Tuesday, October 16, 2018 Study: Many Gaps Still Exist in Insurer Coverage of Nondrug Treatments for LBP According to authors of a new study, physical therapy and occupational therapy to treat low back pain (LBP) frequently may be included in public and private insurer plans, but there's a lack of consistency in factors such as copays, referral requirements, prior authorization, and treatment limits. Coupled with a general lack of attention to many other nonpharmacological approaches to LBP, the inconsistencies create coverage gaps at a time when increased emphasis is being placed on nonopioid pain treatment, they write. The study, published in JAMA Network Open, looked at 2017 data from 15 commercial, 15 Medicaid, and 15 Medicare Advantage (MA) health plans in 16 states selected to provide a cross section of relative wealth, geographic location, and other factors. In addition to the insurers studied—a sample that authors claim represents insurers of more than half of the nation's populace—researchers also interviewed 43 "senior medical and pharmacy health plan executives" to get their take on the use of, and barriers to, nonpharmacological treatments for LBP. Researchers were interested in the degree to which insurers were covering nonpharmacological treatments for LBP and, if so, what restrictions they were placing on that use. It's an area in need of study, they say, given the current opioid crisis, the link between later opioid abuse and initial prescriptions of opioids to treat pain, and recommendations from the US Centers for Disease Control and Prevention (CDC) and others pushing for nonopioid approaches as first-line treatment for chronic noncancer pain. The study focused on 5 nonpharmacological therapies for LBP across all plans: physical therapy, occupational therapy, chiropractic care, acupuncture, and therapeutic massage. Additionally, because the information was readily available through Medicaid, researchers added 6 more approaches to their review of Medicaid plans: transcutaneous electrical nerve stimulation (TENS), psychological interventions, steroid injections, facet injections, laminectomy, and discectomy. Here's what they found: Physical therapy and occupational therapy fared well in terms of medical necessity. Among both commercial insurers and MA, physical therapy and occupational therapy were almost always deemed a "medical necessity" and thus subject to coverage. Of the commercial insurer coverage policies reviewed, all included physical therapy, and all but 1 included occupational therapy. But exactly how that physical therapy is covered? That's another matter. Researchers found that when it comes to utilization management issues, not all plans are equal. Among the 15 commercial insurers studied, researchers found 1 instance of prior authorization requirements, 10 instances of limits put on visits to a physical therapist (PT), and 1 instance of a referral requirement. The prior authorization (PA) situation in MA is worse (a fact that APTA is working with other groups to change), with 5 of the 15 plans studied requiring PA, and 1 requiring a referral. Copays can vary, too—sometimes by a lot. In the MA plans studied, patient copays for physical therapy for LBP ranged from $32.50 to $40 per session; the range was $15 to $50 per session among the commercial payers. Coverage for other nonpharmacological treatments for LBP is spotty. Of the commercial plans studied, only a few conferred "medical necessity" status on acupuncture (3 providers), TENS (3 providers), steroid injections (3 providers), and facet injections (3 providers). The MA system consdiered TENS, steroid injections, and facet injections medically necessary. Medicaid reflected the same general coverage patterns. As in the commercial and MA study group, the Medicaid plans included in the research largely covered physical therapy and occupational therapy (14 of 15, with the remaining plan being "unclear or not found"). All other treatments were in the single digits, with the exception of TENS (10 plans covered) and chiropractic care (12 plans covered). Are health plan execs on board with making it easier to access nonpharmacological pain treatments? Not exactly. In their interviews with health plan executives, authors of the study found that "overall, informants indicated a low level of integration between coverage decision making for nonpharmacologic and pharmacologic therapies." Researchers noted that when the interviewees did mention "innovative strategies to combat the opioid epidemic," those strategies tended to center around improved formulary management of opioids, substance abuse treatment, and identification of opioid over-users and over-prescribers—"less so on innovations aimed at optimizing coverage and access to nonpharmacologic therapies for chronic pain," they write. "The findings of this study support what we find on the ground with our members—namely, that while we have made progress in areas such as basic coverage and direct access, there's still much more work to be done to increase patient access to physical therapy and other nonopioid treatments," said Carmen Elliott, MS, APTA vice president of payment and practice management. "That's why we continue to engage with commercial payers, utilization management providers, and insurer interest groups to help them find a way to apply the evidence of physical therapy's effectiveness to their own policies." Authors of the study echo that sentiment, writing that "despite a growing evidence base supporting the effectiveness and cost-effectiveness of many of the nonpharmacological treatments examined in our study, our findings depict inconsistent and often absent coverage for many of these treatments." These inconsistencies present a challenge for patients, particularly those who are pursuing a multidisciplinary approach to treatment, they add. "Treatment-based approaches can require a co-payment for each visit, in addition to costs associated with travel and missed work," authors write. "These issues are multiplied if a patient is taking a multipronged approach that incorporates multiple therapies for chronic pain. In addition, the wide variation in utilization management criteria…underscores the uncertainty that may exist around what constitutes an appropriate duration and intensity of treatment (eg, physical therapy) for chronic noncancer pain." Authors of the study believe the way out of this dilemma may depend on establishing and promoting the evidence base for nonpharmacological pain treatment and—most important—for these treatments to be widely used by providers. "Utilization management requirements were highly variable, which speaks to a need for evidence-based guidance regarding optimal use of these therapies, and standardized, comprehensive training for practitioners to effectively implement the evidence base into their practice," they write. Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.