Articles by JCS
To: Editor, USA Today
From: JC Smith, MA, DC
RE: Response to Some chiropractors making big Medicare-paid adjustments
The recent front-page article, Some chiropractors making big Medicare-paid adjustments by Jayne O'Donnell, Meghan Hoyer, and Yamiche Alcindor (USA TODAY, April 29, 2014), was fraught with inaccuracies that must be challenged.
As you know, their article highlighted one chiropractor in Brooklyn, Alexander Khavash, for allegedly bilking Medicare or more than $1 million in 2012. Another claim was the “…indictment of a Wichita chiropractor for a $1.3 billion fraud scheme” when, in fact, an October 18, 2013 story in The Wichita Eagle set the figure at $1.3 million.
Certainly these examples alone will raise eyebrows among readers to create a negative stereotype about chiropractors, but the writers failed to put this amount in perspective with other chiropractors and spine care providers in Medicare.
This USA Today article was prompted by the recent release of physician payment data by the Centers for Medicare & Medicaid Services (CMS) that revealed many shocking costs and important issues not mentioned in your article about chiropractic care.
AMA Gag Order on Medicare
Undoubtedly the most important omission in this article is that the AMA had prevented the release of this information for the past 35 years until a court recently lifted the AMA’s injunction concerning what monies were paid to its members.
Apparently transparency is not high on the AMA’s agenda. Considering the AMA is simply a trade association, not a branch of government, this censorship of public information about public program paid by public taxes for the public’s good is inexplicably unconscionable, yet ignored in this USA Today article. Is this not a newsworthy issue worth mentioning?
10% of What?
The Medicare data showed in 2012 there were more than 880,000 total providers, $252.4 billion in charges, and $77.4 billion in payments. The average reimbursement for the year was $87,883 per physician. More than 2,000 of those medical providers broke $2 million in Medicare receipts.
The statistics also reveal that seven MDs received more than $10 million in payments, and that three Florida ophthalmologists each billed at least $22 million. In this light, the one million allegedly paid to Dr. Khavash, while also shocking, seems pale in comparison.
The USA Today writers also misled readers when they said, “But just 600 chiropractors, including Khavash, accounted for more than 10% of the Medicare payments.” Clearly this suggests the 10% was of the total payout for all providers.
If this were true, it would equate to $7.7 billion annually when, in fact, the amount paid to all chiropractors was only $469 million, which equates to 0.61% of the Medicare budget, not 10%. This gross misrepresentation of the facts is inexcusable for a national publication and demands a retraction.
Medicare Data: Chiropractors Cheapest
The USA Today article also says, “More than 36,000 chiropractors were paid nearly $500 million by the federal government in 2012, making chiropractors one of the largest groups of Medicare providers.” Once again this was a misleading claim as “one of the largest groups of Medicare providers.” Yes, chiropractors were second in number of participants to physical therapists, but certainly not nearly the largest paid by any means as the opening sentence of the article states.
The actual average amount paid by Medicare to each chiropractor @ $13,605 is insignificant compared to the average paid to medical providers @ $87,883, another misrepresentation worth noting.
To clear the air, the comparative costs of all spine care providers were also revealed by CMS yet ignored by the writers. The following sampling compares the various spine care providers:
Provider type Average pay
At a mere $13,605, chiropractors had the lowest average pay and would still be cheapest at three times the price. Indeed, the $469 million paid to all chiropractors is trivial compared to the overall cost incurred by spine surgeries alone in Medicare @ $12.8 billion in 2011, another fact omitted in the USA Today article. 
Not only costly, spine surgeries have nearly doubled considering there were more than 465,000 spinal-fusion operations in the U.S. in 2011 compared with 252,400 in 2001. Hospital costs alone for a spine procedure average $27,568 and total costs can hit six figures for major spinal-fusion procedures.
Unfortunately, the omission of the much higher costs by the main medical rivals to chiropractors makes one wonder if the writers were truly interested in writing a balanced story on Medicare payments to spine care providers or was their intent simply to create a negative media stereotype based mostly on falsehoods against the much maligned chiropractic profession.
