 404-562-7723. Reports 

are also available on the World Wide Web at our home page address: 

http://www.dhhs.gov/progorg/oei 
TABLE OF CONTENTS 

PAGE

EXECUTIVE SUMMARY ............................................... 1

INTRODUCTION ..................................................... 3

FINDINGS

Managed care versus fee-for-service utilization ............................... 6

Direct access versus physician referral ...................................... 7

Direct access versus fee-for-service ........................................ 8

Chiropractors provided most treatments ..................................... 9

Co-payments not limiting access .......................................... 10

AGENCY COMMENTS .................................................... 11

APPENDICES

A. Respondent vs. Non-Respondent Analysis ............................... A-1

B. Summary of Chiropractic Utilization ................................... B-1

C. HCFA Comments ................................................. C-1
EXECUTIVE SUMMARY 

PURPOSE 

To compare chiropractic utilization in Medicare managed care risk plans to that in fee-forservice. 

BACKGROUND 

We previously completed a report describing policies and practices for providing 

chiropractic services to Medicare beneficiaries in seven managed care organizations — 

report number OEI-04-97-00494. Following issuance of that report, Health Care 

Financing Administration staff requested that we do a national analysis of chiropractic 

utilization in managed care as compared to that in fee-for-service. 

Most Medicare beneficiaries can choose between the Medicare managed care program and 

the fee-for-service program. Medicare fee-for-service coverage of chiropractic services is 

limited to manual manipulation of the spine to correct a subluxation. Managed care plans 

offer that service, and can offer other chiropractic services. However, in this study, 

“chiropractic services” refers solely to the allowed Medicare benefit of manual 

manipulation of the spine to correct a subluxation. 

We e-mailed a standardized survey to all 310 Medicare managed care risk plans to obtain 

utilization and other data. We obtained fee-for-service chiropractic utilization data from 

the Health Care Financing Administration — Part B Extract and Summary System, annual 

Data Compendiums, and the National Claims History file. We did a comparative analysis 

of the managed care and fee-for-service chiropractic utilization data from 1996 through 

1998. 

FINDINGS 

Chiropractic utilization in managed care risk plans was lower than in fee-forservice. In 1998, 1.43 percent of beneficiaries in managed care risk plans used 

chiropractic services compared to more than 4 percent of beneficiaries in fee-for-service. 

In the same year, managed care beneficiaries received about seven chiropractic treatments 

per beneficiary compared to approximately nine treatments per beneficiary in fee-forservice. 

Chiropractic utilization was higher in managed care risk plans when direct access 

was allowed versus primary care physician referral, but it was still lower than in feefor-service. In 1998, 2.14 percent of beneficiaries in managed care risk plans that allowed 

direct access used chiropractic services compared to 1.08 percent of beneficiaries in plans 

that required a physician referral. Whereas, 4.42 percent of beneficiaries in fee-for-service 

used chiropractic services. During the same year, beneficiaries in managed 

Chiropractic Care: Medicare Managed Care and Fee-For-Service 1 OEI-04-97-00495 
care risk plans that required a physician referral received about six treatments per 

beneficiary. In contrast, beneficiaries in managed care risk plans that allowed direct access 

and beneficiaries in fee-for-service received about nine treatments per beneficiary. 

Chiropractors provided most of the chiropractic treatments to beneficiaries in 

managed care risk plans. In 1998, chiropractors performed 91 percent of the 

chiropractic treatments in managed care risk plans and 99 percent of the treatments in feefor-service. 

Managed care risk plans did not use co-payments to limit beneficiary access to 

chiropractic services. Of the 244 respondents, 220 plans required a co-payment to 

access chiropractic services. The co-payments ranged from $3-$27 with the most 

common co-payment being $5. The chiropractic co-payments were the same as copayments for other similar services. 

COMMENTS 

The HCFA concurred with our findings and offered several technical comments. We 

made appropriate revisions. The full text of their comments is in Appendix C. 

Chiropractic Care: Medicare Managed Care and Fee-For-Service 2 OEI-04-97-00495 
INTRODUCTION 

PURPOSE 

To compare chiropractic utilization in Medicare managed care risk plans to that in fee-forservice. 

