Arete Healthcare LLC

Independent Practices | Shared Infrastructure | Clinician-Led Governance

Key Findings

In Pictures

The five figures below carry this paper’s central comparison: how chiropractic’s industry financial relationships and clinical-trial infrastructure compare with a broad set of physician and non-physician specialties. Each figure’s full caption and interpretation appear here only — not repeated in Results.

Figure 1. Share of 2021–2024 CMS Open Payments general-payment dollars by specialty. Across the 12 selected specialties represented in Open Payments, orthopedic surgery accounted for 53.44% of aggregate general-payment dollars, while chiropractic accounted for 0.05% ($2.28 million of $4.57 billion). Percentages represent share of dollars, not share of providers or payment transactions. Physical therapists and clinical social workers are not covered recipients under the Sunshine Act and therefore are not represented in this figure. Visualization was human generated.

Figure 2. Distribution of 2021–2024 CMS Open Payments general-payment dollars by payment type and specialty. Each bar sums to 100% of a specialty’s general-payment dollars. Chiropractic’s comparatively small payment pool was concentrated in compensation for non-continuing-education speaking/faculty services (27.7%), food and beverage (25.0%), ownership or investment interests (14.1%), long-term medical supply or device loans (13.5%), consulting fees (6.2%), and travel and lodging (5.9%). The distribution describes composition, not absolute payment volume. Visualization was human generated.

Figure 3. ClinicalTrials.gov registered studies by specialty across all available study years in the source extract. Studies were assigned using tiered keyword matching against intervention names, and a study could be counted in more than one specialty when interventions crossed specialty domains. Chiropractic matched 188 studies, compared with 3,710 for Pain Medicine, 3,027 for Physical Therapy, and 1,367 for Orthopedic Surgery. Visualization was human generated.

Figure 4. Distribution of ClinicalTrials.gov studies by lead-sponsor institution type. Institution type was derived from ClinicalTrials.gov sponsor agency class plus sponsor-name rules that distinguish universities, academic medical centers, hospitals, chiropractic colleges, industry, government, and other organizations. Chiropractic was distinctive: 36.2% of matched studies were led by chiropractic colleges, 30.9% by universities, 6.9% by government entities, 6.4% by academic medical centers, 4.8% by hospitals, and 0% by industry. Visualization was human generated.

Figure 5. ClinicalTrials.gov chiropractic studies by lead sponsor across all available study years in the source extract. Life University was the largest lead sponsor with 18 studies, followed by Northwestern Health Sciences University with 8 and Canadian Memorial Chiropractic College with 6. Seventy-one entities sponsored a single matched study, illustrating a dispersed sponsor base. Sponsor counts are based on the workbook provided for this analysis. Visualization was human generated.

Arete's Take

At a Glance

Open Payments scope: 2021–2024 general payments, 12 specialties with Sunshine Act coverage (PT and Clinical Social Work excluded — not covered recipients). ClinicalTrials.gov scope: all available study years, 15 specialty domains via non-exclusive intervention-keyword matching — a study may count in more than one specialty. Full detail in Appendix A.

Abstract

This report extends Arete Healthcare's “outlier” research theme from organizational structure and digital connectivity into two additional domains: industry financial relationships and clinical evidence-generation infrastructure. Using CMS Open Payments general-payment data for 2021–2024 and a ClinicalTrials.gov intervention-based specialty mapping, we compare chiropractic with a broad set of physician and non-physician specialties. The analyses are descriptive and intentionally separate financial exposure from research capacity; receiving more industry money is not assumed to be intrinsically beneficial, and receiving less is not assumed to be intrinsically harmful.

The pattern is nevertheless pronounced. Chiropractic accounted for only 0.05% of aggregate Open Payments general-payment dollars among the selected covered specialties during 2021–2024. In 2024, chiropractic general payments equaled about $25 per active Medicare provider. In ClinicalTrials.gov, 188 studies matched chiropractic interventions across all available years, versus 3,027 for Physical Therapy, 3,710 for Pain Medicine, and 1,367 for Orthopedic Surgery. Only three chiropractic studies were Phase 3/4, none were industry-led, and more than one-third were led by chiropractic colleges — difference is not deficiency here: chiropractic colleges leading their own trials is evidence of a self-sustained research pipeline, not only an absence of outside sponsorship.