I suggest your writers review the Medicare stats to correct their inaccuracies as well as review my Postscript for more important aspects of the paradigm shift in spine care.
JC Smith, MA, DC
I WAS TOLD THIS LETTER WAS WAY TOO LONG FOR PUBLICATION, SO I RESIZED IT TO 250 WORDS TO MEET THE CRITERIA AT USA TODAY.
Word count: 250
To: Editor, USA Today
Date: May 8, 2014
From: JC Smith, MA, DC
RE: Response to Some chiropractors making big Medicare-paid adjustments (USA TODAY, April 29, 2014 by Jayne O'Donnell, Meghan Hoyer, and Yamiche Alcindor)
The recent front-page article, Some chiropractors making big Medicare-paid adjustments, is an interesting but inaccurate story. For example, the article stated “…indictment of a Wichita chiropractor for a $1.3 billion fraud scheme” when, in fact, an October 18, 2013 story in The Wichita Eagle set the figure at $1.3 million; a few zeros make for a big mistake.
The writers also stated: “600 chiropractors…accounted for more than 10% of the Medicare payments.” Clearly this suggests the 10% was of the total payout for all providers. If this calculation were true, it would equate to $7.7 billion annually when, in fact, the amount paid to all chiropractors was only $469 million, which equates to 0.61% of the Medicare budget, not 10%.
The article claimed chiropractors were “one of the largest groups of Medicare providers.” True, chiropractors were second in number of participants to physical therapists, but certainly not nearly the largest paid. The actual average amount paid by Medicare to each chiropractor @ $13,605 is the lowest average pay compared to the average paid to medical providers @ $87,883.
Another omission in this article that your readers might find interesting is that the AMA had lobbied to prevent the release of this Medicare information for the past 35 years until a court recently lifted the AMA’s injunction concerning what monies were paid to its members.
The story is newsworthy and by correcting the inaccuracies will provide readers with more meaningful information and fairer to chiropractors once put in an accurate perspective.
JC Smith, MA, DC
Warner Robins, GA
This USA Today article broaches many issues in spine care that need to be discussed but too lengthy for a typical letter-to-the-editor. Although not germane to the errors and omissions in the current article, I have included the issues that are relevant in this era of ‘best practices’ to improving outcomes and lowering costs in spine care that I believe the editors of USA Today should consider for future articles.
The Rest of the Story
Certainly there is a much bigger story to be told in spine care than just the one DC who allegedly abused the Medicare system. While the USA Today writers, Jayne O'Donnell, Meghan Hoyer, and Yamiche Alcindor, found one egregious chiropractor to paint a negative image of the entire chiropractic profession, they might have also looked at the costly, ineffective, addictive, and often disabling world of medical spine care to give the readers a 'fair and balanced' analysis of the entire spine care industry.
In fact, as a 35-year chiropractic practitioner and journalist, I contend the main reason why back pain is the #1 disabling condition in the nation is due to the medical war against chiropractors. Imagine if the AMA had waged a similar propaganda war against dentists, Americans’ smiles would be as bad as the spines we chiropractors see daily.
The USA Today article made no mention about the abuses of other spine care providers as mentioned by other publications.
“The effectiveness and safety of epidural administration of corticosteroids have not been established, and FDA has not approved corticosteroids for this use [back pain].”
“Pharmacists dispensed in 2010 over 101 tons of opioids like pure oxycodone and hydrocodone—equivalent to 40 5-mg Percocets and 24 5-mg Vicodins for every US resident that caused 14,800 deaths and untold addictions, including to the unborn.”
The proliferation of these ‘pill mills’ led Thomas Frieden, MD, director for CDC, to admit that physicians have supplanted street corner drug pushers as the most important suppliers of illicit narcotics.
Federal Antitrust Trial
Steven Brill spoke of the need for Obamacare to cover the high costs of medical care in his TIME article (March 4, 2013) cover story, “Bitter Pill: Why Medical Bills Are Killing Us”. I suggest the high cost of medical spine care is due to the century long boycott and defamation of chiropractors in my article, Bitter Pill: Part 2.
