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Insurers slighting claims for non-opioid pain treatments
By JOHN W. MILLER |October 10, 2018
G. Caleb Alexander, MD, co-director of the Johns Hopkins Center for Drug Safety and Effectiveness
Johns Hopkins Bloomberg School of Public Health
Quick Takeaway
  • 67 percent of insurance plans lacked coverage for acupuncture.
  • 80 percent were silent on psychological interventions for pain.
  • Physical therapy was subject to widely varying visit caps and preauthorization rules.

Despite the opioid epidemic, health insurers are still failing to reimburse chronic pain patients for effective non-opioid treatments, including psychological counseling and acupuncture. Even coverage for physical and occupational therapy varies widely in terms of the number of visits allowed, and whether prior authorization is required.

Those are among the findings of a new study on insurance coverage for lower back pain, published last week in the online journal JAMA Network Open. The research was led by researchers at the Johns Hopkins Bloomberg School of Public Health, and was related to work that generated a related paper in June, also published in JAMA Network Open. The earlier study concluded that insurers were still too readily covering prescriptions of opioid pills for lower back pain.

The authors say their research is the “most comprehensive assessment of coverage policies” for non-pharmacological pain treatment “in the opioid era.”

Despite evidence supporting its effectiveness, acupuncture was not covered by 67 percent of the coverage plans studied.

Despite evidence supporting its effectiveness, acupuncture was not covered by 67 percent of the coverage plans studied. Similarly, 80 percent of the Medicaid plans examined “lacked information” about psychological interventions to fight pain, the report found.

Although most plans did cover physical therapy (98 percent), occupational therapy (96 percent), and chiropractic care (89 percent), even with those treatments the plans “varied widely” with respect to visit limits and whether prior authorization was necessary.

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Both the Centers for Disease Control and Prevention and the President’s Commission on Combating Drug Addiction and the Opioid Crisis have said that increasing the range of treatments available for pain that don’t involve taking a pill are important objectives in fighting the epidemic. Current CDC guidelines say that “non-opioid therapy is preferred for chronic pain outside of active cancer, palliative, and end-of-life care.” The government has urged insurers to change their coverage to reflect the guidelines.

Although there are many factors contributing to rises in opioid misuse and overdose deaths, the study assumes that the four-fold increase in opioid prescribing between 1999 and 2010 was an important factor. The CDC’s latest figures estimate that 49,031 people died from opioid overdose in 2017, and that 18,226 of them had at least one prescription opioid in their systems at the time of death. (That’s using the CDC’s most conservative definition of “prescription opioid”—one that excludes all synthetic opioids, like fentanyl.) Surveys performed by the Substance Abuse and Mental Health Services Administration suggest that more than 2 million Americans suffer from opioid use disorder.

A premise of the Johns Hopkins study is that one important contributor to increased use of opioids over the past 20 years “has been their overuse for the treatment of chronic, noncancer pain in the absence of data demonstrating long-term benefit.”

For physical therapy some plans covered two visits, some six, some 12.

The opioid crisis is forcing “a sea change in how chronic pain is diagnosed and managed,” says the study’s senior author, G. Caleb Alexander, MD, in an interview. He is the co-director of the Johns Hopkins Center for Drug Safety and Effectiveness. “In the last few years we have seen many insurers modifying their policies to reduce the vast overuse of opioids, but clearly we still have a long way to go.”

Even physical therapy, “a mainstay for many types of chronic pain”, is “underutilized,” asserts Alexander.

In this study, the Johns Hopkins researchers, with funding and assistance from the National Institutes of Health and the CDC, studied 45 insurance plans that were offered in 2017 in 16 states, representing more than half the US population. The policies included 15 commercial, 15 Medicaid, and 15 Medicare Advantage health plans. The researchers supplemented their quantitative analysis with interviews with 43 health plan executives.

The study focuses on five non-pharmacological treatments: physical therapy, occupational therapy, chiropractic care, acupuncture and therapeutic massage.

The big issue, Alexander says, is that there is still no industry consensus on what and what not to cover. The result is a patchwork of care and insurance offerings that doesn’t send a clear signal that the first answer to chronic pain should never be opioids.

In the case of physical therapy, for example, coverage was inconsistent.

“It’s not just about paying for treatments that work. It’s also about not paying for treatments that don’t.”

“Some plans covered two visits, some six, some 12,” explains Alexander. “Some allowed you to refer yourself for treatment, while others required referral by a doctor. That variation indicates a lack of consensus among insurers regarding what model coverage should be, or a lack of willingness to pay for it.”

Insurers also have work to do in weeding out remedies that don’t work. “It’s important that insurers are covering evidence-based treatment,” Alexander says. “It’s not just about paying for treatments that work. It’s also about not paying for treatments that don’t.”

In some cases, plans covered treatments without any scientific backing. For example, “steroid injections were covered by nearly two-thirds of the Medicaid plans examined . . .  despite a lack of high-quality data supporting the use of these interventions for low back pain,” the study found.

The Medicare Advantage plans were similar to private plans in how much they covered physical therapy, occupational therapy, transcutaneous electrical nerve stimulation, and steroid injections.

But the Medicare Advantage plans were more likely to cover steroid injections, and less likely than commercial plans to cover acupuncture and disc-removal surgery, which are considered more effective.

One of the report’s most puzzling findings was that 80 percent of plans simply “lacked information” about psychological interventions for treating pain.

“There was no definitive yes or no in most cases,” lead author Jamie Heyward explains in an email to Opioid Watch. Researchers “examined publicly available documents … for each plan [but] were typically unable to find any mention of psychological interventions for pain management.”

“We were perplexed by the absence of information about coverage of psychological therapies,” adds Alexander in an email. “There is plenty of evidence to support the value of cognitive approaches (or psychological approaches) as part of a multimodal treatment plan for chronic pain—and we were surprised that the coverage documents we examined were silent on this matter.”

Cathryn Donaldson, a spokeswoman for America’s Health Insurance Plans, provided a statement to Opioid Watch about the study. AHIP is a trade group representing insurance companies.

“The authors of this report acknowledged that insurance providers offer ‘near universal’ coverage of physical and occupational therapy,” the statement says. “Other therapies such as chiropractic care was also frequently covered. Additionally, health insurance providers interviewed for the study confirmed that they have undertaken strategies to expand access to nonpharmacologic therapies in recent years including more emphasis on physical therapy, chiropractic care, mindfulness training. . . .

“[It’s] important to clarify that coverage for alternative therapies is about evidence base—not cost. And clinical guidelines for treating pain, while available from entities such as the CDC and … others, may not be easy to follow. Also, while there is a strong evidence base for other pain management approaches—including OTC, PT, and OT—other forms, such as acupuncture and yoga, don’t have the same evidence base yet. But that evidence base is growing . . .

“We agree there is work to be done, and health insurance providers continue to be committed partners in battling this epidemic by improving pain care and continuing to reduce opioid prescribing.”