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The American Journal of Managed Care July 2015
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Acupuncture and Chiropractic Care: Utilization and Electronic Medical Record Capture
Charles Elder, MD, MPH; Lynn DeBar, PhD, MPH; Cheryl Ritenbaugh, PhD, MPH; William Vollmer, PhD; Richard A. Deyo, MD, MPH; John Dickerson, PhD; and Lindsay Kindler, PhD, RN
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Wayne Matthews, MS, PA-C, DFAAPA
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Acupuncture and Chiropractic Care: Utilization and Electronic Medical Record Capture

Charles Elder, MD, MPH; Lynn DeBar, PhD, MPH; Cheryl Ritenbaugh, PhD, MPH; William Vollmer, PhD; Richard A. Deyo, MD, MPH; John Dickerson, PhD; and Lindsay Kindler, PhD, RN
Most patients with chronic musculoskeletal pain use acupuncture or chiropractic care. A substantial percentage of this utilization, however, is not captured by the electronic medical record.

Objectives: To describe acupuncture and chiropractic use among patients with chronic musculoskeletal pain (CMP) at a health maintenance organization, and explore issues of benefit design and electronic medical record (EMR) capture.  

Study Design: Cross-sectional survey.

Methods: Kaiser Permanente members meeting EMR diagnostic criteria for CMP were invited to participate. The survey included questions about self-identified presence of CMP, use of acupuncture and chiropractic care, use of ancillary self-care modalities, and communication with conventional medicine practitioners. Analysis of survey data was supplemented with a retrospective review of EMR utilization data.

Results: Of 6068 survey respondents, 32% reported acupuncture use, 47% reported chiropractic use, 21% used both, and 42% used neither. For 25% of patients using acupuncture and 43% of those using chiropractic care, utilization was undetected by the EMR. Thirty-five percent of acupuncture users and 42% of chiropractic users did not discuss this care with their health maintenance organization (HMO) clinicians. Among chiropractic users, those accessing care out of plan were older (P <.01), were more likely to use long-term opioids (P = .03), and had more pain diagnoses (P = .01) than those accessing care via clinician referral or self-referral. For acupuncture, those using the clinician referral mechanism exhibited these same characteristics.

Conclusions: A majority of participants had used acupuncture, chiropractic care, or both. While benefit structure may materially influence utilization patterns, many patients with CMP use acupuncture and chiropractic care without regard to their insurance coverage. A substantial percentage of acupuncture and chiropractic use thus occurs beyond detection of EMR systems, and many patients do not report such care to their HMO clinicians.

Am J Manag Care. 2015;21(7):e414-e421
Take-Away Points
  • A majority of health maintenance organization (HMO) participants with chronic musculoskeletal pain had used acupuncture, chiropractic care, or both. 
  • While benefit structure may materially influence utilization patterns, many patients with chronic pain use acupuncture and chiropractic care without regard to their insurance coverage. 
  • A substantial percentage of acupuncture and chiropractic use occurs beyond detection of electronic medical record systems, and many patients do not report their acupuncture and chiropractic utilization to their HMO clinicians. 
  • Better acupuncture and chiropractic integration offers opportunities for improved management algorithms and more efficient utilization of resources.
Acupuncture and chiropractic care are popular among patients, especially those who suffer from chronic musculoskeletal pain.1 Caring for this population has become an increasingly important and visible challenge for the healthcare system. Pharmaceuticals are commonly used for managing pain, yet the use of such agents on a chronic basis is of questionable efficacy, and can be associated with high costs and significant adverse effects.2,3 For example, nonsteroidal anti-inflammatory drugs can cause gastrointestinal toxicity or renal failure, while use of narcotic analgesics can be associated with somnolence, constipation, addiction, diversion of medications, and other problems.

Although many health insurers cover acupuncture and chiropractic care for pain management, such coverage is often limited in scope, and integration of acupuncture and chiropractic care with conventional practice may be piecemeal or nonexistent.4-10 Health insurance providers may allow patients to self-refer for acupuncture and chiropractic care, or may require patients to first obtain a referral from a primary care physician. Which mechanism is optimal in terms of patient satisfaction, inter-clinician communication, and clinical outcomes has not been explored.

