Part 2 of 9: Understanding the Impact of First Provider Seen

Introduction

Musculoskeletal (MSK) conditions—like neck and back pain—are among the top three cost categories in U.S. healthcare. Yet the care pathways for these conditions vary dramatically depending on who the patient sees first. That initial provider selection has significant implications for:

• Episode costs

• Type of services delivered

• Number of providers seen

• Episode duration

• Overall outcomes

This paper explores how the initial provider seen impacts MSK care delivery, using Episode Treatment Group (ETG) data to analyze care patterns, clinical appropriateness, and cost-effectiveness. All data referenced is drawn from ETG studies by Dr. David Elton, DC, and limited to neck and back complaints for consistency. Links to these studies are included at the bottom under “References”.

What Is ETG Data?

Episode Treatment Group (ETG) data organizes all healthcare claims related to a specific condition (e.g., low back pain) into a single “episode,” capturing the full cycle of care—from the first claim to the last. The episode is defined by a “no-claim period” (typically 3-6 months) before the first claim and after. This includes office visits, imaging, and procedures performed by any provider at anytime during an “episode”. ETG methodology adjusts for severity and comorbidities, offering a fair, apples-to-apples comparison across provider types.

Services Prioritized by Provider Type

One of the clearest differentiators across disciplines is the type of care prioritized when a patient first enters the system. The table below summarizes services commonly billed in neck and back episodes, and whether those services align with American College of Physicians (ACP) clinical guidelines.

	Services Prioritized	Guideline Concordant?
Chiropractic	Manipulation (90%), Active Care (40%), Passive (30%), X-rays (25%), Manual (20%)	Yes
Physical Therapy	Active Care (85%), Manual (60%), Passive (40%), X-rays (10%), NSAIDs (8%)	Yes
Primary Care	X-rays (34%), NSAIDs (29%), Muscle Relaxants (24.4%), Opioids (19.6%), Active Care (9.6%)	No
Orthopedics	X-rays (50%), NSAIDs (35%), Muscle Relaxants (28%), Opioids (25%), Injections (15%)	No

Key Insight: Only chiropractors and physical therapists consistently deliver care that aligns with ACP guidelines. Primary care and orthopedic providers tend to default to pharmacological or interventional approaches early in the care process, increasing costs and risks.

Episode Closure: Who Resolves the Case?

A unique strength of ETG data is that it tracks which provider ends the episode—meaning no further claims are submitted for that condition afterward. This offers a valuable proxy for real-world resolution.

	When 1st Provider	When 2nd Provider	When 3rd Provider
Chiropractic	84%	73%	68%
Physical Therapy	60%	71%	63%
Primary Care	71%	66%	61%

Key Insight: Chiropractors are more likely to be the last provider seen, suggesting efficient resolution of care. PTs also show relatively high closure rates, though generally involve longer episodes.

Episode Outcomes by Initial Provider

The next table shows average costs, provider visits, duration, and downstream service utilization based on who the patient sees first. This data includes all services used during the episode, even those delivered by other providers later in the pathway.

Table 3: Outcomes by Initial Provider: Note: Data reflects full episode utilization, not services directly delivered by the initiating provider.

						Data isolated to patients that did not end up receiving surgery
	Avg ETG Cost	Avg # providers seen	Avg episode duration	% of patients that get MRI	% of patients that get opioid	% of patients that get injection	% of patients that get surgery
Chiropractor	$	1.6	93	2.5%	4.5%	1.3%	0.7%
Physical Therapist	$$$	2.6	127	17.7%	9.1%	9.5%	5.3%
Primary Care	$$	3.7	96	8.0%	20.0%	3.8%	2.7%
Orthopedics	$$$$	3.7	106	24.8%	13.0%	10.5%	9.4%

Key Insight: Patients who begin care with chiropractors or physical therapists use fewer services, receive fewer high-risk interventions, and experience lower total episode costs—with chiropractic standing out as the most efficient care pathway.

Summary

Chiropractic and physical therapy providers consistently deliver guideline-concordant, cost-effective care for neck and back pain. Yet they remain underleveraged within the healthcare system. This analysis shows:

• MSK outcomes and costs are heavily influenced by the first provider seen.

• Chiropractors and PTs deliver higher-value care than more commonly selected medical providers for MSK entry.

• ETG data offers a compelling case for shifting patient steerage and contracting strategies toward these disciplines.

But the data also raises the question: if DCs and PTs deliver such strong results, why aren’t they better positioned and reimbursed in the healthcare system?

That’s where we go next.

Next Up – Day 3:

We'll explore how fragmentation and the rise of third-party intermediaries have prevented chiropractors and physical therapists from converting clinical value into financial leverage.

Patient Education Material: You can use the following charts for patient education.

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American College of Physicians Guideline Schematic for Low Back and Neck Pain