Physical Therapy, Chiropractic Back Care Cut Opioid Use, Costs

October 23, 2018 - Payers could improve outcomes, increase cost-effectiveness, and reduce opioid use for lower back pain by expanding non-pharmacological coverage such as physical therapy and chiropractic care, according to a new study published in JAMA Network Open.

Researchers from Johns Hopkins, HHS, and NIH explained that some payer groups may promote best practices to reduce opioid dependency risks and make pain treatments affordable for beneficiaries. Expanding beneficiary access to physical therapy, chiropractic, and acupuncture services may allow payers to provide clinically-proven solutions for temporary pain without relying on opioid prescriptions.

“Recognizing the importance of non-opioid therapies, HHS’s National Pain Strategy urges changes to insurers’ coverage policies to enable greater access and adherence to non-opioid therapies for pain,” the researchers said.

Many payers already cover non-opioid pain management and treatment services to some degree, but they often limit the duration of services or require administrative actions that could create barriers to care.

Private payers frequently categorized acupuncture, chiropractic treatment, physical therapy, and steroid injections as medically necessary services. MA plans also categorized chiropractic care and physical therapy as key medical benefits, but felt that acupuncture was not a treatment to address immediate clinical needs.

The team also pointed out that there was not enough information from commercial and MA payers to determine if psychological treatment was deemed by payers as a medically necessity for lower back pain treatment.

Coverage utilization varied between private and public payers, with Medicaid less likely to cover acupuncture or psychological services for back pain, the study said.

Over 80 percent of Medicaid plans provided coverage for physical therapy and chiropractic care, but only 13 percent of Medicaid plans covered acupuncture and 20 percent covered psychological treatments for beneficiaries. Medicaid plans frequently implemented utilization management policies like visit limits, prior authorization, and clinical criteria.

Every Medicaid plan surveyed had visit limits for physical therapy and 92 percent of plans capped beneficiary visits for chiropractic care. Fifty percent of Medicaid plans had prior authorization requirements for acupuncture services and 75 percent of Medicaid plans had condition requirements before beneficiaries could access chiropractic services.

Utilization management policies were less common in commercial insurance and Medicare Advantage than Medicaid, but were still present in a majority of private plans, the team found.

Sixty-seven percent of commercial and MA plans had visit limits on physical therapy and 62 percent of plans had limits on chiropractic visits. Seventy-five percent of MA plans restricted coverage requirements for chiropractic services to patients with spinal subluxation.

However, prior authorization requirements were far less common in private insurance and MA than in Medicaid. Only 33 percent of commercial and MA plans required prior authorization for physical therapy services.

Out-of-pocket costs for patients receiving non-opioid treatments for lower back pain varied between in-network and out-of-network utilization, the team found.

Median in-network copays for commercial and MA beneficiaries were similar. Commercial and MA members paid $40 and $30 dollars for physical therapy copays, respectively. Private plans required a fifty percent copay for out-of-network care while MA plans required a 35 percent copay.

The team concluded that payers may need to improve patient access to chiropractic or lower back pain services that don’t include opioid treatments. Payers in both private and public insurance sectors are inconsistent when it comes to covering non-pharmacological benefits that improve overall health.

“Given recommendations in recent clinical practice guidelines that prioritize non-opioid treatments, including non-pharmacological treatments, as first-line therapy for many types of chronic pain, including low back pain, our findings highlight a number of opportunities across a broad range of public and private payers to improve coverage and reimbursement policies for non-pharmacological treatments for pain.”

In an accompanying commentary, clinical experts from Duke University and the Spine Institute for Quality agreed that restricting non-opioid treatments for back pain is likely detrimental for beneficiaries.

Promoting non-opioid treatments may improve the underlying challenges of chronic pain treatment and steer beneficiaries away from potentially addictive opioids for long-term pain.

“Well-conceived guidelines that encourage the use of evidence-based, nonpharmacological treatment options exist and must be enabled by changes in public health policies that better guide care delivery and reimbursement,” the experts explained.

“Health plans are uniquely positioned to bring about the sweeping changes needed to offer diverse pain management options for individuals with chronic pain. The findings from [the study] shed light on the ways in which current coverage policies run counter to this strategy and provide the beginnings of a roadmap to implement change on this critical issue.”