Study Design Retrospective study. Background Alternative models of care that allow patients to choose direct access to physical therapy have shown promise in terms of cost reduction for neck and back pain. However, real-world exploration within the US health care system is notably limited. Objectives To compare total claims paid and patient outcomes for patients with neck and back pain who received physical therapy intervention via direct access versus medical referral. Methods Data were accessed for patients seeking care for neck or back pain (n= 603) between 2012 and 2014, who chose to begin care either through traditional medical referral or direct access to a physical therapy-led spine management program. All patients received a standardized, pragmatic physical therapy approach, with patient-reported measures of pain and disability assessed before and after treatment. Patient demographics and outcomes data were obtained from the medical center patient registry and combined with total claims paid calculated for the year after the index claim. Linear mixed-effects modeling was used to analyze group differences in pain and disability, visits/time, and annualized costs. Results Patients who chose to enter care via the direct-access physical therapy-led spine management program displayed significantly lower total costs (mean difference, 1543;95%confidenceinterval: 51, 3028;P=.04)thanthosewhochosetraditionalmedicalreferral.Patientsinbothgroupsshowedclinicallyimportantimprovementsinpainanddisability,whichweresimilarbetweengroups(P>.05).ConclusionTheinitialpatientchoicetobegincarewithaphysicaltherapistforbackorneckpainresultedinlowercostofcareoverthenextyear,whileresultinginsimilarimprovementsinpatientoutcomesatdischargefromphysicaltherapy.Thesefindingsaddtotheemergingliteraturesuggestingthatpatients'choicetoaccessphysicaltherapythroughdirectaccessmaybeassociatedwithlowerhealthcareexpendituresforpatientswithneckandbackpain.LevelofEvidenceEconomicanddecisionanalyses,level4.JOrthopSportsPhysTher2018;48(2):63–71.Epub26Oct2017.doi:10.2519/jospt.2018.7423