Part 4 of 9: How System Design Impacts Provider Scope and Consumer Access
- garret78
- 2 days ago
- 7 min read
Updated: 22 hours ago
Understanding Scope: Policy vs. Practice
Scope of practice is often thought of as a matter of professional licensing and state regulations. However, in day-to-day healthcare delivery, scope is not just determined by policy—it is operationalized by reimbursement rules, utilization management protocols, and benefit design. It is easily argued that the most influential contributor to scope of practice is intermediary managed networks in chiropractic and physical therapy.
In theory, chiropractors (DCs) and physical therapists (PTs) have broad legal scopes of practice in most U.S. states. These scopes allow them to assess, diagnose, and treat a wide range of musculoskeletal (MSK) conditions without physician oversight. These scopes are important to protect consumer access to these high value providers. Yet in practice, what they are allowed to do is often constrained by what insurers will pay for, how services are authorized, and how providers are ranked and tiered.
For example:
Chiropractors frequently encounter per diem reimbursement models or evaluation codes reimbursed at rates that fail to support time-intensive assessments or treatment planning. Below is a chart showing average evaluation code reimbursement for chiropractors across multiple states through a single intermediary. Important context is that in many cases evaluation codes are bundled with all other codes into a per diem (per visit) rate. This per visit rate very often closely aligns with the reimbursement rate for 9894x (chiropractic manipulation). Thus, evaluations are effectively not covered.
Physical therapists often face referral requirements, narrow episode definitions, or authorization processes that restrict their ability to initiate care independently—even when state law allows direct access.
As a result, policy-defined scope is narrowed into a smaller, operational scope. This hidden limitation directly affects patient access to high-value care.
Consumer Consequences: Access Barriers to Top-of-Scope Providers
A large body of research shows that when patients with back or neck pain begin care with a chiropractor or physical therapist, they are:
Less likely to receive opioids, injections, advanced imaging, or surgery.
More likely to resolve their condition through conservative care.
Have lower total episode costs.
According to analysis of commercial claims data by Elton et al. (2022, 2023 – medRxiv.org), chiropractors had the highest rate of resolving MSK episodes as the only provider seen, with total costs significantly lower than all other provider types commonly seen for neck and back complaints.
Despite this, most consumers do not enter the healthcare system through these high-value channels. Instead, patients often begin care with providers who are less specialized in conservative MSK management, leading to increased imaging, prescriptions, and referrals.
This is not a failure of consumer preference—it’s a failure of system design.
Access barriers include:
Insurance plans that limit or exclude evaluation and management by DCs and PTs.
Utilization management tools that require physician referrals or impose visit caps.
Lack of integration into employer or health system care pathways.
In effect, consumers are steered away from high-value care not by clinical judgment—but by coverage limitations.
Top-of-Scope in Medical Professions: A Proven Value Strategy
The movement to allow providers to practice at the top of their license has gained wide support in medical care. Nurse practitioners (NPs) and physician assistants (PAs), for example, have increasingly been granted full practice authority in many states and integrated into team-based care models. This has expanded access to primary care, reduced wait times, and improved cost efficiency—particularly in underserved areas.
According to the National Academy of Medicine and the American Association of Nurse Practitioners, allowing NPs to practice independently is associated with lower costs, comparable outcomes, and increased consumer satisfaction.
The same logic applies to MSK care. Imagine the savings possible if chiropractors and physical therapists became the most commonly used portal of entry providers for musculoskeletal complaints. Chiropractors and physical therapists, when operating at the top of their scope, can dramatically reduce downstream costs and unnecessary interventions. Yet they remain underutilized as first-contact providers because the system does not reward—or even allow—this level of practice in many cases.
There is a notable contrast to highlight. While health systems that contract directly with insurers are increasingly prioritizing top-of-scope care to improve access and efficiency, intermediary-managed networks—especially in chiropractic and physical therapy—often move in the opposite direction. Many large, national intermediaries operate under capitated contracts, where profit increases as service scope and access decrease. This creates a direct financial incentive to restrict reimbursable services, deny coverage for evaluations or rehab, and suppress utilization. As a result, while the broader healthcare system embraces top-of-license practice, intermediary models often drive scope to its minimum, limiting patient access and provider potential for reasons that are economic—not clinical. Yet evidence consistently shows that top-of-scope care is associated with higher value for consumers, including lower costs, fewer invasive procedures, and better functional outcomes.
A Vision for the Ideal System
To fully realize the value of DCs and PTs in MSK care, system-wide changes are needed. These include both provider-driven reforms and payer/employer commitments:
1. Professional Alignment and Education
Chiropractic and physical therapy associations and educational institutions should continue to promote top-of-scope clinical training.
Providers must be encouraged to practice in ways that align with system-level goals: conservative care, efficient resolution, and whole-patient assessment.
2. Coverage Reform
Insurers and self-funded employers should design benefits that cover:
Comprehensive MSK evaluations by DCs and DPTs that allow prevent these disciplines from continuing on the path toward limited scope "technicians" and rather, embrace these providers as ideal portal of entry and contributors to population-based healthcare
Rehabilitative exercise and manual therapies as core services.