BACKGROUND 

We recently completed a report describing policies and practices for providing 

chiropractic services to Medicare enrollees in seven managed care organizations.1 That 

report compared chiropractic utilization in the managed care organizations to that in feefor-service. As our report represented a limited sample, the results were not projectable. 

However, following issuance of that report, Health Care Financing Administration staff 

requested that we do a national analysis of chiropractic utilization in managed care as 

compared to that in fee-for-service. Such a national study would enhance their 

understanding of chiropractic policies and practices in managed care organizations. 

Chiropractic Services in Managed Care and Fee-For-Service 

Most Medicare beneficiaries can choose between Medicare managed care plans, or the 

fee-for-service program.2 Managed care risk plans require beneficiaries to use approved 

plan providers.3 About 5.3 million Medicare beneficiaries were enrolled in managed care 

risk plans in 1998. 

Fee-for-service allows beneficiaries to use any doctor, hospital, or other health care 

provider who accepts Medicare. About 32.5 million Medicare beneficiaries were enrolled 

in fee-for-service in 1998. 

Medicare fee-for-service and managed care plans are required to provide the chiropractic 

service of manual manipulation of the spine to correct a subluxation.4 In addition, 

managed care plans can offer other chiropractic services. Beneficiary utilization, however, 

can differ among fee-for-service and managed care plans. In this study, “chiropractic 

services” refers solely to the Medicare benefit of manual manipulation of 

1 Chiropractic Services Covered by Medicare Managed Care Organizations (OEI-04-97-00494) 

2 Beneficiaries with end-stage renal disease are not eligible to participate in the managed care program. 

3

The managed care risk plans discussed in this report are now known as Medicare+Choice risk plans. The name 

change is due to the Balanced Budget Act of 1997 which established the Medicare+Choice program beginning 1999. 

4 According to the Medicare Carrier Manual, a subluxation is defined as the incomplete dislocation, off centering, 

misalignment, fixation, or abnormal spacing of vertebrae or intervertebral units. 

Chiropractic Care: Medicare Managed Care and Fee-For-Service 3 OEI-04-97-00495 
the spine to correct a subluxation. Such chiropractic services can be provided by any 

provider meeting the definition of “physician”. The term “physician” as defined by 

section 1861 of the Social Security Act, includes doctors of medicine, osteopathy, and 

chiropractic. 

Prior Chiropractic Studies 

As part of our continuing study of Medicare and Medicaid issues, we published several 

reports on chiropractic care over the past two years. For example, in addition to the 

previously mentioned study of seven managed care organizations, we issued reports on 

controls used by Medicare, Medicaid, and other payers, Medicaid coverage of chiropractic 

care, and utilization parameters for chiropractic treatments. Our website, 

http://www.dhhs.gov/progorg/oei, lists our current reports on chiropractic issues. 

METHODOLOGY 

The Health Care Financing Administration maintains centralized data systems that capture 

utilization data on services provided to Medicare beneficiaries enrolled in fee-for-service. 

However, no such centralized data system exists to capture utilization data for 

beneficiaries enrolled in managed care plans. Therefore, we developed our own database 

on chiropractic utilization in managed care risk plans. 

To do so, we surveyed all 310 managed care risk plans in April 1999. We e-mailed a 

standardized data collection instrument to each plan. As needed, we followed-up on 

incomplete and non-responses. Ultimately, 244 plans provided self-reported information 

— a 79 percent response rate. In instances where managed care plans did not respond to 

a particular question, we based our analysis on the number who responded. Where 

applicable, we noted the differences throughout the report. 

Although HCFA did not require managed care plans to capture utilization data for 

chiropractic services, 190 of the 244 respondents claimed to capture such data. However, 

not all 190 plans provided complete utilization data for each year of our inspection period 

— 1996 through 1998. We defined complete utilization data to include the number of 

beneficiaries enrolled, the number of beneficiaries receiving chiropractic services, and the 

number of treatments received. For example, 125 plans provided complete 1998 

utilization data. The 125 plans represented 53 percent of the Medicare enrollees in the 

244 plans that responded. 

