Oregon Medicaid’s Solution for Chronic Pain

When the EHB Advisory Committee met earlier this year to discuss what Oregon’s 2017 Benchmark plan should look like, someone brought up the very good point that it should include the benefits found on the Oregon Health Plan (OHP), the state’s Medicaid program.

Image courtesy of Ambro at FreeDigitalPhotos.netThe reason behind this suggestion was that a huge number of people who will be on the exchange plans are constantly bouncing between OHP and private insurance, depending on their work situation and financial situation on any given month. Thus, having an identical scope of benefits between the two would provide a more-or-less seamless transition whenever the consumer qualified for Medicaid or had to purchase a private plan. If not the exact same providers (since not all providers work with OHP), then at least the same types of providers.

Alas, that was not to be. CAM providers were (yet again) not accounted for in the benchmark plan.

But were CAM providers really in a better position on OHP plans? Funny you should ask. In fact, back in March, the Health Evidence Review Commission (HERC), released a paper that suggested OHP take a very different approach:

Until now, the OHP has limited [back condition] treatment to patients who have muscle weakness or other signs of nerve damage. Beginning in 2016, treatments will be available for all back conditions. Before treatment begins, providers will assess patients to determine their level of risk for chronic back pain, and whether they meet criteria for a surgical consultation. Based on the results, one or more of the following covered treatments may be appropriate:

  • Acupuncture
  • Chiropractic manipulation
  • Cognitive behavioral therapy (a form of talk therapy)
  • Medications (including short-term opiate drugs, but not long-term prescriptions)
  • Office visits
  • Osteopathic manipulation
  • Physical and occupational therapy
  • Surgery (only for a limited number of conditions where evidence shows surgery is more effective than other treatment options)

In addition, yoga, intensive rehabilitation, massage, and/or supervised exercise therapy are recommended to be included in the comprehensive treatment plans. These services, which also have evidence of effectiveness, will be provided where available as determined by each Coordinated Care Organization (CCO). [emphasis mine]

Massage! Yoga! Manipulations! I love it. It feels like the people in charge are finally trying to figure out what actually helps reduce or manage chronic pain. This is a great development, and it has the power to change a lot of lives.

How do we solve the problem of chronic pain? For so long, the answer has been prescription medication. Hydrocodonebtibu75200However, as I wrote about earlier, many people and organizations are starting to realize that these medications have drawbacks and limitations. Indeed, one of the reasons alternative care has taken hold in this country recently is because of the need to find another way to treat chronic pain.

Having options is nice, but it’s a luxury that people with limited means can barely afford. When your health insurance covers prescription medicine but not alternative care treatments, what can you do? In such cases, the choice between painkillers and CAM isn’t really a choice.

And the long-term use of painkillers can become a problem. As illustrated in this article, “In 2012, more than 900,000 Oregonians received an opioid prescription…About one third of hospitalizations related to drug abuse here are due to opioids.” Indeed, the HERC document points out that, “OHP has spent a great deal of public money on treatments such as surgery and medications, without good evidence that they improve patient’s lives. At the same time, narcotics also carry risks of dependency, misuse and overdose.”

Starting in January, OHP patients will have a real choice in how they want to manage their chronic back pain.

The weird tangent to all of this, however, is that Oregon’s Medicaid will soon have a wider scope of provider types and covered services than most of the plans on Oregon’s Exchange. Even in private plans that do cover certain CAM services, the insurance companies will still be allowed to discriminate against providers until 2017. Whereas, if a provider wanted to work with a Medicaid patient, he or she would only have to talk to the patient’s CCO to make it happen. It seems to me that the state is actually invested in making people’s lives better, while the insurance companies are focused only on the short-term gains.

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Oregon and Rhode Island News

Oregon Locator MapI meant to write about this earlier: Back in April, Oregon signed into law House Bill 2468, which pertains to network sufficiency and provider non-discrimination. That’s right, Oregon’s very own Section 2706.

The details regarding network sufficiency are new (from what I understand, the ACA expressed that network sufficiency was necessary but didn’t go into specifics), but the non-discrimination provision is identical to Section 2706.

This is awesome! Such great news! Unfortunately, it comes with a huge caveat: The law doesn’t take effect until January 2017.

Postponing implementation for a year and a half was an apparent concession to the insurers, allowing them to drag their feet for just a little longer before they’re forced to comply. Essentially, insurers are admitting that they don’t have to follow the federal law – they’ll only listen when the same exact law is also mandated by the state.

Rhode Island Locator MapIn the meantime, Rhode Island has passed HB 168, their own state-version of the non-discrimination provision. While the bulk of the statute (which was already in effect) pertains to insurance reimbursement specifically for certified registered nurse anesthetists, the non-discrimination language that was added does not specify any single provider type (such as the Hawaii bill from earlier this year that has currently been deferred).

The best part about this bill? It takes effect immediately. I’m very curious to see whether the insurance companies will actually fall in line without having to be forced.

The Evolution of Alternative Medicine

The Atlantic just published a really great article about how attitudes towards and acceptance of CAM treatments and integrative care has changed over the years.

The article touches on research being done about the placebo effect and the power of one’s own body to heal, something I’ve written about elsewhere. It talks about how modern medicine has evolved since the 1960s to focus more on overall wellness, instead of just acute disease treatment:

The actual treatments they use vary, but what ties integrative doctors together is their focus on chronic disease and their effort to create an abstract condition called wellness. In the process, they’re scrutinizing many therapies that were once considered alternative, subjecting them to the scientific method and then using them the same way they’d incorporate any other evidence-based medicine.

This approach is forcing the entire medical community to grapple with certain questions: How has the role of a doctor changed over the years? Are there better ways to treat the kinds of health problems that can usually only be managed, not cured? And how do you gather evidence on therapies that involve not only the body but also the mind?

The article does a great job discussing chronic pain, both how widespread it is and how difficult it is to treatment with modern medicine. There’s a lot of research being done at NIH and its newly named NCCIH (National Center for Complementary and Integrative Health) about how best to manage pain (eg, how does yoga affect health?), and I can’t wait to read more about what they’ve found.

Going one step further than the scope of this article, and circling it back to the primary focus of this blog, how much research will it take before insurance companies understand that the face of medicine is changing? If chronic pain is so widespread (and it is), and the most beneficial treatments are traditional medicine (acupuncture), complementary care (massage), and day-to-day wellness (yoga and meditation), when will insurance companies decide that this is where they should be focusing? If not for the goal of improving health (none of us are that naive!), then certainly for the goal of improving their bottom line.

Properly managing chronic pain improves health, which lowers costs. Simple as that.