Taken together with Arete's prior Organizational Outlier and Digital Outlier analyses, these findings describe a profession that is not simply organized differently from much of healthcare. It also sits at the edge of the commercial and research infrastructures that often connect clinical disciplines to technology development, multicenter evidence generation, academic medical centers, and industry-sponsored R&D. The practical question is not whether chiropractic should seek more industry payments. It is whether the profession has enough diversified, scalable research infrastructure to generate and validate evidence at the pace required for deeper integration into contemporary healthcare.

Methods

Study Design

Two independent descriptive analyses were combined into one report because they address related but distinct forms of external connectivity. The Open Payments analysis measures financial relationships between covered recipients and manufacturers or group purchasing organizations. The ClinicalTrials.gov analysis measures registered study activity and the institutional infrastructure behind that activity. Neither dataset directly measures quality of care, appropriateness of treatment, or clinical outcomes. Every headline figure in this report was independently recomputed from the underlying Mimilabs-sourced workbooks rather than carried forward from any prior draft; reconciliation detail is maintained in the internal AI Assistance and Reproducibility Record under the Arete Research Library Governance Framework.

Open Payments Data and Specialty Mapping

Open Payments data were drawn from the CMS Open Payments general-payment table through Mimilabs. The analysis was restricted to program years 2021–2024 so that the numerator data aligned with the most recent available Medicare Physician & Other Practitioners denominator through 2024. Providers were mapped to selected specialties using covered-recipient primary type for chiropractors, optometrists, podiatrists, nurse practitioners, and physician assistants, and covered-recipient specialty strings for physician specialties. Psychiatry required terminal-segment and subspecialty matching because the Open Payments taxonomy nests Psychiatry under the parent category “Psychiatry & Neurology.”

Physical Therapy and Clinical Social Work were not included in the Open Payments comparison because they are not covered-recipient categories under the Sunshine Act for this general-payment dataset. Consequently, the Open Payments figures compare 12 specialties, whereas the ClinicalTrials.gov analysis compares 15.

Open Payments Measures

• Aggregate payment dollars and each specialty's share of the selected-specialty total for 2021–2024.

• Distribution of each specialty's payment dollars across CMS nature-of-payment categories.

• Providers receiving at least one general payment, using distinct covered-recipient NPI by year.

• Active Medicare providers, defined as distinct NPIs rendering at least one Medicare Part B fee-for-service service in the corresponding year.

• Dollars per active Medicare provider, calculated as total general-payment dollars divided by active Medicare providers. This is a normalized intensity measure and should not be interpreted as the typical payment received by an individual clinician.

ClinicalTrials.gov Data and Specialty Mapping

ClinicalTrials.gov data were accessed through Mimilabs using the most recent source-file date in the interventions, studies, and sponsors tables. ClinicalTrials.gov does not record the specialty of the investigator or treating clinician. The analysis therefore used tiered keyword matching against intervention names to identify studies relevant to each specialty's clinical domain. Specialty-named interventions formed the highest-specificity tier; specialty-defining procedures formed a second tier; and selected condition- or drug-based terms were used for broader specialties such as Internal Medicine and Family Medicine.

A study could be assigned to more than one specialty when its interventions crossed domains. The source analysis therefore reports both total matched studies and an exclusive-study count, along with an overlap percentage. Chiropractic, Physical Therapy, Orthopedic Surgery, Pain Medicine, Optometry, Podiatry, Psychiatry, and Clinical Psychology were classified as high-confidence mappings because their interventions are commonly named directly or through specialty-defining procedures. Internal Medicine, Family Medicine, and Physician Assistant mappings were classified as lower confidence because the relevant interventions are less specialty-specific.

Sponsor and Institution Classification

Lead sponsors were classified using the ClinicalTrials.gov agency_class field and sponsor-name rules. The generic OTHER category was decomposed into University, Academic Medical Center, Hospital, Chiropractic College, and Other. Industry, NIH/Federal/other government, and chiropractic colleges were classified before more general university or hospital rules so that professional schools using “University” in their names — Life University, Parker University, University of Western States, and similar institutions — were not automatically counted as conventional research universities. Collaborator names were also aggregated as a proxy for funders or supporting organizations, although that field is voluntary and incomplete and should not be treated as a comprehensive funding registry.