Not only have spine surgeons and ‘pill mills’ been proven to be bad buys in spine care, the medical association had perpetrated for nearly a century an illegal defamation campaign against chiropractors spewing their usual malicious allegations, such as ‘chiropractors are quacks,’ or ‘chiropractic is a dangerous, unproven, unscientific cult,’ in order to frighten patients.
However, when the AMA’s leadership testified in a federal court of law, they could not prove any of their salacious accusations. What was proven was that they were parroting their own propaganda.
This historic Wilk v. AMA antitrust trial occurred when four chiropractors sued the medical profession to reveal the long-time and illegal goal of the AMA’s Committee on Quackery—“to contain and eliminate the chiropractic profession.”
Simply, this medical war against chiropractors was an attempt by one trade association, the AMA, to discredit their competitors, chiropractors, in order to corner the spine care market place.
At the trial conclusion in 1987, Judge Susan Getzendanner mentioned the impact of this propaganda campaign in her opinion, indicating the real motive was money and concluded that the AMA failed to carry its burden of persuasion on the patient care defense.
“For example, in 1973, Dr. Sabatier, an AMA official, described chiropractors as rabid dogs and killers,” the judge wrote. She also pointed to another statement by Dr. Sabatier, a member of the Committee on Quackery, that “the doctor of chiropractic is stealing the young medical physician’s money.” She also noted the damage of this defamation campaign:
“The [illegal] activities of the AMA undoubtedly have injured the reputation of chiropractors generally…In my judgment, this injury continues to the present time and likely continues to adversely affect the plaintiffs [chiropractors]. The AMA has never made any attempt to publicly repair the damage the boycott did to chiropractors’ reputations.”
However, another huge revelation that came out at trial by Mr. George McAndrews, the plaintiffs’ lead counsel, was that the majority of primary care physicians were untrained in spine care, and this fact remains true today.
Inept MDs in Spine Care
Noted spine researcher at Emory, Scott Boden, MD, has admitted: “Many, if not most, primary care providers have little training in how to manage musculoskeletal disorders.”
Other experts agree that primary care physicians are typically inept in their training on musculoskeletal disorders, prone to ignore recent guidelines, and more likely to suggest spine surgery than surgeons themselves.
George McAndrews recently commented again on the real quacks in spine care in his article, When the TMA [Texas Medical Association] Looks for Quacks, It Should Search Its Own House, that was published in Dynamic Chiropractic on April 1, 2014, in which he states:
”The AMA, we now know, is interested in one thing: a monopoly over all health care delivery. I could list the many social programs the AMA has been opposed to, but suffice it to say, its goals are not lofty, its intent is not honorable and its methodology is not laudable…
Cost-effectiveness and patient satisfaction, evidence and outcomes are all clearly evident and not contested. The education and training of the DC is superior for NMS conditions, and for anyone to call the DC a quack when the very definition of Quack – a person who falsely pretends to have medical skills or knowledge – is unquestionably the medical physician, whose limited training and skills are obvious from their own tests and studies. This should cause concern about who is calling whom a quack.”
Moreover, patients don’t realize that 50% of all medical schools do not even teach one class in musculoskeletal disorders. Indeed, researchers have found that medical primary care physicians are actually the least educated to diagnose and treat musculoskeletal chronic pain problems, and only 2% of medical PCPs refer to DCs.
Many physicians suffer from what is now dubbed “professional amnesia” when they pose as experts in back pain to unknowing patients and then forget to inform patients that chiropractic care is recommended as an initial option by virtually every guideline.
If not mere forgetfulness, I see the failure to cooperate with chiropractors as ‘chirophobia’—the irrational hate and/or fear of chiropractors. After a century of hate mongering fomented by the AMA, it is to be expected that many MDs still hold a strong bias against chiropractors, just as the proverbial Jim Crow, MD, remains racist today.
“National Scandal” in Spine Care
The comparison among spine care providers is not a comparable matter of ‘six or one-half a dozen’ considering the superior outcomes and high satisfaction rates with chiropractic care.
Over the last twenty years of research, chiropractic care has been vindicated and proven to be safer, faster, cheaper, and more effective than anything the medical profession has to offer for the 85% of ‘mechanical’ back pain cases, excluding the 15% of red flags—fractures, cancers, infections, and the one-in-100 disc case unresponsive to conservative care.