Ultimately, better integration may require a more robust evidence base toward identifying the optimal clinical context for acupuncture and chiropractic use. In developing such an evidence base, attention is turning to analyses of data from clinical and administrative electronic medical records (EMRs) to enhance both conventional and innovative study designs.11 EMRs contain potentially useful information on large numbers of patients that is already being collected in the context of routine care delivery. It is unclear, however, to what extent such electronic databases contain information about acupuncture and chiropractic utilization that is accurate or complete.

We recently surveyed chronic musculoskeletal pain patients in a large health maintenance organization (HMO) to ascertain the extent to which EMRs are capturing acupuncture and chiropractic utilization among their membership. In particular, we address the following questions:

1. Description of acupuncture and chiropractic use. What is the prevalence of self-reported acupuncture and chiropractic use among chronic musculoskeletal patients at the HMO? Which types of patients use acupuncture? Chiropractic care? What are the perceived barriers to such use? How often do acupuncture and chiropractic users communicate such use to their HMO clinicians?

2. Medical record capture. To what extent is acupuncture and chiropractic utilization captured by the HMO’s EMR?

3. Utilization and benefit coverage. How, if at all, do patients who access acupuncture and chiropractic care through various mechanisms differ from one another?


Setting and Coverage Policies

Kaiser Permanente Northwest (KPNW) is a group model HMO serving approximately 500,000 members in Oregon and Washington. KPNW members can be referred by an HMO clinician for acupuncture and chiropractic care based upon locally developed evidence-based referral guidelines.12,13 In brief, for chiropractic care, referrals are approved for acute nonradicular back or neck pain. Acupuncture referrals can be approved for most chronic pain conditions. Acupuncture and chiropractic care are provided by clinicians affiliated with Complementary Health Plans (CHP), a network of credentialed acupuncturists and chiropractors with which KPNW contracts. CHP acupuncturists and chiropractors bill KPNW directly for services provided under this mechanism. We describe this mechanism for accessing care as “clinician referral.”

In addition, many KPNW members or their employers have purchased a self-referral insurance rider, which allows patients to directly access a CHP acupuncturist or chiropractor for any indication, up to annual utilization limits. Payment for these benefits is made on a capitated basis from KPNW to CHP, and acupuncture and chiropractic clinicians thus bill CHP for office visits and services provided. Approximately one-third of KPNW patients reside in southwest Washington, where some coverage of acupuncture and chiropractic services is mandated by the state, while the remainder live in Oregon, where there is no such mandate. All KPNW Washington members have a self-referral benefit for chiropractic care, paid for on a capitated basis. We describe this mechanism for accessing care as “self-referral.”

KPNW infrastructure includes a comprehensive EMR used for all patient encounters. This EMR allows for tracking of patient demographics, diagnoses, referrals, billing, and utilization. We are thus able to capture acupuncture and chiropractic services billed and received through the “clinician referral” mechanism electronically with the KPNW EMR. For this analysis we accessed EMR data for the years 2009 to 2011.

CHP also maintains an electronic database, tracking visits, diagnoses, and procedures for “self-referral” patients. Electronic data from the CHP database were available for this analysis for the year 2011.


We developed a comprehensive International Classification of Diseases, Ninth Revision, Clinical Modification code list to identify patients whose pattern of clinical diagnoses in their EMR was consistent with chronic musculoskeletal pain.14 The sample was operationally defined as including KPNW members aged at least 18 years at the time of their first medical visit with a pain-related diagnosis, with ≥3 outpatient (ie, emergency department, ambulatory visit, e-mail, or telephone) encounters evident in the EMR, spanning at least 180 days but no more than 18 months. We required appropriate diagnostic codes indicating: 3 occurrences of musculoskeletal pain diagnoses; or first diagnosis of musculoskeletal pain and 2 subsequent diagnoses of nonspecific chronic pain; or first diagnosis of musculoskeletal pain with 1 additional musculoskeletal pain diagnosis and 1 nonspecific chronic pain diagnosis. These eligibility criteria are described in more detail elsewhere.14