Results

A note before the numbers: difference is not deficiency. Lower industry-payment exposure and a smaller registered-trial footprint are not, on their own, evidence of a weaker profession — they may equally reflect a narrower reliance on drugs, implants, and other commercially developed technologies than device- or pharmaceutical-intensive specialties. The results below describe where chiropractic sits relative to comparator specialties; the interpretive question of what that position means is addressed directly in Discussion and in Arete's Take.

Open Payments: Chiropractic Occupies the Extreme Low End of Industry Financial Exposure

Across the selected Open Payments specialties, general payments totaled approximately $4.57 billion during 2021–2024. Orthopedic Surgery alone accounted for $2.44 billion, or 53.44% of the total. Nurse Practitioners accounted for 10.57%, Internal Medicine 9.19%, Psychiatry 8.07%, and Physician Assistants 5.41%. Chiropractic accounted for $2.28 million, or 0.05% (Figure 1). On an aggregate-dollar basis, Orthopedic Surgery received approximately 1,069 times the chiropractic total over the four-year period.

The normalized 2024 measure tells the same story without relying solely on total specialty size. General payments equaled approximately $30,268 per active Medicare orthopedic surgeon, $4,610 per Pain Medicine provider, $3,947 per psychiatrist, $2,638 per podiatrist, $1,279 per Internal Medicine provider, $743 per PM&R provider, and $25 per active Medicare chiropractor (Appendix A, Table A1). Among chiropractors, 1,853 distinct NPIs received at least one general payment in 2024, equal to 5.9% of the 31,446 active Medicare chiropractic providers used as the denominator.

The content of the chiropractic payment pool also differs from the high-dollar commercial patterns visible in specialties with device or pharmaceutical pipelines. Chiropractic dollars were most commonly attributable to non-CE faculty/speaker compensation (27.7%) and food and beverage (25.0%). Ownership or investment interests accounted for 14.1% and long-term medical supply or device loans 13.5%, but these categories were generated by relatively small numbers of transactions and therefore should not be interpreted as broad-based engagement. Consulting fees represented 6.2% and travel and lodging 5.9% (Figure 2). By contrast, orthopedic surgery was dominated by royalty/license payments, while several primary-care and advanced-practice specialties were dominated by high-volume food-and-beverage payments.

ClinicalTrials.gov: The Evidence-Generation Gap Is Larger Than the Payment Gap Alone Suggests

The ClinicalTrials.gov analysis identified 188 chiropractic-relevant registered studies across all available years in the source extract. That count was far below Pain Medicine (3,710), Physical Therapy (3,027), Orthopedic Surgery (1,367), PM&R (924), and Optometry (655) (Figure 3). The comparison is not a direct measure of research quality, but it is an informative measure of the scale of registered intervention research associated with each specialty's clinical domain.

The gap is more pronounced in recent years. From 2020 forward, 77 chiropractic studies were registered compared with 1,987 Physical Therapy studies, 2,174 Pain Medicine studies, and 577 Orthopedic Surgery studies. Physical Therapy therefore had approximately 25.8 times as many recent matched studies as chiropractic, compared with approximately 16.1 times as many across all available years. This pattern is consistent with a relative widening of the study-volume gap, although differences in intervention naming, research culture, and the types of questions appropriately registered in ClinicalTrials.gov limit causal interpretation.

Late-phase research was particularly limited. Only three chiropractic studies were classified as Phase 3 or Phase 4, compared with 469 Pain Medicine studies, 74 Physical Therapy studies, and 72 Orthopedic Surgery studies (Appendix A, Table A2). Many non-drug or behavioral studies legitimately carry no phase designation, so Phase 3/4 counts should not be used as a universal measure of methodological quality. They do, however, illustrate the limited presence of chiropractic interventions in the late-stage drug/device trial framework used by commercially intensive specialties.