While the USA Today article focused mainly on cost, the overall debate in spine care research concerns both cost and clinical-effectiveness. Without question this oversight is the most important difference in spine care providers today.
Unbeknownst to most people, back pain is the #1 disabling condition in the world with total costs in the US over $300 billion and $600 billion globally, and is only getting worse as the statistics show.
Not only is the cost rising in an alarming fashion, so is the rise of opioid drugs, epidural steroid injections, and spine surgery. From 1994 to 2007, spinal fusion surgery increased 204%, spinal injections increased 629%, and opiate use increased 423%. Most of all, the most complex type of back surgery increased 15-fold.
Richard Deyo, MD, MPH, openly admits that too many people are getting risky and expensive back surgery when more minimal approaches would work. He mentioned one strong motivation included “financial incentives involving both surgeons and hospitals.” Deyo pulled no punches when he said, “More people are interested in getting on the gravy train than on stopping the gravy train.”
Indeed, the scandal and money in spine care are both shocking. According to the Short-Term National Q3FY13 Report−Target Area Summary Report, the cost for Medical Back Problems (non-surgical) nationwide for CMS alone totaled $381,556,000 from Q4 FY 2012 to Q3 FY 2013. Spinal Fusion alone totaled $3,504,705,000 for the same fiscal period.
Both categories together totaled $3,886,261,000, (that’s $3.8 billion) which explains why CMS is taking a very close look at the huge costs for spine surgeries and hospitalization. Contributing to this waste is the cost of unnecessary lumbar spine MRIs that were deemed appropriate for only 44% of low back cases. More than half were inappropriate or of uncertain value.
Considering in 2006 the Dartmouth Institute of Health Policy suggested 30-40% of spine surgeries (and the associated tests and hospitalization costs) were unnecessary, a 40% reduction in this $3.886 billion dollar cost equates to a $1.554 billion savings for one fiscal year alone.
Indeed, more research has revealed spine fusions were costly for consumers after the surgery, too. According to Trang Nguyen, MD, fusion surgeries are “associated with significant increase in disability, opiate use, prolonged work loss, and poor return to work status.” 
Although the issues of cost, waste, and abuse in medical spine care were omitted from the USA Today article, it has not eluded the international spine research community. Mark Schoene, editor of The BACKLetter, an international spine research journal, recently summarized the research consensus when he stated: “Spinal medicine in the U.S. is a poster child for inefficient spine care.”
Mr. Schoene also admits, “such an important area of medicine has fallen to this level of dysfunction should be a national scandal. In fact, this situation is bringing the United States disrespect internationally.”
Paradigm Shift in Spine Care
In the present era of ‘best practices’ based on evidence-based guidelines to improve outcomes and lower costs, a huge paradigm shift in spine care has occurred that unfortunately remains outside the scope of lay newspaper articles.
Not only is medical spine care “inefficient” to say the least, most ironic is the opinion that spine surgery has been shown to be based on an outdated theory. For decades the common medical diagnoses for back pain were either ‘pulled muscles’ or ‘bad discs,’ but research now has thoroughly debunked this medical ruse.
This revelation began in 1990 by Dr. Scott Boden at Emory who found ‘bad discs’ in pain-free people. Boden’s research began a paradigm shift in spine care away from the pathoanatomical explanations (bad discs, bone spurs, arthritis) to the pathophysiological (bad function due to poor spinal alignment, compression, inflexibility, and lack of core strength).
In other words, what matters is how the spine functions, not what it looks like on an MRI or x-ray image. Indeed, the ‘bad disc’ theory has been chided by Dr. Deyo as irrelevant as “finding grey hair” and he has dubbed ‘bad discs’ as “incidentalomas” since they also occur in pain-free people.
CMS and some private payors, such as the North Carolina BC/BS, now realize that ‘bad discs’ are “red herrings,” but remains the primary sales pitch by spine surgeons eager to sell disc fusions to gullible patients. Fortunately, some Medicare Accounting Contractors have denied payment for spine fusions if conservative care like chiropractic manipulation is not done beforehand. In fact, the Palmetto MAC denied 65% of spine fusions in 2012.