The 54 plans (244-190) provided several reasons why they did not capture utilization data. 

The two most common reasons were they 1) paid physicians a set amount to provide 

chiropractic services to their enrolled beneficiaries, i.e. a capitated payment, and 2) had 

few Medicare beneficiaries enrolled. 

We obtained fee-for-service chiropractic utilization data from the Health Care Financing 

Administration. First, we used Data Compendiums to identify the number of Medicare 

beneficiaries. Next, we used a 1 percent sample of the National Claims History file to 

estimate the number of beneficiaries using chiropractic services. The 1 percent sample 

Chiropractic Care: Medicare Managed Care and Fee-For-Service 4 OEI-04-97-00495 
provided a large number of claims, and a high degree of precision. Finally, we used the 

Part B Extract and Summary System to determine the number of treatments received by 

beneficiaries and the allowed charges for the treatments. The specific codes associated 

with the chiropractic service were A2000, 98940, 98941, and 98942. 

We did a comparative analysis of the managed care and fee-for-service chiropractic 

utilization data for 1996 through 1998 as shown in Tables 1 through 6. In addition, we 

summarized the tables in Appendix B. 

Finally, we conducted non-response analyses. First, we did an analysis to determine if 

significant differences existed between the 244 plans that responded and the 66 plans that 

did not respond. We found a significant difference based on the size of the plan, therefore, 

we conducted more detailed analyses. We based the analyses on whether plans required 

co-payments, and whether a plan allowed direct access or required a physician referral. 

We found no response/non-response bias. 

The second analysis was conducted because all respondents did not provide complete 

utilization data. Among the 125 plans that provided complete utilization data for 1998, 

we found no bias in plans that conducted or did not conduct utilization reviews. Appendix 

A shows our non-response analysis in detail. 

____ ____ ____ ____ 

We conducted our inspection between January 1999 and November 1999. We conducted 

this inspection in accordance with the Quality Standards for Inspections issued by the 

President’s Council on Integrity and Efficiency. 

Chiropractic Care: Medicare Managed Care and Fee-For-Service 5 OEI-04-97-00495 
FINDINGS 

Chiropractic utilization in managed care risk plans was lower 

than in fee-for-service, but it has increased 

Beneficiary use 

Beneficiaries in managed care (MC) risk plans used chiropractic services to a lesser extent 

than did those in fee-for-service (FFS). Table 1, for example, shows that 1.43 percent of 

beneficiaries in managed care risk plans used chiropractic services in 1998. In contrast, 

more than 4 percent of fee-for-service beneficiaries used chiropractic services. 

Table 1 

Beneficiaries Using Chiropractic Services: Managed Care versus Fee-For-Service 

1996 1997 1998 

57 MC 

risk plans 

FFS 99 MC 

risk plans 

FFS 125 MC 

risk plans 

FFS 

Number of Medicare 

Beneficiaries 

1,532,256 33,509,382 2,224,235 32,933,535 2,767,418 32,545,955 

Beneficiaries using 

chiropractic services 

10,644 1,391,600 26,763 1,405,400 39,669 1,437,200 

Percent using 

chiropractic services 

0.69% 4.15% 1.20% 4.27% 1.43% 4.42% 

Treatments per beneficiary 

Beneficiaries enrolled in managed care risk plans, on average, received fewer chiropractic 

treatments per beneficiary than did those in fee-for-service. To illustrate, Table 2 shows 

that managed care beneficiaries received about 7 treatments per beneficiary in 1998. 

Medicare beneficiaries in fee-for-service averaged about 9 chiropractic treatments. 

