Article can be found in full at Integrative Medicine for Chronic Pain Management
Low back pain (LBP) is the leading cause of years lost to disability worldwide, and in the United States, the leading cause of disability for Americans under 45 years of age. Individuals not only face extreme adversity in daily functioning; LBP also imposes a significant financial burden on the American economy—estimated at $100 billion—primarily attributable to lost wages and limited productivity. The incidence of LBP and price of subsequent care have been rapidly increasing, calling into question the efficacy and cost-effectiveness of current treatment approaches. A prominent aspect is the over-reliance, prolonged use, and subsequent abuse of opioids. A recent cross-sectional study of adults with chronic LBP in the United States found that opioids were the most commonly administered prescription pain medication. The use of opioid was considered long term in 75% of individuals with LBP, and prescriptions were frequently co-administered with antidepressants, benzodiazepines, and hypnotics. Although treatment of LBP is highly determined by payor coverage, opioid administration may also be influenced by socioeconomic status. Prior research has suggested that individuals of a lower socioeconomic status were 63% more likely to receive opioid therapy, as opposed to multiple non-pharmacological options that were more frequently offered to people of higher socioeconomic statuses. Recent evidence has challenged common therapies for LBP. Treating chronic LBP with opioids augments the risk of adverse outcomes, and these pharmacologic strategies have not been proven a more effective or superior to non-opioid therapies. As increasing evidence supports the clinical benefits, cost-efficacy, and safety of non-pharmacological therapies, these safer alternatives are increasingly incorporated into formal protocols for chronic pain treatments. Recommendations for non-pharmacological treatment considerations of chronic pain are now supported by the U.S. Center for Disease Control, Institute of Medicine, The National Pain Strategy, the Veterans Health Administration and Department of Defense, and the Academic Consortium for Integrative Medicine and Health.
One of the most anticipated guidelines specific to the treatment of LBP was published in 2017 by the American College of Physicians (ACP).19 The 2017 recommendations aimed to encompass available evidence for nonpharmacological approaches to pain management—including multidisciplinary rehabilitation, exercise, acupuncture, mindfulness-based stress reduction (MBSR), tai chi, yoga, progressive relaxation, biofeedback, cognitive behavioral therapy (CBT), and spinal manipulation. The recommendations also heavily emphasized the use of select nonpharmacologic treatments for the initial management of chronic LBP.
Despite multiple recommendations encouraging clinicians to initially prioritize use of nonpharmacologic treatments for the management of LBP, gaps remain between evidence-based guidelines and standard clinical practices. One of the primary factors driving this inconsistency has been attributed to payment models, which may restrict coverage for nonpharmacologic therapies. The shortfalls associated with lack of coverage may impose the greatest burden on individuals with the utmost need for coverage of non-pharmacological therapies such as those who rely primarily on the Essential Health Benefits (EHB). The EHB are the basic set of insurance benefits that most health plans sold in the individual and small group markets within each of the 50 states and the District of Columbia must cover. The EHB were created through the Affordable Care Act and require health plans in the individual and small group markets to cover 10 broad categories of health benefits: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care. Defining each of the 10 EHB categories was left to the U.S. Department of Health and Human Services, which created a process for each state and the District of Columbia to choose from one of the 10 existing plans for sale in the state and to create a benchmark plan by supplementing any categories or otherwise specified requirements that were not covered by the chosen plan. For example, there was a process for states to add maternity coverage, habilitative services, and pediatric dental and vision to the EHB benchmarks if they were not in the state’s chosen plan. Although coverage policies are a key element in utilizing health services, an information gap exists surrounding coverage of non-pharmacologic therapies for chronic LBP that constrains policy development and implementation processes.
Each states’ benefits are detailed in the certificates of coverage that are provided to enrollees in the benchmark insurance plan. Aspects provided in the benchmark plans vary by state and coverage category. The benchmark plans do not detail specific diagnoses or procedures that are covered within each category.
Individual and small group market health insurance plans must provide the services in the EHB benchmarks as a minimum. Replacements and substitutions must also be explained (eg, a plan may replace chiropractic care with acupuncture) if the visit limits are the same. While plans may provide additional benefits, significant variation is limited in the individual market because the premium subsidies that reduce the cost of insurance to enrollees only apply to the EHB packages. Although non-pharmacological strategies for managing pain have demonstrated effectiveness, the availability, affordability, and accessibility to such treatments are often limited by overarching policies. The present study aimed to review the 2017 state-by-state EHB benchmarks to assess the landscape of coverage pertaining to nonpharmacological treatments of chronic LBP. We did not pursue formal hypothesis testing or infer causal pathways surrounding official coverage policies.
