An unfortunate tendency of pain management is that patients seem to choose the least expensive, most readily available option, even if it is not the most effective or appropriate. Given this commonality, a new study and associated commentary published in JAMA Network Open present some troubling evidence concerning the U.S. pain and opioid epidemic.
The study, “Coverage of Nonpharmacologic Treatments for Low Back Pain Among U.S. Public and Private Insurers,” examines coverage policies across a nationally representative sample of commercial, Medicare Advantage and Medicaid plans.
Lead author James Heyward, MPH, a research data analyst at the Johns Hopkins Center for Drug Safety and Effectiveness, found a wide range of copayments for nonpharmacologic care for pain, such as chiropractic care and physical and occupational therapy. One commercial health plan, for example, required their members to pay a co-pay of as much as $60 per encounter for chiropractic care. Meanwhile, in the commentary, Christine M. Goertz, DC, Ph.D., and Steven Z. George, PT, Ph.D., cite research that shows health plans’ preferred generic opioid prescription costs members only $10 a month.
While follow-up chiropractic care visits typically only take 10 to 15 minutes, patients still need to leave home or work and cope with weather, traffic and parking—having to then pay a large copayment is a significant additional burden that can dissuade them from choosing the safer and more effective treatment plan. The financial incentive to refill a prescription must be weighed against the cost of adverse side effects, including misuse, abuse, addiction and in some cases fatality. Despite the convenience of simply taking a pill, choosing a much safer, more effective and less intrusive option should be encouraged and embraced, especially when the opposition could potentially cost one their life.
Overcoming barriers to care
To help stem the opioid crisis and steer more Americans toward evidence-based, effective, clinical pathways for pain management, health insurers and government healthcare policymakers cannot simply move opioids to a higher price tier or require a more rigorous preauthorization process for the medications. In fact, the Economic Policy Institute has found that increased cost-sharing in health plan policies tends to burden those patients who need the care the most, leading them to forgo care.
Health plan members and beneficiaries should instead be incentivized to pursue nonpharmacological care for their chronic, neuro-musculoskeletal pain. That means reducing copayments to at least the same levels as generic prescription opioids. In addition, the Heyward study found that more than half of all insurers placed visit limits on chiropractic care, physical and occupational therapy, while others instituted medical necessity reviews and other preauthorization requirements. Eliminating burdensome administrative requirements and visit limits would encourage patients to make these drug-free, effective therapies an unobtrusive part of their lives and integral to their long-term, chronic pain management strategy.
Multidisciplinary coordination and collaboration
What may help in this regard is improved coordination and collaboration by health insurers regarding the most effective, evidence-based care. In interviews with health plan leaders, Heyward found a “low level of integration between coverage decision making for nonpharmacologic and pharmacologic therapies, such as through the use of step therapy requirements that encourage use of physical therapy before initiation of long-acting or extended-release opioids.”
Collaboration and coordination, however, is essential to producing optimal outcomes. As recently highlighted in an article in Becker’s Spine Review, doctors of chiropractic are highly beneficial contributors to collaborative, comprehensive and patient-centered care teams. The article summarized four recent independent studies published in academic journals that demonstrated patient satisfaction, improved health outcomes and ease of integration with chiropractic care. For example, a four-year, randomized controlled trial involving 750 active-duty military personnel found that their low back pain intensity and disability improved by incorporating chiropractic care compared to clinical pathways without the care.
Toward evidence-based, patient-centered policies
While the causes of our opioid epidemic are numerous, there are opportunities for health plans to reverse the trend. For example, in light of the recently passed federal opioid legislation, the Centers for Medicare and Medicaid Services should seek input from doctors of chiropractic and other practitioners of evidence-based, nonpharmacological pain management care to design its new policies.
Given that a recent Gallup-Palmer College of Chiropractic report showed that 79% of Americans would prefer a drug-free treatment for pain before considering an opioid, it behooves public and commercial health plan leaders to remove the barriers to effective and preferred care pathways for chronic pain by making them more affordable and accessible for their members and beneficiaries.
About the author:
Sherry McAllister, DC, is executive vice president of the Foundation for Chiropractic Progress and Foundation for Chiropractic Education. A not-for-profit organization, Foundation for Chiropractic Education (501c3) and the Foundation for Chiropractic Progress (501c6) provide information and education regarding the value of chiropractic care and its role in drug-free pain management.