Table 2 

Chiropractic Treatments Per Beneficiary: Managed Care versus Fee-For-Service 

1996 1997 1998 

57 MC 

risk plans 

FFS 99 MC 

risk plans 

FFS 125 MC 

risk plans 

FFS 

Beneficiaries using 

chiropractic services 

10,644 1,391,600 26,763 1,405,400 39,669 1,437,200 

Number of 

treatments received 

70,592 12,274,583 185,820 12,957,421 295,226 13,491,616 

Treatments per 

beneficiary 

6.63 8.82 6.94 9.22 7.44 9.39 

Chiropractic Care: Medicare Managed Care and Fee-For-Service 6 OEI-04-97-00495 
Recent overall increases 

From 1996 through 1998, chiropractic use increased in both managed care risk plans and 

fee-for-service. However, chiropractic use increased to a greater extent in the managed 

care risk plans. To illustrate, Table 1 shows that the percent of beneficiaries using 

chiropractic services increased from 0.69 to 1.43 percent in managed care plans. In feefor-service, however, the increase was from 4.15 to 4.42 percent. 

Also, from 1996 through 1998, the average number of treatments per beneficiary 

increased more in managed care than in fee-for-service. To illustrate, Table 2 shows that 

the number of treatments per beneficiary increased from 6.63 to 7.44 treatments in 

managed care risk plans — an increase of .81 treatments per beneficiary. In fee-forservice, the increase was from 8.82 to 9.39 — an increase of .57 treatments per 

beneficiary. 

Chiropractic utilization was higher in managed care risk 

plans when direct access was allowed versus primary care 

physician referral 

Beneficiary use 

More beneficiaries used chiropractic services when managed care plans allowed direct 

access than when the plans required a primary care physician referral. For example, in 

1998, 2.14 percent of beneficiaries enrolled in managed care risk plans that allowed direct 

access used chiropractic services. Conversely, 1.08 percent of beneficiaries enrolled in 

managed care risk plans that required a primary care physician (PCP) referral used 

chiropractic services. 

Table 3 

Beneficiaries Using Chiropractic Services: Managed Care Direct Access versus 

Primary Care Physician Referral 

1996 — 57 plans 1997 — 99 plans 1998 — 125 plans 

Direct 

Access 

(17 plans) 

PCP 

Referral 

(40 plans) 

Direct 

Access 

(35 plans) 

PCP 

Referral 

(64 plans) 

Direct 

Access 

(43 plans) 

PCP 

Referral 

(82 plans) 

Number of Medicare 

Beneficiaries 

522,727 1,009,529 762,904 1,461,331 919,037 1,848,381 

Beneficiaries using 

chiropractic services 

4,444 6,200 12,739 14,024 19,622 20,047 

Percent using 

chiropractic services 

0.85% 0.61% 1.67% 0.96% 2.14% 1.08% 

Chiropractic Care: Medicare Managed Care and Fee-For-Service 7 OEI-04-97-00495 
Treatments per beneficiary 

Beneficiaries received more chiropractic treatments, per beneficiary, when managed care 

plans allowed direct access than when the plans required a primary care physician referral. 

To illustrate, in 1998, beneficiaries received, on average, 9 treatments when allowed direct 

access. However, beneficiaries enrolled in plans requiring a primary care physician 

referral, received about 6 treatments per beneficiary. 

Table 4 

Chiropractic Treatments Per Beneficiary: Managed Care Direct Access versus 

Primary Care Physician Referral 

1996— 57 plans 1997— 99 plans 1998— 125 plans 

Direct 

Access 

(17 plans) 

PCP 

Referral 

(40 plans) 

Direct 

Access 

(35 plans) 

PCP 

Referral 

(64 plans) 

Direct 

Access 

(43 plans) 

PCP 

Referral 

(82 plans) 

Beneficiaries using 

chiropractic services 

4,444 6,200 12,739 14,024 19,622 20,047 

Number of 

treatments received 

40,684 29,908 106,676 79,144 178,424 116,802 

Treatments per 

beneficiary 

9.15 4.82 8.37 5.64 9.09 5.83 

Chiropractic utilization was lower in managed care risk plans 

that allowed direct access than in fee-for-service 

Beneficiary use 

Beneficiaries enrolled in managed care plans that allowed direct access used chiropractic 

services to a lesser extent than did beneficiaries enrolled in fee-for-service. For example, 

in 1998, 2.14 percent of beneficiaries enrolled in managed care risk plans that allowed 

direct access used chiropractic services. Conversely, 4.42 percent of beneficiaries enrolled 

in fee-for-service used chiropractic services. 