The 2017 EHB benchmark plan coverage manuals and summary statements for each state and the District of Columbia published by the Centers for Medicare & Medicaid Services were electronically identified.
Authors reviewed plan information for treatments recommended by the ACP guidelines including acupuncture, biofeedback, CBT, yoga, MBSR, tai chi, progressive relaxation, massage, and manipulation. We aimed to determine coverage for multidisciplinary rehabilitation as a well as massage, tai chi, and yoga as distinct entities beyond traditionally covered physical therapies. Each EHB benchmarks for all 50 states and the District of Columbia were reviewed for coverage determination. Nonpharmacological treatments were coded via binomial classification according to coverage status. Unmentioned, unclear, or contradictory treatments were coded as “not covered.” This classification is supported by policy statements shown to exclude services not specifically mentioned by default. Additionally, plans were reviewed to determine whether:
• Mental health treatments, including CBT, were exclusively covered for disorders classified in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5VR) 26 implying lack of coverage for pain conditions (DSM-5 exclusions).
• Complementary and alternative medicine (CAM) therapies were excluded based on plan designations (CAM exclusion). This incorporated exclusion based on wording such as complementary, alternative, holistic, or nontraditional.
• Massage was covered as a distinct entity as opposed to a subcomponent of physical and manipulative therapy that may not be billed by certain providers (eg, massage therapists).
• Chronic pain or pain management in the nonacute, nonpalliative setting was mentioned as a distinct entity.
• Multidisciplinary rehabilitation was mentioned and whether it was described as a distinct multi-profession collaborative therapy. Tai chi, yoga, and MBSR were designated “not covered.” In cases where individual or group exercise, fitness, recreation, or stress management therapies were not covered, exclusions were noted.
• Other exclusions and limitations were listed for the above therapies including practitioner exclusions, visit limits, and requirements for combined therapies.
• The process for coverage determinations was consitent within policy statements.
Results – Analysis of Non-pharmacological Treatments
Manipulation, chiropractic, or osteopathic coverage determination was noted in plan information for all states. Coverage was recorded in a binary fashion regardless of the type of professional providing the treatment. Spinal manipulation was covered in 46 states and the District of Columbia. Four states (California, Colorado, Hawaii, and Oregon) did not cover manipulation. In several benchmarks, manipulation was only covered for acute musculoskeletal disorders and not a benefit when provided for chronic conditions. In most other benchmarks, there was not clear elaboration of coverage for chronic conditions.
Acupuncture coverage determination was noted in plan information for all states. Five states (Arkansas, California, Maryland, New Mexico, and Washington) consider acupuncture an EHB. In 1 additional state (Montana), acupuncture was noted as a benefit in the summary statement, despite contradiction in the official coverage manual under CAM exclusions. Based on the discrepancy, acupuncture was categorized as not covered, therefore confirming coverage in 5 total states.
Massage or massage therapy coverage determinations were identified in 37 states’ plans. Of these, 28 plans did not cover massage either explicitly (13 states) or cited it within a CAM exclusion (15 states). Two states (West Virginia and Maine) regarded massage a covered treatment but simultaneously listed it as a CAM exclusion. Three states (Illinois, Texas, and Florida) appeared to cover massage but either did not have specifics on coverage or excluded certain types of massage. Four states only covered massage if administered by physical therapists (California and New Mexico), chiropractors (Louisiana), or both practitioners (Minnesota). Given the restrictions on which health professionals were approved to administer massage, the subsequent 4 states were not included in the cohesive coverage count in states supporting massage therapy. Detailed plan information deemed massage could not be billed as a separate entity or by other licensed therapists such as massage therapists. Based on these subtle restrictions, the levels of coverage for massage as a distinct entity performed by a massage therapist are likely less than noted.
Biofeedback. Biofeedback coverage determination was evident in 30 states’ plans. Biofeedback was specifically mentioned as a covered benefit for pain management in 1 state (Arizona) plan. The remaining 29 state policies explicitly deny biofeedback for various reasons, including unconditional denial of biofeedback, denial based on biofeedback based on CAM designation, or denial based on coverage of biofeedback for medical conditions that did not include LBP. The most commonly cited, covered medical conditions were incontinence, Raynaud’s disease, and headache disorders. Of note, 1 state (Florida) plan excluded biofeedback in 1 section (as a CAM exclusion) but cited it as a covered benefit in an additional… read more at https://mail.google.com/mail/u/0/#inbox/WhctKJVZkNpkdnmzBMNxKQBScqvXzFsFpJztfRXBTSmJVXXNbqbcGwdRgLhFcwtdSVTkgHL?projector=1&messagePartId=0.1