If not ‘bad discs,’ then what causes most back pain? Two studies by Drs. Donald Murphy and Eric Hurwitz found joint dysfunction was the cause of neck pain in 69% of cases and the cause of low back pain (lumbar and sacroiliac) in 50% of patients, which explains why any treatment that restores joint play works best, such as manipulation, decompression, flexibility exercises, and therapeutic massage.,
Considering there are over 300 joints in the spinal column according to Gregory D. Cramer, PhD, it should come as no surprise that joint dysfunction is the primordial problem in the majority of back pain cases considering the lifetime of falls, care accidents, sport injuries, on-the-job injuries, and prolonged sitting in front of computers.
Unfortunately, this paradigm shift in spine diagnosis has been kept secret by the media’s medical newsmen like neurosurgeon Sanjay Gupta @ CNN for obvious reasons—it would decrease the ungodly amount of money he and other spine surgeons make, i.e., $800,000 on the average for surgical fees not including kickbacks that often exceed a million dollars per surgeon from Big Pharma, MRI vendors, hospitals for filling beds, and manufacturers of medical titanium screws they put into patients' spines.
The Evidence is Growing
Just as the AMA gagged the release of Medicare payments for the past 35 years, it also has ignored the release of the ‘best practices’ for low back pain for the past twenty years.
In 1994, the Agency of Health Care Policy and Research (AHCPR), an agency of the U.S. Public Health Service, conducting the most thorough investigation ever done into the epidemic of acute low back pain in adults. This 20+ member panel of experts vindicated chiropractic care as the initial “proven treatment” for low back pain.
Instead of embracing this evidence-based guideline, the medical society fought to destroy the AHCPR, unwilling to relinquish this huge spine care market to chiropractors.
In fact, there is now more evidence supporting chiropractic spine care than medical spine care for the majority of spine-related cases. For example, a recent study in Washington State compared workers suffering from low back injuries with the same diagnostic codes. The results were shocking: only 1.5% of patients who first saw a chiropractor underwent surgery compared to 42.7% of patients who saw a surgeon first.
A similar study by researchers reviewed records from 1,450 patients in the Ohio Bureau of Workers’ Compensation database who had diagnoses of disc degeneration, disc herniation or radiculopathy, a nerve condition that causes tingling and weakness of the limbs. Half of the patients had surgery to fuse two or more vertebrae in hopes of curing low back pain. The other half had no surgery, even though they had comparable diagnoses.
After two years, just 26% of those who had surgery had actually returned to work compared to 67% of patients who didn’t have surgery. Another troubling finding was the 41% increase in the use of opiate painkillers in those who had surgery.
“The study provides clear evidence that for many patients, fusion surgeries designed to alleviate pain from degenerating discs don’t work,” said the study’s lead author Dr. Trang Nguyen, a researcher at the University of Cincinnati College of Medicine.
Today, half of back care in the US is now delivered by chiropractors alone, which explains why chiropractors should be considered “America’s primary spine care providers” in this pandemic of back pain due to their superior training in spine-related conditions and their cost-effective outcomes and patient satisfaction.
The growing number of comparative research studies cannot be clearer that chiropractic stands at the top of cost-effective spinal treatments. Even the North American Spine Society, the bastion of the uber-wealthy spine surgeons, has finally stated spine fusion should be “viewed as a last resort and should be considered only after other conservative (nonsurgical) measures have failed.” 
In the October, 2010, edition of The Spine Journal, researchers confirmed that spinal manipulation should be considered before surgery:
“Several RCTs (random controlled trials) have been conducted to assess the efficacy of SMT (spinal manipulative therapy) for acute LBP (low back pain) using various methods. Results from most studies suggest that 5 to 10 sessions of SMT administered over 2 to 4 weeks achieve equivalent or superior improvement in pain and function when compared with other commonly used interventions…”
The remaining obstacle is disseminating this good news about chiropractic care to the public via the media that has historically been unduly influenced by the AMA with “Quack Packs” (misinformation about chiropractors disseminated to editors, school counselors, politicians) as well as by pharmaceutical sponsors that have no interest in promoting non-drug solutions for back pain.