Chiropractic Care: Medicare Managed Care and Fee-For-Service 8 OEI-04-97-00495 
Table 5 

Beneficiaries Using Chiropractic Services: Managed Care Direct Access versus 

Fee-For-Service 

1996 1997 1998 

Direct 

Access 

(17 plans) 

FFS Direct 

Access 

(35 plans) 

FFS Direct 

Access 

(43 plans) 

FFS 

Number of Medicare 

Beneficiaries 

522,727 33,509,382 762,904 32,933,535 919,037 32,545,955 

Beneficiaries using 

chiropractic services 

4,444 1,391,600 12,739 1,405,400 19,622 1,437,200 

Percent using 

chiropractic services 

0.85% 4.15% 1.67% 4.27% 2.14% 4.42% 

Although beneficiary use was less in plans that allowed direct access, the process for 

beneficiaries to obtain chiropractic services was similar to that for beneficiaries in fee-forservice. The process allowed beneficiaries to go directly to chiropractors and other 

providers without requiring a physician referral. 

Treatments per beneficiary 

Beneficiaries enrolled in managed care risk plans that allowed direct access received 9.09 

treatments per beneficiary in 1998. This is comparable to the 9.39 treatments per 

beneficiary in fee-for-service for the same year. 

Table 6 

Chiropractic Treatments Per Beneficiary: Managed Care Direct Access versus FeeFor-Service 

1996 1997 1998 

Direct 

Access 

(17 plans) 

FFS Direct 

Access 

(35 plans) 

FFS Direct 

Access 

(43 plans) 

FFS 

Beneficiaries using 

chiropractic services 

4,444 1,391,600 12,739 1,405,400 19,622 1,437,200 

Number of 

treatments received 

40,684 12,274,583 106,676 12,957,421 178,424 13,491,616 

Treatments per 

beneficiary 

9.15 8.82 8.37 9.22 9.09 9.39 

Chiropractors provided most of the chiropractic treatments 

to beneficiaries in managed care risk plans 

All 244 managed care risk plans that responded to our survey provided the chiropractic 

benefit of manual manipulation of the spine to correct a subluxation. Of the 244 plans, 

Chiropractic Care: Medicare Managed Care and Fee-For-Service 9 OEI-04-97-00495 
231 used both chiropractors and other providers to perform chiropractic services. Other 

providers included osteopaths, doctors of medicine, orthopedists, physical therapists, 

physiatrists, and rheumotologists. The remaining 13 plans did not use chiropractors, but 

relied solely on the other providers to perform chiropractic services. 

As mentioned in our methodology, only 125 of the 244 plans provided complete 

utilization data for 1998. Of the 125 plans, 110 provided their chiropractic utilization data 

by the type of provider who performed the service. Figure 1 shows that chiropractors 

performed 91.42 percent of the chiropractic treatments in 1998 for the 110 managed care 

risk plans. 

Figure 1 

Percent of Treatments Performed 

by Provider Type in 1998 

D.O. (2.56%) 

M.D. (2.46%) 

OTHER (3.56%) 

D.C. (91.42%) 

In contrast, 99.96 percent of chiropractic treatments were performed by chiropractors 

under the fee-for-service program in 1998. 

Managed care risk plans did not use co-payments to limit 

beneficiary access to chiropractic services 

Of the 244 managed care risk plans, 220 required a co-payment for chiropractic services 

and 24 did not. Of the 220 risk plans, 219 established pre-set co-payment amounts. The 

co-payments ranged from $3-$27 with the most common co-payment being $5. The 

remaining plan set the co-payment at 20 percent of the charged amount. 

Chiropractic co-payments in 208 of the 219 plans were the same as co-payments for 

similar services -- primary care physician office visits, physical therapy, or podiatry 

services. In 10 plans, the co-payment for chiropractic services was $6 higher, on average, 

than such similar services. The remaining plan’s chiropractic co-payment was $2 lower 

than such similar services. 

