Part 1 of 9: Utilization in Outpatient Rehab: A Look at Consumer Behavior, Access, and System Integration

Understanding Utilization in Outpatient Rehabilitation

Outpatient rehabilitation is a cornerstone of musculoskeletal (MSK) care in the U.S., delivering high-value, non-invasive treatment for neck, back, joint, and movement-related conditions. Among the primary disciplines in this space, chiropractic and physical therapy dominate in terms of volume, community access, and consumer awareness.

While both professions are supported by clinical guidelines and positive outcomes data, their utilization pathways, consumer access patterns, and integration into the medical system differ significantly—shaped by history, regulation, and public perception.

Understanding how patients arrive at care, who they are demographically, and how system design either facilitates or limits access is essential for shaping the future of these professions.

Shared Industry Insight: The MSK Gateway Is Still Underdeveloped

Most patients with MSK complaints initiate care in a fragmented system. Patients experiencing neck and back complaints most often seek care from primary care providers (41-60%). Chiropractors (30-35%) are the second most common portal of entry provider. Physical therapists are significantly under-utilized as portal of entry providers (6%).

Following the first provider seen, MSK value is plagued by patients bouncing around the system and consequentially, high use of unnecessary and low value care.

The schematic above demonstrates utilization of provider types among consumers with neck and back complaints, and the likelihood of the provider type being the "last provider seen" based on when they enter a care pathway (https://doi.org/10.1101/2022.10.27.22281624)

Despite strong evidence supporting conservative care as quickly as possible in a care pathway, high-value providers like chiropractors and physical therapists are underutilized as portal of entry providers relative to their potential impact, which is discussed in Part 2 of this series.

Chiropractic Utilization: Strong Direct Access, Limited System Integration

Chiropractors are unique in healthcare in that the majority of their patients self-refer, similar to primary care. This creates a powerful, independent access channel, allowing chiropractors to build localized, community-based practices that often serve as the first provider seen, especially for spine-related complaints.

Utilization Highlights:

• Among commercially insured adults with neck or back pain, 30–35% utilize chiropractic care—second only to primary care (60+%).

• Demographics:

  • Slightly more female than male (~57–60% female),

  • Average age ~42; highest claim volume comes from the 45–64 age bracket.

• Payer Mix:

  • About 60% of visits are covered by insurance; 40% are paid out-of-pocket.

  • 70-80% of chiropractic patients access the system using insurance benefits.

Challenges:

• Low referral rates from the medical system: Despite outcomes data showing chiropractic as highest value among all provider types for neck and back presentations, fewer than 10% of chiropractic patients arrive via referral. This represents the biggest opportunity for chiropractic.

• Perceived variability in philosophy and approach across the profession creates hesitation among referring providers (see Part 7 of this series).

• System marginalization: Chiropractors are often excluded from care coordination, data integration, and value-based payment models (see Parts 2 and 3 of this series).

Physical Therapy Utilization: Medical Integration, Consumer Access Gaps

Physical therapy represents the clinically integrated side of outpatient rehab. Most patients arrive through referrals from primary care, orthopedics, or surgical providers. PTs are well-positioned within health systems but often miss the opportunity to serve as a true portal-of-entry provider.

Utilization Highlights:

• A significant majority of PT episodes begin through a medical referral, despite widespread legal direct access rights in most states.

• Studies show that direct-access PT leads to lower cost, fewer imaging studies, less medication, and faster resolution—but system design still favors physician-mediated access.

• Demographics:

  • ~58% of patients are female,

  • Two age peaks: younger adults (sports and post-injury rehab) and older adults (joint pain, surgical recovery).

Challenges:

• Administrative barriers: Even in direct-access states, many employers and health systems require a referral.

• Utilization control: PTs are often subject to strict prior authorization and utilization management protocols—especially when managed through third-party intermediaries.

• The above two challenges contribute to episode treatment group data, which is discussed in Part 2 of this series, reflecting poorly, despite PTs delivering excellent value and outcomes within their clinic settings

• Limited consumer recognition: Despite positive clinical evidence, PTs are often seen as a follow-up or secondary care provider, not a first stop.

Industry Perspective: Two Professions, One Goal

Chiropractic and physical therapy offer distinct entry points into the outpatient rehab market:

• Chiropractic’s strength is in direct, consumer-driven access, but its weakness lies in lack of integration and referral flow.

• Physical therapy’s strength is in systemic legitimacy and clinical integration, but its weakness is in limited autonomy and consumer access barriers.

Together, they represent the under-utilized front door to high-value conservative MSK care.

Conclusion: Reshaping Utilization Through Design and Data

To fully unlock the potential of outpatient rehab:

• Chiropractors, whether as a profession or organized movement within a distinct group of the profession, must standardize core service delivery, clarify philosophical alignment, and better integrate with medical pathways without losing consumer loyalty.

• Physical therapists must aggressively pursue referral independence, fight for reduced authorization barriers, and raise awareness of their direct-access capabilities.

• Both professions must invest in clinically integrated networks and practice-based data strategies—like Arete—to track, prove, and advocate for their value in real-world conditions.

The future of MSK care won’t be won by marketing alone. It will be won by proving, at scale, that outpatient rehab can deliver what the system needs: faster resolution, lower cost, higher satisfaction, and better health outcomes—starting with access.

References:

(1) Low back pain care pathways – is the last provider seen more important than the first: A retrospective cohort study. David Elton, Meng Zhang. medRxiv 2022.10.27.22281624; doi: https://doi.org/10.1101/2022.10.27.22281624