As Mr. McAndrews commented on the antics of the AMA:
“The issue simply is that the AMA has in the past, and will in the future, continue to be one of the major causes of, not solutions for, the health care crisis in America. By its power and influence, the AMA has managed to "contain and eliminate" lower-cost and more effective health care providers from offering services that would impact the AMA directly as competition in health care delivery.”
Other Benefits of Chiropractic Care
The USA Today article also failed to mention that chiropractors also contribute by keeping other Medicare medical costs lower. In a study by the well-known Washington, DC-based firm, Muse & Associates, Medicare beneficiaries who had chiropractic care had an average payment of $4,426 for all Medicare services. Those who had other types of medical care had an average of $8,103 payment for all Medicare services.
In a Congressionally-mandated pilot project conducted from April, 2005, to March, 2007, Medicare patients also gave a high rate of satisfaction with the care they received from doctors of chiropractic. When asked to rate their satisfaction on a 10-point scale, 87% of patients in the study gave their chiropractor a level of 8 or higher, and 56% of those patients rated their chiropractor with a perfect 10.
After a century-long war by political medicine, the facts are emerging in favor of chiropractors. Anthony Rosner, PhD, testified in 2003 before The Institute of Medicine: “Today, we can argue that chiropractic care, at least for back pain, appears to have vaulted from last to first place as a treatment option.”
I urge the editors @ USA Today to consider a ‘fair and balanced’ article along the perspective I’ve mentioned to undo the damage of the negative media stereotype fomented by its latest article. A few years ago I wrote an article printed in the USA Weekend edition that you might like to review, The Medical War Against Chiropractors, about the historical and contemporary issues in spine care.
 Peter Eisler, Meghan Hoyer and Alex Beall, 7 doctors got more than $10M from Medicare in 2012, USA TODAY April 9, 2014
 Medicare data cast spotlight on most prolific spinal surgeons by Joe Carlson @ Modern Healthcare on April 24, 2014.
 Medicare data cast spotlight on most prolific spinal surgeons by Joe Carlson @ Modern Healthcare on April 24, 2014.
 Centers for Disease Control and Prevention Press Release, CDC Vital Signs: Overdose of Prescription Opioid Pain Relievers—United States, 1999-2008; 2011: www.cdc.gov/media/releases/2011/t1101_prescription_pain_relievers.html.
 Wilk et al v AMA et al., US District Court Northern District of Illinois, No. 76C3777, Susan Getzendanner, presiding judge; Judgment dated August 27, 1987.
 S Boden, et al. “Emerging Techniques For Treatment Of Degenerative Lumbar Disc Disease,” Spine 28(2003):524-525.
 Elizabeth A. Joy, MD; Sonja Van Hala, MD, MPH, “Musculoskeletal Curricula in Medical Education-- Filling In the Missing Pieces, The Physician And Sports Medicine,” 32/ 11 ( November 2004).
 PB Bishop et al., “The C.H.I.R.O. (Chiropractic Hospital-Based Interventions Research Outcomes) part I: A Randomized Controlled Trial On The Effectiveness Of Clinical Practice Guidelines In The Medical And Chiropractic Management Of Patients With Acute Mechanical Low Back Pain,” presented at the annual meeting of the International Society for the Study of the Lumbar Spine Hong Kong, 2007; presented at the annual meeting of the North American Spine Society, Austin, Texas, 2007; Spine, in press.
 SS Bederman, NN Mahomed, HJ Kreder, et al. In the Eye of the Beholder: Preferences Of Patients, Family Physicians, and Surgeons for Lumbar Spinal Surgery,” Spine 135/1 (2010):108-115.
 Weiner SS, Weiser SR, Carragee EJ, Nordin M. Managing nonspecific low back pain: Do nonclinical patient characteristics matter? Spine 2011; 36:1987-1994.