Direct access and transparent authorization pathways.
3. Strategic Integration
Health systems and primary care organizations should incorporate DCs and PTs into standard MSK pathways as first-contact providers.
Referral and co-management models should be built with shared data, outcome tracking, and episode-based payment structures.
4. Support for Doctor of Physical Therapy Autonomy
Direct access laws for PTs must be accompanied by benefit designs that support top-of-license practice.
Insurers should eliminate administrative gatekeeping that treats DPTs as ancillary providers, and instead recognize them as primary MSK providers.
Projected Consumer Impact
The potential benefits of reconfiguring access to MSK care are substantial. Based on current claims data and care pathway research, redirecting even a modest share of MSK patients to DCs and PTs as first-contact providers could yield:
30–40% reduction in total episode cost for neck and back pain.
Significant declines in opioid prescriptions, MRI orders, and specialist referrals.
Shorter episode durations and improved functional outcomes.
Reduced out-of-pocket costs for consumers when unnecessary imaging, emergency visits, or prescriptions are avoided.
For example, in markets where chiropractors are the initial provider for >30% of patients with low back pain, total cost of care has been shown to be $400–$600 lower per episode compared to primary care initiation (Elton, medRxiv, 2022).
Conclusion: Unlocking Access, Unlocking Value
Chiropractors and physical therapists are among the most effective and efficient providers for musculoskeletal care. Yet systemic barriers prevent consumers from fully benefiting from their expertise.
Scope of care is not just a matter of regulation—it’s a reflection of reimbursement design, benefit coverage, and system incentives. If we are to prioritize value-based care and empower patients to access the right care at the right time, then we must operationalize top-of-scope practice for DCs and PTs—not just permit it in theory.
The path forward is clear:
Educate and empower providers to lead at the top of their training.
Design benefits that cover comprehensive MSK care.
Give consumers direct access to the right providers—from the start.
Only then will the system begin to reflect the value it claims to support.
Special Section: A Call to Action for Doctors of Chiropractic
Clarify, Align, and Lead
Chiropractors play a vital role in the musculoskeletal (MSK) care landscape. Research consistently shows that when patients begin care with a Doctor of Chiropractic, they experience fewer invasive procedures, lower total costs, and faster resolution. In fact, chiropractors capture 30–35% of consumers with neck and back complaints as the first provider seen—a testament to the profession’s visibility and accessibility.
Yet despite this strong consumer footprint, chiropractors receive only 5–10% of medical referrals for these same conditions. The discrepancy highlights a fundamental challenge: while the value of chiropractic care is increasingly recognized by the medical community, there remains a reluctance to refer into a profession perceived as inconsistent in philosophy, scope, and care delivery.
A 2015 survey published in Chiropractic & Manual Therapies (DOI: 10.1186/s12998-015-0066-5) found that approximately 80% of chiropractors identify as “top-of-scope” providers, integrating assessment, soft tissue work, exercise, and broader functional care into their practice. The remaining ~20% self-identify as “straight” chiropractors, limiting their care primarily to adjustments.
This variation creates confusion for referring providers. Few physicians are willing to refer patients into a discipline without knowing what type of care will be delivered. Lack of clarity leads to lack of trust—and missed opportunities to serve more patients through conservative, cost-effective means.
Two Urgent Actions for the Chiropractic Profession
1. Clarify Professional Identity: Align or Distinguish Scope
The chiropractic profession must either:
Align around a shared scope of practice that reflects top-of-license care—including diagnosis, soft tissue therapy, rehabilitative exercise, and care coordination.
Or clearly distinguish between limited-scope and top-of-scope chiropractors so that referral networks, payers, and patients can make informed choices.
This does not mean sacrificing individuality or specialization. It means presenting coherent, trusted clinical pathways to the broader healthcare system.
80% of chiropractors are already well-positioned to align with medical expectations and become preferred partners for MSK care. But as long as there’s no mechanism for the medical system to identify top-of-scope providers, the entire profession remains underleveraged.
2. Oppose Scope Restriction in Policy and Reimbursement
Scope limitation—whether imposed through regulatory policy or reimbursement strategy—is a critical liability to the profession. Reimbursement models that:
Eliminate evaluation codes via per diem payment,
Deny coverage for soft tissue or rehabilitative services,
Or enforce narrow utilization benchmarks based on flawed claims data,
…ultimately reduce chiropractic to a passive, commoditized service, regardless of training or legal scope.
Chiropractors must vigorously denounce any effort—explicit or covert—to restrict scope through these levers. These strategies not only suppress individual provider potential, but also damage the credibility and viability of the profession in a value-based healthcare system.
Conclusion: Your Positioning Matters
The healthcare system is beginning to see the data. Referring providers, employers, and payers are asking: “Can we count on chiropractic?”
The answer must be a resounding yes—but that confidence will depend on consistency, clarity, and collective leadership. Chiropractors are already serving as trusted access points for millions of patients. Now is the time to unify scope, protect it, and elevate the profession’s rightful role in modern MSK care.