A Distinct Sponsor Infrastructure

Chiropractic was also unusual in who led its studies. Chiropractic colleges were the lead-sponsor institution type for 36.2% of matched studies, universities for 30.9%, government entities for 6.9%, academic medical centers for 6.4%, hospitals for 4.8%, other organizations for 14.9%, and industry for 0% (Figure 4). No other specialty in the comparison relied on profession-specific training institutions for a comparably large share of study leadership — read one way, that is a gap relative to specialties with large academic-medical-center pipelines; read another, it is evidence that the profession has built and sustained its own research infrastructure rather than depending on one.

The sponsor distribution was broad but shallow. The workbook identifies 103 unique chiropractic lead sponsors across 188 studies. Life University was the largest with 18 studies, Northwestern Health Sciences University had 8, and Canadian Memorial Chiropractic College had 6 (Figure 5). Logan College of Chiropractic and Southern California University of Health Sciences each led 2 studies. Seventy-one entities led a single matched study. This pattern is consistent with a fragmented research network: many institutions participate, but few appear to have the scale to sponsor a sustained portfolio of registered trials. It is also, notably, a pipeline the profession runs itself — the leading sponsors here are chiropractic-college research programs, not commercial or third-party sponsors, which is a different kind of infrastructure question than an absence of one.

Collaborator data show that some chiropractic research is supported by external organizations, including NCCIH, HRSA, NCMIC-related entities, and other partners. However, 114 of 188 chiropractic studies in the workbook — 60.6% — had no collaborator/funder listed. Because collaborator reporting is voluntary and incomplete and may represent partners as well as funders, this absence cannot be interpreted as proof that the studies were self-funded. It does mean that ClinicalTrials.gov alone does not provide a complete account of chiropractic research financing.

From Organizational and Digital Outlier to Funding Outlier

Arete's prior outlier analyses focused on two forms of separation. The Organizational Outlier documented a chiropractic delivery system dominated by small, single-specialty practices with limited participation in scaled multi-specialty organizations. The Digital Outlier analysis examined technology and interoperability patterns that further separate chiropractic from the shared digital infrastructure increasingly common elsewhere in healthcare. The present analysis adds a third dimension: chiropractic also has unusually little contact with the financial and research systems that surround many other clinical disciplines.

The word “funding” needs care. CMS Open Payments general payments are not synonymous with research funding, and low general-payment exposure can be viewed positively from a conflict-of-interest perspective. Indeed, a profession with few drugs, implants, or proprietary procedures would be expected to have a smaller manufacturer-payment footprint. Chiropractic's limited procedure set and concentration on a narrower group of musculoskeletal conditions make some of the observed difference unsurprising.

The more consequential signal is the convergence of multiple forms of isolation. A discipline can have low commercial payments yet still participate in large academic networks, multicenter trials, federal research programs, technology development, and health-system evidence generation. Chiropractic's ClinicalTrials.gov profile suggests that this broader infrastructure is also limited: fewer studies, almost no late-phase work, no industry-led studies in the extract, limited academic-medical-center leadership, and heavy reliance on chiropractic colleges for study sponsorship.

Why the Distinction Matters

Industry engagement and clinical evidence generation serve different functions, but both can create connective tissue between a profession and the wider healthcare ecosystem. Commercial R&D can bring capital, specialized trial operations, regulatory expertise, and multicenter execution. Academic medical centers and major universities bring biostatistics, grant infrastructure, research faculty, trainees, institutional review capacity, and access to large patient populations. A profession that is weakly connected to both systems may have fewer opportunities to test interventions at scale, replicate findings across institutions, influence guideline development, or participate in cross-disciplinary research agendas.

This matters beyond academic infrastructure. Payers and health plans routinely reference the depth and phase of registered clinical-trial evidence when setting medical-necessity criteria, coverage policies, and utilization-management thresholds, and legislative or regulatory bodies weighing scope-of-practice or reimbursement questions often ask what the trial literature shows. A specialty with fewer registered studies and almost no late-phase trials may face a structural disadvantage in these determinations that is independent of the actual clinical effectiveness of its interventions — an evidence-availability gap can look, to a payer or regulator applying a standard evidence hierarchy, like an effectiveness gap even where it is not. That distinction is one association, advocacy, and payer-relations staff may find useful to make explicitly when engaging on coverage or guideline questions.