 AD Woolf, B Pfleger, “Burden of Major Musculoskeletal Conditions,” Bull World Health Organ 81/09 (2003):646-656
 Matzkin E, Smith MD, Freccero DC, Richardson AB, Adequacy of education in musculoskeletal medicine. J Bone Joint Surg Am 2005, 87-A:310-314
 Anthony Rosner, PhD, “Evidence or Eminence-Based Medicine? Leveling the Playing Field Instead of the Patient,” Dynamic Chiropractic, 20/25 (November 30, 2002)
 J Silberner, “Surgery May Not Be The Answer To An Aching Back,” All Things Considered, NPR (April 6, 2010)
 Joanne Silberner, “Surgery May Not Be The Answer To An Aching Back,” All Things Considered, National Public Radio, Melissa Block, host. April 6, 2010
 “New Study Demonstrates A Three-Fold Increase N Life-Threatening Complications With Complex Surgery,” The BACKLETTER, 25/6 (June 2010):66
 Reed Abelson, “Financial Ties Are Cited as Issue in Spine Study,” NY Times, January 30, 2008
 Half of MRI Scans Unnecessary, BackLetter. 28(8):96, August 2013.
 Elliott Fisher, MD, on the CBS Evening News, “Attacking Rising Health Costs,” June 9, 2006.
 Nguyen TH, Randolph, DC, et al. Long-term outcomes of lumbar fusion among workers' compensation subjects: an historical cohort study. Spine, Feb. 15, 2011;36(4):320-331.
 The BACKPage editorial, vol. 27, No. 11, November 2012.
 US Spine Care System in a State of Continuing Decline?, The BACKLetter, vol. 28, #10, 2012, pp.1
 SD Boden, DO Davis, TS Dina, NJ Patronas, SW Wiesel, “Abnormal Magnetic-Resonance Scans of the Lumbar Spine in Asymptomatic Subjects: A Prospective Investigation,” J Bone Joint Surg Am. 72 (1990):403–408.
 Deyo RA. Conservative therapy for low back pain: distinguishing useful from useless therapy. Journal of the American Medical Association, 1983;250:1057-62.
 DR Murphy, Clinical Reasoning in Spine Pain volume 1, Primary Management of Low Back Disorders Using the CRISP Protocols © Donald Murphy 2013, p. viii
 Todd Schuck, The Future of Spine Surgery: Pervasive Scrutiny & Shifting Trends Create Uncertainty for Inpatient Spine Procedures, Senior Director-Business Development, Specialty Healthcare Advisers | Monday, 13 January 2014
 Donald R Murphy and Eric L Hurwitz, Application of a diagnosis-based clinical decision guide in patients with neck pain, Chiropractic & Manual Therapies 2011, 19:19
 Donald R Murphy and Eric L Hurwitz, “Application of a diagnosis-based clinical decision guide in patients with low back pain,” Chiropractic & Manual Therapies 2011, 19:26
 Greg Cramer, PhD, Dean of Research, National University of Health Sciences, personal communication, April 29, 2009
 “Highest-Paid U.S. Doctors Get Rich with Fusion Surgery Debunked by Studies” by Peter Waldman and David Armstrong, Bloomberg News, Dec. 30, 2010
 Bigos et al. US Dept. of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, Clinical Practice Guideline, Number 14: Acute Low Back Problems in Adults AHCPR Publication No. 95-0642, (December 1994)
 Keeney BJ, Fulton-Kehoe D, Turner JA, Wickizer TM, Chan KC, Franklin GM., Early Predictors of Lumbar Spine Surgery after Occupational Back Injury: Results from a Prospective Study of Workers in Washington State.,Spine (Phila Pa 1976). 2012 Dec 12.
 Nguyen TH, Randolph, DC, et al. Long-term outcomes of lumbar fusion among workers' compensation subjects: an historical cohort study. Spine, Feb. 15, 2011;36(4):320-331
 Should Back Pain Patients Consider More Nonmedical Care? The BACKPage, vol. 28, #10, 2013, p. 120
 Donald R Murphy, Brian D Justice, Ian C Paskowski, Stephen M Perle, Michael J Schneider, The Establishment of a Primary Spine Care Practitioner and its Benefits to Health Care Reform in the United States, Chiropractic & Manual Therapies 2011, 19:17
 David Chapman-Smith, Cost-Effectiveness Revisited, The Chiropractic Report, November 2009 Vol. 23 No. 6
1 Choudhry N, Milstein A (2009) Do Chiropractic Physician Services for Treatment of Low-Back and Neck Pain Improve the Value of Health Benefit Plans? An Evidence-Based Assessment of Incremental Impact on Population Health and Total Health Care Spending. Harvard Medical School, Boston, Mercer Health and Benefits, San Francisco.
