October 09, 2018
By Linda Carroll
(Reuters Health) - When it comes to non-drug therapies for back pain, U.S. insurance plans vary widely in what they will cover, a new study finds.
Private and public insurers are missing important opportunities to promote alternatives to opioids, the investigators wrote October 5 online in JAMA Network Open.
In fact, researchers found, insurers often provide little or no coverage for evidence-backed interventions for chronic pain such as acupuncture and psychological counseling.
"Insurers can be part of the problem or part of the solution," said study coauthor Dr. Caleb Alexander, an associate professor at the Center for Drug Safety and Effectiveness at the Johns Hopkins School of Public Health in Baltimore, Maryland. "We see a lot of variability in coverage of non-drug treatments for chronic pain. We have a long way to go."
The U.S. Centers for Disease Control and Prevention estimates that 42,249 Americans died from opioid overdoses in 2016, with 17,087 deaths attributed to prescription opioids.
Alexander and his colleagues examined the 2017 versions of 45 insurance plans - 15 Medicaid, 15 Medicare Advantage and 15 major commercial plans - to see what non-drug treatments for low back pain were covered.
Nearly all the plans covered physical and occupational therapy.
But despite evidence in the literature to support use of acupuncture, 30 of the 45 plans explicitly did not cover it.
Of the 15 Medicaid plans, just three covered psychological interventions for chronic pain. The researchers could not determine the coverage policies regarding psychological interventions for the Medicare or commercial plans.
Therapeutic massage was almost never covered.
While certain types of non-drug therapies were covered by most policies, some insurers had steep co-pays. "You can provide all the coverage in the world, but if it's not affordable for patients nobody is going to use it," Alexander said.
Even in the case of physical therapy, a well-established treatment for low back pain, the researchers found barriers to use. Some plans covered two visits, some six, some 12. Some allowed patients to refer themselves for physical therapy, while others required referral by a doctor.
Ultimately, it can be easier to prescribe a medication.
"All too often doctors reach for the quick solution, prescription drugs, especially opioids, to manage pain that would be more effectively and safely treated with non-pharmacological approaches," Alexander said. "This is a system that is designed with, and fosters, the idea that there is a pill for every ill. And we're here 20 years after the start of the opioid epidemic, paying the price for that."
The new study is underscores a "very relevant problem, given the public health crisis we're in now," said Dr. Alka Gupta, co-director of the Integrative Health and Wellbeing Program at NewYork-Presbyterian and an assistant professor of medicine at Weill Cornell Medicine in New York City.
"Low back pain is the second most common reasons for primary care visits," Gupta said. "Over the last several years we've seen more and more effective treatments coming out. Those were included in the updated guidelines released by the American College of Physicians in February. We've also seen that insurers have been slow to adapt their policy coverage to reflect that information."
Chronic pain is complicated, Gupta said.
"There are many factors that can amplify or dampen the pain signal," she said. "For example, if you have someone with severe anxiety and you know their pain is at least partially mediated by anxiety, they should have access to . . . psychological therapy."
While insurers may eventually fix the problem on their own, sometimes it takes legislation to make sure everyone gets what they need, said Nadereh Pourat, associate director of the Center for Health Policy Research at the Fielding School of Public Health at the University of California, Los Angeles.
"The big question here is how do you get insurance providers to cover services," Pourat said. "There used to be a similar lack of parity when it came to mental health. That led to the passage of the Mental Health Parity Act, a law requiring that mental health coverage has to be meaningful and that insurers don't put too many restrictions on it or make it difficult to use."
JAMA Network Open 2018.
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