In addition, the chiropractic co-payment in managed care plans was similar to that of feefor-service. The fee-for-service co-payment is 20 percent of allowed charges. The 

average allowed charge in 1998 was $27.75. Hence, the average co-payment was $5.55. 

Chiropractic Care: Medicare Managed Care and Fee-For-Service 10 OEI-04-97-00495 
AGENCY COMMENTS 

The HCFA concurred with our findings and offered several technical comments. The full text of 

their comments is in Appendix C. 

In response to HCFA comments, we added a summary table on chiropractic utilization from 1996 

through 1998 in Appendix B. We further explained that chiropractors and other physicians can 

provide manual manipulation of the spine. Finally, we clarified that beneficiary utilization of 

chiropractic services can differ among fee-for-service and managed care plans. 

We did not add a comparison of chiropractic utilization of fee-for-service and managed care 

organizations in rural versus urban areas as HCFA suggested. This was beyond the scope of our 

study. We also did not make any enrollment comparisons for the entire population of managed 

care plans as HCFA suggested. As explained in our methodology not all plans responded to our 

survey. Therefore, we only had enrollment data for the 244 plans that responded. 

Chiropractic Care: Medicare Managed Care and Fee-For-Service 11 OEI-04-97-00495 
APPENDIX A 

Analysis of Respondents versus Non-Respondents

A consideration in using surveys is whether the results may be biased by significant 

differences between respondents and non-respondents. To determine if significant 

differences occurred in this survey, we conducted two separate analyses. The first was an 

analysis of plans that responded to the survey versus plans that did not respond. The 

second analysis was conducted because all respondents did not provide complete 

utilization data. 

Analysis of respondents vs. non-respondents 

We surveyed all 310 Medicare managed care risk plans in April 1999. Out of the 310, 244 

plans responded to our survey, while 66 plans did not respond. The number of enrollees 

as of April 1999 was the only information we had on both the responding and the nonresponding plans. We ranked the 310 plans based on ascending enrollment size. We then, 

split the plans into three equal groups — small, medium, and large. We defined small 

plans as those with 0 to 3,901 enrollees, the medium with 3,902 to 14,985 enrollees, and 

the large with 14,986 or more enrollees. This analysis is shown in Table 1 below. 

Table 1 

Number of Respondents versus Non-Respondents 

Size of Plan Number of 

Respondents 

Percent of 

Respondents 

Number of NonRespondents Percent of Nonrespondents 

Small 75 31% 29 44% 

Medium 79 32% 24 36% 

Large 90 37% 13 20% 

Totals 244 66 

Chi-Square =7.57- Significant at the 95 percent confidence level 

df=2 

Due to the significant chi-square statistic, additional analysis was necessary. To determine 

whether significant differences existed in this survey, we analyzed co-payment 

requirements, and whether direct access was allowed or a physician referral was required. 

For each of these analyses, we found no relationship based on plan size which suggests 

that no statistical bias was evident. 

Chiropractic Care: Medicare Managed Care and Fee-For-Service A - 1 OEI-04-97-00495 
Analysis of utilization data and utilization reviews 

Out of 244 respondents, 125 provided complete utilization data for 1998. In order to test 

for bias with respect to the utilization data not provided by the remaining 119 plans, we 

performed an analysis on a question where all 244 plans provided a response. 

In the survey, we asked, “Do you conduct utilization reviews for manual manipulation of 

the spine?” The Table below shows that out of 244 respondents, 75 plans indicated “yes” 

they did conduct utilization reviews, and 169 plans indicated “no” they did not conduct the 

reviews. We then, broke out the “yes and no” answers according to whether or not the 

plan provided utilization data. Table 2 below shows this break down. 

Table 2 

Analysis of Conducting Utilization Reviews by Whether Utilization Data was 

Provided 

Did the plans conduct utilization 

reviews? 