Survey Methods

Patients meeting the criteria for chronic musculoskeletal pain described above between 2009 and 2011 were invited to complete a survey online, by mail, or by phone. The invitation emphasized a broad interest in identifying treatment and self-care activities to manage persistent pain, framed as “We want to know what works for you.” The survey included questions related to self-identified presence of chronic pain, self-reported use of acupuncture and chiropractic care, use of ancillary self-care modalities (ie, yoga, tai chi/qigong, supplements, massage, meditation, physical activity, diet, other), and communication with conventional medicine practitioners about acupuncture and chiropractic use. Where patients indicated through survey response that they had utilized acupuncture or chiropractic care without using their HMO insurance, we designated such access to care as “out of plan.”

Prior to survey implementation, we pretested the survey with 5 patients with chronic musculoskeletal pain identified from participants in a psycho-educational program for pain patients offered through the KPNW pain clinic. From this group, we selected for interview patients who, upon completing the draft survey, either had self-identified using out-of-plan complementary/alternative medicine (CAM) services or those whose response patterns evidenced confusion regarding survey questions. The goal of the interviews was to obtain patient feedback regarding important points missed and to tailor wording to enhance acceptability and avoid ambiguity.

Members meeting chronic musculoskeletal pain criteria were contacted by mail with a postcard inviting them to log on to a website to complete the survey online. The initial online response rate to the post card was 4% (N = 1731). After 2 weeks, those who did not respond were contacted by e-mail (N = 4885) or were sent a paper copy of the survey by US mail (N = 34,211). Finally, 10% of nonresponders—selected based upon the date they had been mailed the survey—were called and invited to complete the survey by phone. Ultimately, of the surveys completed, approximately 5% were completed by phone, 18% were completed online, and 77% were completed on paper and mailed back.


Chi-square tests were used for comparisons on categorical variables. ANOVA was used for continuous variables. As our purpose was to generate, rather than test, hypotheses, we did not correct for multiple comparisons.


Description of Acupuncture and Chiropractic Use

Of 49,426 patients invited to participate, 8264 (16.7%) participants responded. Of these, 6068 (73.4%) self-reported chronic musculoskeletal pain and as such, the focus of this manuscript. These 6068 participants were predominantly Caucasian (94%) and female (71%), with a mean age of 61 years (SD = 13). Thirty-two percent reported acupuncture use for pain, while 47% reported chiropractic use for pain. The number reporting both acupuncture and chiropractic use was 21%. Forty-two percent of respondents used neither acupuncture nor chiropractic care.

The 4 usage groups differed significantly in age and gender (Table 1). In addition, the percentage of participants self-reporting back pain, neck pain, muscle pain, headache, fibromyalgia, or abdominal/pelvic pain was highest in the group using both acupuncture and chiropractic services.

Barriers. Among the 4113 individuals who reported never having used acupuncture services, the most commonly cited reasons were: never considered doing so, cost, and didn’t know a reputable provider (Table 2). Among the 3211 individuals who reported never having used chiropractic services, the most commonly cited reasons were: never considered, didn’t think it would help, and cost.

Communication. Of those using only acupuncture, 35% did not discuss their acupuncture use with their primary care provider, while 42% of those using only chiropractic services did not discuss their chiropractic use (Table 3). However, most of these individuals indicated that they would do so if asked about such use.

Medical Record Capture

Figures 1 and 2 describe the distribution of utilization for acupuncture and chiropractic care across different referral mechanisms for the year 2011.

For acupuncture, data were captured for 667 patients. Of these, 168 (25%) utilized acupuncture entirely out of plan, and were not captured by the EMR. Overall, 229 (34%) users of acupuncture were treated with some acupuncture out of plan. More than half (55%) of patients using acupuncture in 2011 did so entirely based upon clinician referral, while 9% of patients used acupuncture entirely based upon a self-referral benefit. Of 428 patients who used a clinician referral, 52 (12%) supplemented their health plan benefit with additional out-of-plan utilization.

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