2 Manga P, Angus D et al. (1993) The Effectiveness and Cost-Effectiveness of Chiropractic Management of Low-Back Pain, Pran Manga & Associates, University of Ottawa, Ottawa, Ontario.
3 (2004) United Kingdom Back Pain Exercise and Manipulation (UK BEAM) Randomised Trial: Cost Effectiveness of Physical Treatments for Back Pain in Primary Care, BMJ;329:1381.
4 Manga P, Angus D (1998) Enhanced Chiropractic Coverage Under OHIP as a Means of Reducing Health Outcomes and Achieving Equitable Access to Select Health Services, Ontario Chiropractic Association, Toronto.
5 Stano M, Smith M (1996) Chiropractic and Medical Costs for Low-Back Care, Med Care 34:191-204.
6 Smith M, Stano M (1997) Cost and Recurrences of Chiropractic and Medical Episodes of Low-Back Care, J Manipulative Physiol Ther, 20:5-12.
7 Jarvis KB, Phillips RB et al. (1991) Cost per Case Comparison of Back Injury of Chiropractic versus Medical Management for Conditions with Identical Diagnosis Codes, J Occup Med, 33:847-52.
8 Ebrall PS (1992) Mechanical Low-Back Pain: A Comparison of Medical and Chiropractic Management within the Victorian Workcare Scheme, Chiro J. Aust 22:47-53.
9 Johnson W, Baldwin M (1996) Why is the Treatment of Work-Related Injuries so Costly? New Evidence from California, Inquiry 33:56-65.
10 Jay TC , Jones SL et al. (1998) A Chiropractic Service Arrangement for Musculoskeletal Complaints in Industry: A Pilot Study, Occup Med 48:389-95.
11 Mosley CD, Cohen IG et al (1996) Cost-Effectiveness of Chiropractic Care in a Managed Care Setting, Am J Managed Care 11:280-2.
12 Legorreta AP, Metz RD, Nelson CF et al. (2004) Comparative Analysis of Individuals with and without Chiropractic Coverage, Patient Characteristics, Utilization and Costs, Arch Intern Med 164:1985-1992.
13 Meade TW, Dyer S et al. (1990) Low-Back Pain of Mechanical Origin: Randomised Comparison of Chiropractic and Hospital Outpatient Treatment, Br Med J 300:1431-37.
14 Haldeman S, Carroll L et al. (2008) The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders; Executive Summary, Spine 33 (4S):S5-S7
15 Wolsko PM, Eisenberg DM et al. (2003) Patterns and Perceptions of Care for Treatment of Back and Neck Pain. Results of a National Survey, Spine 28(3):292-298.
16. Whedon JM, Song Y, Davis MA. Spine J., Trends in the use and cost of chiropractic spinal manipulation under Medicare Part B., 2013 Jun 14. pii: S1529-9430(13)00521-4. doi: 10.1016/j.spine.2013.05.012.
 “Spinal Fusion,” North American Spine Society Public Education Series, www.spine.org/documents/fusion
 When the Texas Medical Association Looks for Quacks, It Should Search Its Own House by George McAndrews, Esq., Dynamic Chiropractic – April 1, 2014, Vol. 32, Issue 07
"Utilization, Cost, and Effects of Chiropractic Care on Medicare Program Costs"
Muse and Associates. American Chiropractic Association 2001.
 WB Stason, G Ritter, DS Shepard, C Tompkins, TC Martin, S Lee, “Report to Congress on the Evaluation of the Demonstration of Coverage of Chiropractic Services Under Medicare,” (June 16, 2009)
 Testimony before The Institute of Medicine: Committee on Use of CAM by the American Public on Feb. 27, 2003.