In Muscatine, Iowa, a medically underserved rural area, a cohort study of health care utilization was made before and after a significant increase in medical manpower. There was a slight increase, rather than a decrease, in the use of chiropractic services associated with the growth in the physician manpower pool. The level of access to physician services was not a significant predictor of chiropractice utilization. (Am J Public Health 70: 415-417, 1980.) ed opportunities of chiropractors make rural locations relatively attractive to them."5 That is, chiropractors could have a "filling" effect by offering their services in medically underserved rural areas, with rural residents using chiropractors to fill primary care needs.We recently had the opportunity to examine whether chiropractic utilization serves as a substitute for orthodox medical services employing two surveys of medical care utilization in a rural community, before and after a dramatic increase in the number of primary care physicians. Methods IntroductionThe place of chiropractic in the delivery of personal health services is not well defined. To many in the medical community it is synonymous with quackery, but to over seven-and-a-half million Americans, chiropractors are a source of health care.' Rural residents, whose health care supply is often deficient, are among the highest users of chiropractors,1 a fact not totally explained by the higher average age and lower family incomes of rural consumers. In keeping with the reduced medical service supply, rural residents average fewer physician visits per year than their urban counterparts. [1][2][3][4] Hassinger, et al, hypothesized that the "erosion of medical and osteopathic physicians (from rural areas) results in need for personal health services, and the more limit-

Capitation is a system of reimbursement for services under which providers are paid a fixed amount per client served per time period. An experiment from April 1981 to December 1981 involved the use of a capitation system of reimbursement to pharmacies participating in the Iowa Medicaid drug program in 32 counties in Iowa. It was essential to demonstrate that cost savings were feasible and pharmacy reimbursement would be adequate before the capitation experiment was begun. An assessment of this issue was developed using simulation and data base management techniques. The positive results of this assessment gave evidence that cost savings due to capitation potentially could be realized by both the Medicaid drug program and pharmacists during the experiment.

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