This does not imply that chiropractic should imitate device-intensive specialties or seek manufacturer relationships for their own sake. The more defensible strategic objective is diversified research capacity: stronger federal and foundation grant pipelines, deeper partnerships with research universities and academic medical centers, multicenter practice-based research infrastructure, common data models, and the operational ability to register, execute, and publish larger pragmatic studies. In that frame, the funding outlier is less about dollars flowing to individual clinicians and more about the institutional infrastructure available to produce credible evidence.

An Opportunity for Practice-Based Research Networks

The chiropractic profession's decentralized practice structure may also be part of the solution. Traditional academic research models are difficult to scale when most care is delivered through small independent practices. A practice-based research network can connect those practices through common governance, data infrastructure, standardized protocols, and shared research operations without requiring consolidation into a single health system. That architecture is directly responsive to the structural conditions identified across the outlier series: it creates a research layer over an otherwise fragmented delivery system.

For Arete, this observation is especially relevant to the development of the Arete Practice-Based Research Network (PBRN), accepted into the AHRQ PBRN registry (ID U245936). The present analysis does not evaluate the PBRN and should not be read as evidence of its effectiveness. It does, however, identify the ecosystem gap the PBRN is intended to address: the absence of scalable infrastructure capable of turning distributed chiropractic and outpatient musculoskeletal practice into a coordinated platform for data generation, prospective study participation, and external academic collaboration.

Key Limitations

• Open Payments is not research funding. The analysis uses the general-payment table. It excludes the separate Open Payments research-payment table, payments to teaching hospitals, and other financial relationships outside the selected data source. The paper therefore describes industry financial relationships, not total research investment.

• Sunshine Act coverage is incomplete across the comparator set. Physical therapists and clinical social workers are not represented as covered recipients in the Open Payments general-payment comparison, so the Open Payments and ClinicalTrials.gov specialty sets are not identical.

• Open Payments specialty and Medicare denominator taxonomies do not align perfectly. Open Payments uses NUCC-style recipient specialty classification, while the Medicare denominator uses CMS rendering-provider specialty categories. Several specialties can therefore show more payment-recipient NPIs than active Medicare providers. For those specialties, penetration rates should be treated as relative intensity indices rather than literal proportions. Chiropractic does not exhibit this >100% issue in the reported years.

• Medicare active-provider counts are a normalization denominator, not the entire workforce. Providers who do not bill Medicare fee-for-service, including clinicians who serve only younger populations, Medicare Advantage patients, or non-Medicare populations, are excluded.

• ClinicalTrials.gov does not identify investigator specialty. Specialties were inferred from intervention names. This approach is highly specific for some disciplines and much less specific for broad prescribing specialties such as Internal Medicine and Family Medicine — the 8,310 Internal Medicine count, for example, reflects studies using Internal-Medicine-associated drug interventions, not studies conducted by internists specifically.

• Study counts are non-exclusive. A single study can be relevant to more than one specialty. The source analysis reports overlap, but the aggregate counts should not be summed across specialties as if they represented unique studies.

• Registered study volume is not equivalent to evidence quality. A large number of registered studies does not guarantee high-quality methods, completed enrollment, publication, replication, or clinically important findings. Conversely, meaningful observational, health-services, or non-registered research may not appear in this analysis.

• Phase is an imperfect cross-specialty comparator. Phase designations are most applicable to drug and device development. Many rehabilitation, behavioral, and pragmatic studies legitimately have no phase designation.

• Sponsor institution type is derived. Academic Medical Center, Hospital, University, Chiropractic College, and Other categories were inferred from sponsor-name patterns. Some institutions may be misclassified, particularly organizations with complex names or mixed missions.

• Collaborator names are an incomplete proxy for funders. ClinicalTrials.gov does not require a comprehensive funding record in the collaborator field. Missing collaborator names therefore do not establish absence of external support.

• The two analyses use different timeframes by design. Open Payments is restricted to 2021–2024 to align with the Medicare denominator. ClinicalTrials.gov results use all available study years in the source extract, with a separate 2020-present comparison.

• Pre-2007 ClinicalTrials.gov studies are underrepresented. Registration became mandatory for most U.S. trials only in 2007 (FDAAA), which particularly affects older chiropractic research relative to the profession's actual research history.