Yes No Totals 

Responses from all 244 plans 

(% of Total) 

75 (31%) 169 (69%) 244 

Number of plans that provided utilization 

data (% of Total) 

52 (42%) 73 (58%) 125 

Number of plans that did not provide 

utilization data (% of Total) 

23 (19%) 96 (81%) 119 

Chi-square=14.21- Significant at the 99 percent confidence level 

df=1 

Since the chi-square test was significant, we performed an analysis on plans that provided 

utilization data based on whether or not plans conducted utilization reviews. 

When 125 plans provided utilization data, the difference between conducting or not 

conducting utilization reviews varied by .55 percent. Approximately 1.72 percent of 

beneficiaries enrolled in plans that conducted utilization reviews, and provided utilization 

data used chiropractic services. Whereas, 1.17 percent of beneficiaries enrolled in plans 

that did not conduct utilization reviews, and provided utilization data used chiropractic 

services. This data is shown in Table 3 below. 

Among the 125 plans that provided utilization data, beneficiaries enrolled in plans that 

conducted utilization reviews received about 2.03 treatments more per beneficiary than 

plans that did not conduct utilization reviews. Table 3 shows that the plans that 

conducted utilization reviews averaged 8.31 treatments per beneficiary. Whereas, the 

plans that did not conduct utilization reviews averaged 6.28 treatments per beneficiary. 

Chiropractic Care: Medicare Managed Care and Fee-For-Service A - 2 OEI-04-97-00495 
Table 3 

Chiropractic Utilization by Plans that Did and Did Not Conduct Utilization 

Reviews 

Conduct 

Utilization 

Reviews 

Number of 

1998 

Enrollees 

Small 

Plans 

Medium 

Plans 

Large 

Plans 

# of 

beneficiaries 

used service 

# of 

treatments 

received 

Yes 1,324,889 13 18 21 22,723 188,782 

10.4% 14.4% 16.8% 1.72% 8.31 

No 1,442,529 18 29 26 16,946 106,444 

14.4% 23.2% 20.8% 1.17% 6.28 

Totals 2,767,418 31 47 47 39,669 295,226 

24.8% 37.6% 37.6% 1.43% 7.44 

Chiropractic Care: Medicare Managed Care and Fee-For-Service A - 3 OEI-04-97-00495 
APPENDIX B 

Summary of Chiropractic Utilization: Managed Care Plans versus Fee-For-Service from 1996 through 1998 

1996 1997 1998 

MC risk plans FFS MC risk plans FFS MC risk plans FFS 

PCP 

referral 

(40) 

Direct 

Access 

(17) 

Total 

(57) 

PCP 

referral 

(64) 

Direct 

Access 

(35) 

Total 

(99) 

PCP 

referral 

(82) 

Direct 

Access 

(43) 

Total 

(125) 

# of Medicare 

beneficiaries 

1,009,529 522,727 1,532,256 33,509,382 1,461,331 762,904 2,224,235 32,933,535 1,848,381 919,037 2,767,418 32,545,955 

Beneficiaries 

using chiropractic 

services 

6,200 4,444 10,644 1,391,600 14,024 12,739 26,763 1,405,400 20,047 19,622 39,669 1,437,200 

% using 

chiropractic 

services 

0.61% 0.85% 0.69% 4.15% 0.96% 1.67% 1.20% 4.27% 1.08% 2.14% 1.43% 4.42% 

# of treatments 

received 

29,908 40,684 70,592 12,274,583 79,144 106,676 185,820 12,957,421 116,802 178,424 295,226 13,491,616 

Treatments per 

beneficiary 

4.82 9.15 6.63 8.82 5.64 8.37 6.94 9.22 5.83 9.09 7.44 9.39 

Chiropractic Care: Medicare Managed Care and Fee-For-Service B - 1 OEI-04-97-00495 
APPENDIX C 

Chiropractic Care: Medicare Managed Care and Fee-For-Service C - 1 OEI-04-97-00495 
Chiropractic Care: Medicare Managed Care and Fee-For-Service C - 2 OEI-04-97-00495 
Chiropractic Care: Medicare Managed Care and Fee-For-Service C - 3 OEI-04-97-00495 
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