Coverage Drives Treatment: The Case of Pain

Last week Congress decided not to move forward with repealing and replacing the Affordable Care Act with the American Health Care Act of 2017. This doesn’t mean health reform is over in the U.S., though.

Patient access to care and the costs of that care are still hot topics in Washington, D.C. and statehouses across the country. As we move forward in reform, I would propose a close look at the opioid epidemic and ways we can push for payers to cover treatment that is patient-centered and evidence-based. Seems straightforward, but it isn’t.

A USA Today op-ed from last fall had a subtitle on the opioid epidemic that said it all: “There are other ways to manage chronic pain, but insurance companies won’t pay for them.”

In the summer of 2016 the U.S. Surgeon General sent a letter to physicians in the U.S. basically saying they haven’t been properly trained to manage pain and they could do better to manage patients with pain than just handing over a prescription for an opioid. Dr. Vivek Murthy was more eloquent, writing, “We often struggle to balance reducing our patients’ pain with increasing their risk of opioid addiction. But, as clinicians, we have the unique power to help end this epidemic.”

Prescriptions for painkillers vary dramatically by state, further supporting the argument that prescribers may not be following a standard of care for treating pain.

Source: CDC, Policy Impact: Prescription Painkiller Overdoses

It is true that clinicians are uniquely situated to address responsible opioid use and pain management, but that will be difficult to do without support from health insurers. Dr. Robert Bonakdar, the author of the USA Today piece and the Director of Pain Management at the Scripps Center for Integrative Medicine, and immediate past president of the Academy of Integrative Pain Management, succinctly explained the entire U.S. health care system’s approach to pain management:

… many well-established non-pharmacologic treatments like biofeedback and cognitive behavioral therapy (CBT), endorsed [by Murthy], are routinely denied by insurance companies. As an ironic example of the campaign’s shortcomings, on the same day I received the surgeon general’s letter, I received one of the standard insurance denial letters for the biofeedback I had requested for a patient’s headache.

Government agencies and other advisory organizations are coming together to acknowledge that addressing pain is not as simple as writing a script – which is clearly what the system pays for right now.

The National Pain Strategy reminds health care providers and policymakers (and anyone else who will read its 72 pages) that, “Chronic pain is a biopsychosocial condition that often requires integrated, multimodal, and interdisciplinary treatment, all components of which should be evidence-based.”

The Principles of Chronic Pain Treatment prompt health care providers who are treating patients with pain to “use nonopioid therapies to the extent possible,” but also to “identify and address co-existing mental health conditions (e.g., depression, anxiety, PTSD)” in patients in order to best define their treatment needs.

The health care system needs to move in the direction of covering what works. Like other examples we have covered in the Pondering Policy blog, opioids are no exception to the rule.