Disclosures and Publication Status

Status. Final. This manuscript completed DAWG review of Findings under the Arete Research Library Governance Framework and is approved for release.

Classification and commercial interest. This work is classified as a public-data industry-relationships and research-infrastructure analysis under the Arete Research Library Governance Framework (§2); it is not PBRN-sponsored human-subjects research. This analysis was produced by Arete Healthcare without external funding; Arete supports independent outpatient chiropractic practices and has a commercial and professional interest in the research and evidence-generation infrastructure available to those practices, including the Arete Practice-Based Research Network.

Data provenance. Source analyses, SQL, and data workbooks were provided from Mimilabs-based extracts of CMS Open Payments, CMS Medicare Physician & Other Practitioners, and ClinicalTrials.gov. Every headline statistic in this report was independently recomputed from the underlying workbooks rather than carried forward from a prior draft on its authority (Governance Framework §9); reconciliation and query-reference detail are maintained in the internal AI Assistance and Reproducibility Record under the Arete Research Library Governance Framework.

AI use disclosure. ChatGPT (OpenAI) produced the initial manuscript, assisting with synthesis of the two analyses, drafting, numerical cross-checking against the supplied workbooks, and figure-caption drafting. Claude (Anthropic, Claude Sonnet 5) independently rebuilt the manuscript from the source data and current governance artifacts per the Fresh-Rebuild Process, including independent recomputation of every headline statistic, and subsequently incorporated Document-Owner-directed editorial revisions to Results and Discussion prose. “Arete's Take” was supplied verbatim by the Document Owner; no AI system drafted or edited that content. Mimilabs' AI-assisted tooling was used in the source analytic workflow described in the internal AI Assistance and Reproducibility Record. AI systems do not constitute the required DAWG or independent human review; every factual assertion and calculation received responsible human verification before publication.

Arete perspective. “Arete's Take” reflects the Document Owner's own institutional interpretation, supplied verbatim and not drafted by AI (Governance Framework §12).

Recommended citation. Arete Healthcare. The Funding Outlier: Industry Financial Relationships and Clinical Trial Infrastructure in Chiropractic. Arete Original Research, Version 1.4. Published August 29, 2026. Report ARETE-OR-2026-008; Dataset ARETE-DATA-2026-008. https://doi.org/10.13140/RG.2.2.17206.87366

References

1. Centers for Medicare & Medicaid Services. Open Payments Program — General Payments data. https://openpaymentsdata.cms.gov/

2. Centers for Medicare & Medicaid Services. Medicare Physician & Other Practitioners public-use data. https://data.cms.gov/

3. National Library of Medicine. ClinicalTrials.gov. https://clinicaltrials.gov/

4. Mimilabs source tables used in this analysis: mimi_ws_1.openpayments.general; mimi_ws_1.datacmsgov.mupphy; mimi_ws_1.clinicaltrialsgov.interventions; mimi_ws_1.clinicaltrialsgov.studies; mimi_ws_1.clinicaltrialsgov.sponsors.

5. Arete Healthcare. The Organizational Outlier: Chiropractic Group Size & Multi-Specialty Scaling. Prior Arete Original Research in the outlier series (ARETE-OR-2026-001).

6. Arete Healthcare. The Digital Outlier: ONC EHR Certification and QPP Promoting Interoperability Adoption in Chiropractic. Prior Arete Original Research in the outlier series.

Appendix A — Supplemental Results Tables

Table A1. 2024 Open Payments Intensity — Selected Specialties

Recipient-to-active-provider ratios can exceed 100% for specialties affected by taxonomy mismatch (Key Limitations); dollars per active provider is used as a normalized intensity measure instead. Values independently recomputed from OpenPaymentsData.xlsx (Summary sheet).

Table A2. ClinicalTrials.gov Study Activity — Selected MSK-Adjacent Specialties

*“Chiro college-led” is a chiropractic-specific institution-type category (68 of 188 studies, 36.2%); no other specialty in this comparison has a non-zero count in this category, since it does not apply to their sponsor base. Independently recomputed from ClinicalTrialsData.xlsx (Summary and SponsorDetailForOther sheets).