Influential U.S. Medical Organizations Call for Insurance Coverage of Non-Pharmacologic Approaches to Pain

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The licensed complementary, alternative, and traditional medicine professionals in North America who deliver integrative health services have long recognized that evidence of effectiveness of their care would not necessarily guarantee inclusion of services of these professions in coverage schemes. Exclusion from their participation in mainstream payment could be maintained via concerns over cost, regardless of other evidence of benefits.

Not surprisingly then, when leaders from a consortium of these disciplines, the Academic Collaborative for Integrative Health, published consensus recommendations for research priorities, they named “costs, cost effectiveness, cost-offsets, and cost-savings” as second in importance only to research on the whole systems of care represented by their professions. ¹ Yet, while the theme stood out in their dialogue with leaders of the U.S. National Center for Complementary and Integrative Health (NCCIH), ² examining cost has not been prioritized at the agency.

This may be changing. The value in this research direction presently has some more powerful allies, according to an analysis recently provided by licensed acupuncturist Mathew Bauer, LAc, of the Acupuncture Now Foundation (ANF) and David Miller, MD, LAc, of the American Society of Acupuncture. In January of 2016, the two not-for-profit organizations had submitted comments to the U.S. Center for Disease Control and Prevention (CDC) on why the acupuncture profession should be considered an ally in the nation's effort to limit opioid abuse. ³ The context was an open public comment period on a draft version of what would become the March 2015 “Guidelines for Prescribing Opioids for Chronic Pain.” ⁴ As previously noted in a September editorial here, that draft and the final guidance each featured a welcome recommendation of non-pharmacologic approaches as a first resort, though, as I noted, with limited explicit mention of approaches, such as acupuncture, in that category. ⁵

ANF was one among roughly 4372 entities to submit comments. ⁶ As an activist organization interested in collaborating with others to “help them develop guidelines physicians could use to recommend acupuncture as a non-drug option,” Bauer, Miller, and their colleagues scoured the comments for signs of potential allies. What they found was, to Bauer, “something really amazing” (pers. comm., Mathew Bauer, November 13, 2016). Wrote Bauer: “Mainstream group after mainstream group [was] telling the CDC that physicians can't act on the CDC's number one recommendation regarding how to avoid relying on opioids because of a lack of insurance coverage for CAM/integrative therapies. I have never seen anything like this.”

Nor have I. While many European and Asian nations are accustomed to more inclusive coverage schemes, interest has lagged in supporting reimbursement for conservative care inside the United States' volume-based, for-profit industry. Now, the opioid crisis, in the midst of a broader U.S. movement for value-based care, may be turning the tide. Here are some remarkable examples from the ANF's collection of extracts from these historic comments to the CDC that were attached to Bauer's e-mail.

• American Medical Association: “Non-pharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic pain. Providers should only consider using opioid therapy if expected benefits for pain and/or function are anticipated to outweigh risks. In order to achieve this goal, public and private payer policies must be fundamentally altered and aligned to support payment for non-pharmacologic treatments and multimodal care.” ^a

• American Society of Anesthesiologists: “A major challenge in incorporating the Guideline in daily practice is that some of these recommendations may not be covered by the patient's insurance, which inhibits physicians' ability to treat patients using non-opioid approaches. We recommend that the Guideline clearly state that the federal government should encourage insurance coverage for therapies that would prevent opioid dose escalation or decrease. In addition, insurance coverage should include nonpharmacological therapies (all modalities available), and payers should reduce patient co-insurance and co-pays to encourage the use of non-pharmacological therapies.” ^b

• American Pain Society: “We agree that non-pharmacologic therapies are important tools in the management of many types of chronic pain. Unfortunately, many non-pharmacological therapies are not reimbursed by Medicaid, Medicare, or third-party payers. Support for such therapies in the guidelines might be useful for implementation of this recommendation. We believe that patients should have both pharmacological and non-pharmacological approaches available and reimbursed … for the management of their chronic pain.” ^c

• American College of Physicians: “The College also suggests that the Guideline document call for payment policy changes both within the public and private sector that will facilitate access to nonpharmacological therapies.” ^d

• Medical Board of California: “While it is true that many non-pharmacologic modalities are effective for the treatment/control of chronic pain, the [draft] Guidelines fail to address the fact that many patients do not have access to these modalities, due to lack of insurance coverage or low availability. These Guidelines do not have to solve this problem, but it should mention that this may be an issue and educate on how to mitigate this situation.” ^e

• Trust for America's Health: “Many insurers don't adequately cover or reimburse for non-pharmacologic therapies such as acupuncture, biofeedback, relaxation, and other interactive, multimodal therapies. Payer policies—both public and private—would need to be fundamentally changed to support this recommendation.” ^f

• American Academy of Pain Management: “At a bare minimum, recommendations that payers provide universal coverage for the five types of nonpharmacologic care mentioned in the [Department of Defense/Veteran's Administration] pain guideline (physical manipulation, massage, acupuncture, biofeedback, and yoga) should be issued.” ^g

The ANF-ASA document includes similar statements from others: the American College of Physicians, Providence Health, Alliance for Patient Access, American Academy of Addiction Psychiatry, and the American Osteopathic Academy of Addiction Medicine.

A recent article on the website of the Journal of the American Medical Association (JAMA) reinforces the integrative health dimensions in these recommendations. The JAMA article is entitled “As Opioid Epidemic Rages, Complementary Health Approaches to Pain Gain Traction.” ⁷ Writer Jennifer Abbasi links the opioid crisis to a September 2016 publication by a team at the NIH NCCIH on complementary and integrative approaches that may be valuable for pain treatment. ⁸ Noted approaches are: acupuncture (back pain, osteoarthritis of the knee); massage therapy (neck pain—with adequate doses and for short-term benefit; back pain); osteopathic manipulation (back pain); relaxation techniques (severe headaches and migraine; fibromyalgia); spinal manipulation (back pain); t'ai chi (osteoarthritis of the knee; fibromyalgia); and yoga (back pain).

Abbasi concludes by noting how the lack of insurance coverage hinders access to such integrative strategies for combating the opioid crisis. She quotes an orthopedic physician on medical doctors' “tendency to default to medications” because patients cannot afford uncovered options. “Physicians,” the rehabilitation specialist is quoted as stating, “are often backed into a corner when dealing with a patient's pain.” She adds, “We need to create better access to CAM therapies. By reducing the cost burden on the patient, these therapies become far more accessible.”

Bettering the physician's options, and the patient's experience, may not be the only benefits from a shift to more inclusive coverage schemes. Positive evidence on cost benefits is emerging. Much has been aggregated on the Project for Integrative Health and the Triple Aim website of the Academic Collaborative for Integrative Health, ⁹ the organization whose push for prioritization of research on cost is at the top of this column.

The opioid crisis, and the calls for change from the influential stakeholders whose comments were aggregated by Bauer and the ANF/ASA, may finally be providing the lobbying leverage for getting both physicians and patients out of the opioid-besotted corner and into an integrative model in the United States. More attention to cost outcomes from researchers and from their funders will be both useful and reassuring guidance in this transition in the nation's therapeutic order ¹⁰ in pain treatment toward more conservative care.